Biomedical subjects

M J Radford

Publications and source records attributed to M J Radford.

At least 37 records · Page 2Linked to original sources

PubMed2001

Quality of care among elderly patients hospitalized with unstable angina.

BACKGROUND: Guidelines for the management of unstable angina have been published by the United States Agency for Health Care Policy and Research (currently known as the Agency for Healthcare Research and Quality); however, little information is available about the quality of unstable angina care, particularly among elderly patients. METHODS: We examined 1196 elderly Medicare-insured patients hospitalized with unstable angina (ruled out for acute myocardial infarction) at Connecticut hospitals between August and November 1995 to evaluate quality of care provided during hospitalization. Patients without therapeutic contraindications were evaluated for the use of 5 Agency for Health Care Policy and Research guideline-recommended measures: electrocardiographic examination within 20 minutes of admission, use of aspirin on admission, intravenous heparin on admission, achievement of therapeutic anticoagulation among patients provided heparin, and prescription of aspirin on discharge. RESULTS: Less than half (49.6%) of patients underwent electrocardiographic examination within 20 minutes of admission. After excluding patients with contraindications, aspirin was provided to 80.1% of patients and intravenous heparin to 59.2% of indicated patients, of whom only 43.3% achieved therapeutic anticoagulation. Aspirin was prescribed to 82.3% of eligible patients at discharge. Performance on the 5 quality measures varied widely among hospitals. CONCLUSIONS: Agency for Health Care Policy and Research guideline-recommended risk stratification and therapeutic interventions are underused in elderly patients hospitalized with unstable angina, with quality of care varying widely among hospitals.

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PubMed2001

The Connecticut Cardiovascular Consortium: a unique, state-wide research collaboration to advance clinical outcomes in patients with heart disease.

The establishment of "best clinical practices" founded upon evidence-based medicine has become an increasingly important priority. Frequently, management guidelines are derived from published research data and disseminated among practitioners to help optimize patient care. The ultimate clinical impact of these guidelines in the "real world," however, is often clouded by an incomplete assessment of patient outcomes throughout the continuum of health-care delivery models. In order to address this gap in clinical outcome assessment, we propose to establish the Connecticut Cardiovascular Consortium. The Consortium will consist of a collaborative partnership among all 31 Connecticut hospitals working in concert with Connecticut Office of Health Care Access (OHCA). The primary objective of the Consortium will be to assess, compare, and optimize clinical outcomes among Connecticut residents with cardiovascular disease. As an initial goal for the Consortium, we further propose to undertake a prospective, observational study of Connecticut residents who present with ST Segment Elevation Acute Myocardial Infarction (STEMI). Recent advances in pharmacologic and mechanical reperfusion for STEMI have resulted in a need to define the optimal use of these therapies in the community at large. The primary purpose of this study will be to determine the relative merits of different treatment patterns for STEMI with regard to the use of fibrinolytic therapy and percutaneous coronary intervention (PCI). Particular emphasis will be placed on assessing the relative benefits of urgent mechanical revascularization performed at the state's seven tertiary facilities with PCI capability compared to all other treatment modalities. Successful completion of this unique collaborative endeavor is expected to have significant impact on improved patient care and on current health-care policy for medical resource allocation. Moreover, continued collaboration of health-care providers within the Connecticut Cardiovascular Consortium infrastructure should serve as a useful mechanism for ongoing improvements in evidence-based cardiovascular medicine and clinical research in the state of Connecticut.

Connecticut↗

PubMed2000

Correlates and impact on outcomes of worsening renal function in patients > or =65 years of age with heart failure.

1.5 mg/dl. Based on the number of these factors, a patient's risk for developing worsening renal function ranged between 16% (< or =1 factor) and 53% (> or =5 factors). After adjusting for confounding effects, worsening renal function was associated with a significantly longer length of stay by 2.3 days, higher in-hospital cost by $1,758, and an increased risk of in-hospital mortality (odds ratio 2.72; 95% confidence interval 1.62 to 4.58). In conclusion, worsening renal function, an event that frequently occurs in elderly patients hospitalized with heart failure, confers a substantial burden to patients and the healthcare system and can be predicted by 6 admission characteristics.

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PubMed2000

Care and outcomes of elderly patients with acute myocardial infarction by physician specialty: the effects of comorbidity and functional limitations.

PURPOSE: Whether patients with acute myocardial infarction who are treated by cardiologists have better outcomes than patients treated by generalist physicians is controversial. Because some of the survival benefit associated with cardiology care may be due to baseline differences in patient characteristics, we evaluated how differences in case-mix of comorbid illness and functional limitations may explain the association between specialty care and survival. MATERIALS AND METHODS: We examined the records of 109,243 Medicare beneficiaries hospitalized for myocardial infarction from 1994 to 1995 from the national Cooperative Cardiovascular Project to evaluate the association of physician specialty with 30-day and 1-year mortality. We assessed the extent to which this relation was mediated by differences in the use of guideline-supported therapies (aspirin, beta-blockers, reperfusion, angiotensin-converting enzyme inhibitors) or differences in the clinical characteristics of the patients. RESULTS: Patients who had board-certified cardiologists as attending physicians had the least number of comorbid conditions, whereas patients who had general practitioners or internal medicine subspecialists as attending physicians usually had the most comorbidities. Cardiologists had the greatest use of most guideline-supported therapies, and general practitioners had the lowest use. After adjustment for severity of myocardial infarction, clinical presentation, and hospital characteristics, patients treated by cardiologists were less likely to die within 1 year (relative risk [RR] = 0.92, 95%, confidence interval [CI]: 0.89 to 0. 95), and patients cared for by other general practitioners were more likely to die within 1 year (RR = 1.09, 95% CI: 1.03 to 1.14), than patients cared for by general internists. After adjusting for additional measures of comorbid illness and functional limitations, the 1-year survival benefit associated with cardiology care was attenuated relative to internists (RR = 0.97, 95% CI: 0.94 to 1.0), and the excess mortality associated with general practitioners decreased (RR = 1.05, 95% CI: 1.00 to 1.11). After further adjustment for the use of guideline-supported therapies, both differences in 1-year survival between patients treated by cardiologists or general practitioners were not significantly different from those of patients treated by internists. CONCLUSION: Studies comparing outcomes by physician specialties that do not adjust adequately for differences in patient characteristics may attribute more benefit than is appropriate to specialists who treat patients who have fewer comorbid conditions. Some of the remaining benefit-at least among patients with myocardial infarction-may be attributable to greater use of recommended therapies.

Activities of Daily Living↗

PubMed2000

Are beta-blockers effective in elderly patients who undergo coronary revascularization after acute myocardial infarction?

BACKGROUND: Although randomized clinical trials have demonstrated that beta-blocker therapy is effective in reducing mortality after acute myocardial infarction (AMI), many of these studies excluded patients who undergo coronary revascularization. However, the clinical practice guidelines established by the American College of Cardiology and the American Heart Association recommend that beta-blocker therapy be considered for patients who underwent successful revascularization after AMI. METHODS: Using data from the Cooperative Cardiovascular Project, we compared the initiation of beta-blocker therapy at discharge in patients aged 65 years or older who underwent coronary artery bypass surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) during their hospitalization for AMI with that of patients who did not undergo revascularization. We then examined whether beta-blocker therapy was associated with lower 1-year mortality between revascularized and nonrevascularized groups. RESULTS: After excluding patients with contraindications to beta-blocker therapy, 84 457 patients remained in the study sample. Of these, 8482 patients underwent CABG, and 13 997 patients underwent PTCA. After adjusting for demographic and clinical factors, we found that these patients were less likely to initiate beta-blocker therapy after CABG (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.41-0.47) or PTCA (OR, 0.89; 95% CI, 0.85-0.93) relative to the nonrevascularized group. After adjusting for potential confounders, beta-blockers were significantly associated with lower 1-year mortality in patients who underwent CABG (hazard ratio [HR], 0.70; 95% CI, 0.55-0.89) or PTCA (HR, 0.86; 95% CI, 0.74-1.00), similar to that of the non-revascularized group (HR, 0.83; 95% CI, 0.80-0.87). CONCLUSIONS: Therapy after AMI with beta-blockers appears to be as effective in reducing 1-year mortality for elderly patients who have undergone CABG or PTCA as for a nonrevascularized group. Our findings suggest that routine use of beta-blockers should be considered for patients who undergo revascularization after AMI.

Adrenergic beta-Antagonists↗

PubMed2000

Mental disorders and use of cardiovascular procedures after myocardial infarction.

CONTEXT: A number of studies have found race- and sex-based differences in rates of cardiovascular procedures in the United States. Similarly, mental disorders might be expected to be associated with lower rates of such procedures on the basis of clinical, socioeconomic, patient, and provider factors. OBJECTIVE: To assess whether having a comorbid mental disorder is associated with a lower likelihood of cardiac catheterization and/or revascularization after acute myocardial infarction. DESIGN: Retrospective cohort study using data from medical charts and administrative files as part of the Cooperative Cardiovascular Project. SETTING: Acute care nongovernmental hospitals in the United States. PATIENTS: National cohort of 113653 eligible patients 65 years or older who were hospitalized for confirmed acute myocardial infarction between February 1994 and July 1995. MAIN OUTCOME MEASURES: Likelihood of cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), or coronary artery bypass graft (CABG) surgery during the index hospitalization, comparing patients with and without mental disorders (classified as schizophrenia, major affective disorder, substance abuse/dependence disorder, or other mental disorder). RESULTS: Compared with the remainder of the sample, patients with any comorbid mental disorder (n = 5365; 4.7%) were significantly less likely to undergo PTCA (11.8% vs 16.8%; P<.001) or CABG (8.2% vs 12.6%; P<.001). After adjusting for demographic, clinical, hospital, and regional factors, individuals with mental disorders were 41% (for schizophrenia) to 78% (for substance use) as likely to undergo cardiac catheterization as those without mental disorders (P<.001 for all). Among those undergoing catheterization, rates of PTCA or CABG for patients with mental disorders were not significantly different from rates for patients without mental disorders (for those with any mental disorder, P = .12 for PTCA and P = .06 for CABG). In multivariate models, the 30-day mortality did not differ between patients with and without mental disorders. CONCLUSIONS: In this study, individuals with comorbid mental disorders were substantially less likely to undergo coronary revascularization procedures than those without mental disorders. Further research is needed to understand the degree to which patient and provider factors contribute to this difference and its implications for quality and long-term outcomes of care.

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PubMed2000

Predictors of readmission among elderly survivors of admission with heart failure.

BACKGROUND: Readmission rates for patients discharged with heart failure approach 50% within 6 months. Identifying factors to predict risk of readmission in these patients could help clinicians focus resource-intensive disease management efforts on the high-risk patients. METHODS: The study sample included patients 65 years of age or older with a principal discharge diagnosis of heart failure who were admitted to 18 Connecticut hospitals in 1994 and 1995. We obtained patient and clinical data from medical record review. We determined outcomes within 6 months after discharge, including all-cause readmission, heart failure-related readmission, and death, from the Medicare administrative database. We evaluated 2176 patients, including 1129 in the derivation cohort and 1047 in the validation cohort. RESULTS: Of 32 patient and clinical factors examined, 4 were found to be significantly associated with readmission in a multivariate model. They were prior admission within 1 year, prior heart failure, diabetes, and creatinine level >2.5 mg/dL at discharge. The event rates according to number of risk predictors were similar in the derivation and the validation sets for all outcomes. In the validation cohort, rates for all-cause readmission and combined readmission or death were 26% and 31% in patients with no risk predictors, 48% and 54% in patients with 1 or 2 risk predictors, and 59% and 65% in patients with 3 or all risk predictors. CONCLUSIONS: Few patient and clinical factors predict readmission within 6 months after discharge in elderly patients with heart failure. Although we were unable to identify a group of patients at very low risk, a group of high-risk patients were identified for whom resource-intensive interventions designed to improve outcomes may be justified.

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PubMed2000

Thrombolytic therapy in older patients.

OBJECTIVES: We compared outcomes following thrombolytic therapy and primary angioplasty with no reperfusion therapy in a population-based cohort of older patients presenting with acute myocardial infarction (AMI) and indications for acute reperfusion. BACKGROUND: Evidence supporting the efficacy of acute reperfusion (thrombolytic therapy or primary angioplasty) in the elderly with suspected AMI is not as strong as it is in younger groups. METHODS: From a national cohort of Medicare beneficiaries with AMI, we identified 37,983 patients age 65 or older who presented within 12 h of symptom onset with ST elevation or left bundle branch block. A total of 14,341 (37.8%) received thrombolytic therapy and 1,599 (4.2%) underwent primary angioplasty within 6 h of hospital arrival. RESULTS: After adjustment for demographic, clinical, hospital and physician factors, and co-interventions, thrombolytic therapy was not associated with a better 30-day survival (odds ratio [OR] 1.01; 95% confidence interval [CI]: 0.94 to 1.09) compared with no therapy, whereas primary angioplasty was (OR 0.79; 95% CI: 0.66 to 0.94). At one year, both thrombolytic therapy (OR 0.84; 95% CI: 0.79 to 0.89) and primary angioplasty (OR 0.71; 95% CI: 0.61 to 0.83) were associated with a survival benefit. CONCLUSIONS: In this national sample of older patients, those who received thrombolytic therapy or primary angioplasty had lower mortality at one year compared with those who did not receive a reperfusion strategy. However, only primary angioplasty was associated with better survival at 30 days. Our findings should heighten interest in further investigating the best approach to the treatment of older patients with suspected AMI and ST segment elevation or left bundle branch block.

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PubMed2000

Factors associated with delay in reperfusion therapy in elderly patients with acute myocardial infarction: analysis of the cooperative cardiovascular project.

BACKGROUND: Many elderly patients with an acute myocardial infarction (AMI) do not receive thrombolysis within 30 minutes of hospital arrival as recommended by the American College of Cardiology/American Heart Association Guidelines. We sought to identify factors associated with delay in administration of thrombolysis after arrival to the hospital in these patients and to determine whether this delay is associated with increased mortality rates. METHODS AND RESULTS: By using the Cooperative Cardiovascular Project database, we identified patients who received thrombolysis for an AMI. The patients were stratified into groups by time to thrombolysis after hospital arrival. Among a cohort of 17,379 patients, 22.2% received thrombolysis in the first 30 minutes after hospital arrival. Patients treated after the first 30 minutes were more likely to be older, be female, be diabetic, have a history of hypertension or heart failure, and have less marked ST elevation. They were also more likely to be admitted to smaller hospitals with a lower volume of AMIs and to hospitals without a cardiac catheterization laboratory. The 30-day mortality rate was significantly lower for patients treated within the first 30 minutes. After adjustments were made for clinical and hospital characteristics, delays in therapy beyond 30 and 90 minutes were associated with an increase in 1-year mortality rates of 9% and 27%, respectively, compared with delays for patients treated within 30 minutes. CONCLUSIONS: After hospital arrival, time to treatment with thrombolytic therapy is longer than recommended in a significant proportion of patients. Clinical characteristics and institutional factors are associated with the delay in treatment. The more rapid treatment of appropriate elderly patients with an AMI probably will reduce mortality rates.

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PubMed2000

Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation.

BACKGROUND AND PURPOSE: Antithrombotic therapy can prevent strokes and transient ischemic attacks (TIAs) in carefully selected patients who have chronic nonvalvular atrial fibrillation (NVAF). Our objectives were 3-fold: to document the use of warfarin and aspirin therapy in Missouri Medicare beneficiaries with chronic NVAF; to identify factors associated with warfarin and aspirin underuse; and to determine the association between prescription of warfarin and aspirin at hospital discharge and adverse outcomes in this elderly, frail population. METHODS: We linked chart reviews from all Missouri hospitals to Medicare claims data from 1993 to 1996. From chart reviews, we documented Medicare beneficiaries' demographic factors, comorbid conditions, and antithrombotic therapy prescribed at the time of hospital discharge. From Medicare claims, we determined the date of outcomes-death from any cause or hospitalization for an ischemic event (a stroke, a TIA, or a myocardial infarction). RESULTS: Only 328 (55%) of the 597 Medicare beneficiaries were prescribed antithrombotic therapy at hospital discharge: 34% received warfarin and 21% received aspirin. Advanced age, female gender, and rural residency predicted underuse of antithrombotic therapy. After controlling for these factors, as well as stroke risk factors and contraindications to anticoagulation, the prescription of warfarin was associated with a 24% relative risk reduction (RRR) in adverse outcomes (P=0.003). Prescription of aspirin was associated with a nonsignificant 5% RRR in these events (P=0.56). CONCLUSIONS: The underuse of antithrombotic therapy in Medicare beneficiaries who have NVAF is associated with measurable adverse outcomes. The benefit of warfarin therapy may extend to frail, elderly patients, a group that was excluded from randomized controlled trials. The role of antiplatelet therapy in this population deserves further study because many of these patients have relative contraindications to warfarin.

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PubMed2000

Intracranial hemorrhage associated with thrombolytic therapy for elderly patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project.

BACKGROUND AND PURPOSE: Intracranial hemorrhage is a serious complication of thrombolytic therapy for acute myocardial infarction, especially among the elderly, but little information exists on estimating risk. Better estimation of risk in individual patients may allow for withholding or using alternate therapies among those at highest risk. METHODS: To quantify the risk and identify predictors of intracranial hemorrhage associated with thrombolytic therapy, we performed a retrospective cohort study using data from medical charts. The study involved nearly all acute-care hospitals in the United States. All Medicare patients discharged with a principal diagnosis of acute myocardial infarction during a 9-month period in 1994 to 1995 were included. The main outcome measure was intracranial hemorrhage among those treated with thrombolytic therapy. RESULTS: The rate of intracranial hemorrhage was 1.43% (455 of 31 732). In a logistic model, age > or =75 years, female, black race, prior stroke, blood pressure > or =160 mm Hg, tissue plasminogen activator (versus other thrombolytic agent), excessive anticoagulation (international normalized ratio > or =4 or prothrombin time > or =24), and below median weight (< or =65 kg for women; < or =80 kg for men) were independent predictors. A risk stratification scale was developed on the basis of these factors: with none or 1 of the factors (n=6651), the rate of intracranial hemorrhage was 0.69%; with 2 factors (n=10 509), 1.02%; with 3 factors (n=9074), 1.63%; with 4 factors (n=4298), 2.49%; and with > or =5 factors (n=1071), 4. 11% (Mantel-Haenszel; P<0.001). CONCLUSIONS: The rate of intracranial hemorrhage in older patients after treatment with thrombolytic therapy exceeds 1%. Readily available factors can identify elderly patients with acute myocardial infarction at high and low risk for intracranial hemorrhage associated with thrombolytic therapy.

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PubMed1999

Early beta-blocker therapy for acute myocardial infarction in elderly patients.

BACKGROUND: Despite the evidence supporting the importance of early beta-blocker therapy, this intervention has received little attention as an indicator of quality of care. OBJECTIVES: To determine how often beta-blockers are administered as early treatment of acute myocardial infarction in patients 65 years of age or older, to identify predictors of the decision to use beta-blockers, and to evaluate the association between the early use of beta-blockers and in-hospital mortality. DESIGN: Observational study. SETTING: Nongovernment, acute care hospitals in the United States. PATIENTS: Medicare beneficiaries who were 65 years of age or older, were hospitalized with an acute myocardial infarction in 1994 and 1995, and did not have a contraindication to beta-blocker therapy. MEASUREMENTS: Medical chart review to obtain information about the use of beta-blockers, contraindications to these drugs, patient demographics, and clinical factors. RESULTS: Of the 58 165 patients (from a total of 4414 hospitals), 28 256 (49%) received early beta-blocker therapy. Patients with the highest risk for in-hospital death were the least likely to receive therapy. Patients who received beta-blockers had a lower in-hospital mortality rate than patients who did not receive beta-blockers (odds ratio, 0.81 [95% CI, 0.75 to 0.87]), even after adjustment for baseline differences in demographic, clinical, and treatment characteristics between the two groups. CONCLUSIONS: Early beta-blocker therapy was not used for 51% of elderly patients who were hospitalized with an acute myocardial infarction and did not have a contraindication to this therapy. Increasing the early use of beta-blockers for these patients would provide an excellent opportunity to improve their care and outcomes.

Adrenergic beta-Antagonists↗

PubMed1999

Beta-blocker therapy for secondary prevention of myocardial infarction in elderly diabetic patients. Results from the National Cooperative Cardiovascular Project.

OBJECTIVES: We sought to determine the use and association with one-year mortality of beta-blocker therapy for the treatment of acute myocardial infarction (AMI) in elderly diabetic patients and to examine whether beta-blocker therapy was associated with increased rates of hospital readmission for diabetic complications traditionally associated with beta-blockers. BACKGROUND: Although many randomized trials have demonstrated that beta-blockers are effective in reducing mortality after AMI, some experts are concerned about the use of beta-blockers in diabetic patients. Little is known about the effectiveness and complication rate of beta-blocker therapy after AMI for elderly diabetics in community practice settings. METHODS: We conducted a retrospective cohort study using the National Cooperative Cardiovascular Project, which contained data abstracted from hospital medical records of Medicare beneficiaries admitted with an AMI during 1994 and 1995. RESULTS: Out of 45,308 patients without contraindications to beta-blocker therapy, 7.4% were insulin-treated diabetics and 18.5% were non-insulin-treated diabetics. Beta-blockers were prescribed at discharge for 45% of insulin-treated diabetics, 48.1% of non-insulin-treated diabetics and 51% of nondiabetics (p < 0.001). After adjusting for demographic and clinical factors, diabetics continued to be less likely to receive beta-blockers at discharge compared with nondiabetics (odds ratio [OR] for insulin-treated diabetics 0.88, 95% confidence interval [CI] 0.82 to 0.96; OR for non-insulin-treated diabetics 0.93, 95% CI 0.88 to 0.98). After adjusting for potential confounders, beta-blockers were associated with lower one-year mortality for insulin-treated diabetics (hazard ratio [HR] = 0.87, 95% CI 0.72 to 1.07), non-insulin-treated diabetics (HR = 0.77, 95% CI 0.67 to 0.88) and nondiabetics (HR = 0.87, 95% CI 0.80 to 0.94). Beta-blocker therapy was not significantly associated with increased six-month readmission rates for diabetic complications among diabetics and nondiabetics. CONCLUSIONS: Beta-blockers are associated with a lower one-year mortality rate for elderly diabetic patients to a similar extent as for nondiabetics, without increased risk of readmission for diabetic complications. Increasing the use of beta-blockers in elderly diabetic patients represents an opportunity to improve the care and outcomes of these patients after AMI.

Adrenergic beta-Antagonists↗

PubMed1999

Comparing AMI mortality among hospitals in patients 65 years of age and older: evaluating methods of risk adjustment.

BACKGROUND: Interest in the reporting of risk-adjusted outcomes for patients with acute myocardial infarction is growing. A useful risk-adjustment model must balance parsimony and ease of data collection with predictive ability. METHODS AND RESULTS: From our analysis of 82 359 patients >/=65 years of age admitted with acute myocardial infarction to 2401 hospitals, we derived a parsimonious model that predicts 30-day mortality. The model was validated on a similar group of 78 699 patients from 2386 hospitals. Of the 73 candidate predictor variables examined, 7 variables describing patient characteristics on arrival were selected for inclusion in the final model: age, cardiac arrest, anterior or lateral location of myocardial infarction, systolic blood pressure, white blood cell count, serum creatinine, and congestive heart failure. The area under the receiver-operating characteristic curve for the final model was 0.77 in the derivation cohort and 0.77 in the validation cohort. The rankings of hospitals by performance (in deciles) with this model were most similar to a comprehensive 27-variable model based on medical chart review and least similar to models based on administrative billing codes. CONCLUSIONS: A simple 7-variable risk model performs as well as more complex models in comparing hospital outcomes for acute myocardial infarction. Although there is a continuing need to improve methods of risk adjustment, our results provide a basis for hospitals to develop a simple approach to compare outcomes.

Age Factors↗

PubMed1999

Do "America's Best Hospitals" perform better for acute myocardial infarction?

BACKGROUND: "America's Best Hospitals," an influential list published annually by U.S. News and World Report, assesses the quality of hospitals. It is not known whether patients admitted to hospitals ranked at the top in cardiology have lower short-term mortality from acute myocardial infarction than those admitted to other hospitals or whether differences in mortality are explained by differential use of recommended therapies. METHODS: Using data from the Cooperative Cardiovascular Project on 149,177 elderly Medicare beneficiaries with acute myocardial infarction in 1994 or 1995, we examined the care and outcomes of patients admitted to three types of hospitals: those ranked high in cardiology (top-ranked hospitals); hospitals not in the top rank that had on-site facilities for cardiac catheterization, coronary angioplasty, and bypass surgery (similarly equipped hospitals); and the remaining hospitals (non-similarly equipped hospitals). We compared 30-day mortality; the rates of use of aspirin, beta-blockers, and reperfusion; and the relation of differences in rates of therapy to short-term mortality. RESULTS: Admission to a top-ranked hospital was associated with lower adjusted 30-day mortality (odds ratio, 0.87; 95 percent confidence interval, 0.76 to 1.00; P=0.05 for top-ranked hospitals vs. the others). Among patients without contraindications to therapy, top-ranked hospitals had significantly higher rates of use of aspirin (96.2 percent, as compared with 88.6 percent for similarly equipped hospitals and 83.4 percent for non-similarly equipped hospitals; P<0.01) and beta-blockers (75.0 percent vs. 61.8 percent and 58.7 percent, P<0.01), but lower rates of reperfusion therapy (61.0 percent vs. 70.7 percent and 65.6 percent, P=0.03). The survival advantage associated with admission to top-ranked hospitals was less strong after we adjusted for factors including the use of aspirin and beta-blockers (odds ratio, 0.94; 95 percent confidence interval, 0.82 to 1.08; P=0.38). CONCLUSIONS: Admission to a hospital ranked high on the list of "America's Best Hospitals" was associated with lower 30-day mortality among elderly patients with acute myocardial infarction. A substantial portion of the survival advantage may be associated with these hospitals' higher rates of use of aspirin and beta-blocker therapy.

Adrenergic beta-Antagonists↗

PubMed1999

Sex differences in the clinical care and outcomes of congestive heart failure in the elderly.

BACKGROUND: There is evidence for sex differences in treatment and outcome of ischemic heart disease. However, little and conflicting data exist about sex differences in the care and outcome of elderly patients with heart failure. METHODS: We compared mortality rate, readmission, and use of selected treatments and procedures between women and men in a database of 2445 patients (1426 women) aged >/=65 admitted for heart failure to 18 Connecticut hospitals in 1994 and 1995. Demographic and clinical data were abstracted from the medical records. RESULTS: Women were older and more likely to have a history of hypertension whereas men more often had previous coronary heart disease. Women had more preserved left ventricular systolic function and higher systolic blood pressure on presentation than men. Treatments on day 1 (aspirin, angiotensin-converting enzyme [ACE] inhibitors, and diuretics), procedures during admission (assessment of left ventricular function, coronary angiography, and revascularization), and use of ACE inhibitors among ideal candidates at discharge were similar in men and women. Six-month rehospitalization rates were also similar. Although 30-day mortality rate did not differ between men and women, 6-month and 1-year mortality rates were lower in women after age adjustment (relative risk for 6-month death 0.81, 95% confidence interval, 0.68-0.95). In multivariable analysis, sex differences in mortality rate were reduced (relative risk 0.90, 95% confidence intervals, 0.75-1.08). History of hypertension, systolic blood pressure on admission, and left ventricular function mostly explained the observed sex differences in mortality rate. CONCLUSIONS: Female and male patients hospitalized for heart failure have a similar hospital course, treatment pattern, and readmission rates, but women live longer than men. When baseline differences are accounted for, the mortality risk of women and men becomes very similar.

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PubMed1999

Use of critical pathways to improve the care of patients with acute myocardial infarction.

PURPOSE: While critical pathways have become a popular strategy to improve the quality of care, their effectiveness is not well defined. The objective of this study was to investigate the effect of a critical pathway on processes of care and outcomes for Medicare patients admitted with acute myocardial infarction. SUBJECTS AND METHODS: A retrospective cross-sectional and longitudinal cohort study was made of Medicare patients aged 65 years and older hospitalized at 32 nonfederal Connecticut hospitals with a principal diagnosis of myocardial infarction during two periods: June 1, 1992, to February 28, 1993, and August 1, 1995, to November 30, 1995. The main endpoints of the cross-sectional analyses for the 1995 cohort were the proportion of patients without contraindications who received evidence-based medical therapies, length of stay, and 30-day mortality. Hospitals with specific critical pathways for patients with myocardial infarction were compared with hospitals without critical pathways. The main endpoints of the longitudinal analyses were change between 1992-93 and 1995 in the proportion of patients receiving evidence-based medical therapies, length of stay, and 30-day mortality. RESULTS: Ten hospitals developed critical pathways between 1992-93 and 1995. Eighteen of 22 nonpathway hospitals employed some combination of standard orders, multidisciplinary teams, or physician champions. Patients admitted to hospitals with critical pathways did not have greater use of aspirin within the first day, during hospitalization, or at discharge; beta-blockers within the first day or at discharge; reperfusion therapy; or use of angiotensin-converting enzyme inhibitors at discharge in 1995. The mean (+/- SD) length of stay in 1995 was not significantly different between pathway (7.8 +/- 4.6 days) versus nonpathway hospitals (8.0 +/- 4.2 days), and the change in length of stay between 1992-93 and 1995 was 2.2 days for pathway hospitals and 2.3 days for nonpathway hospitals. Patients admitted to critical pathway hospitals had lower 30-day mortality in 1995 (8.6% versus 11.6% for nonpathway hospitals, P = 0.10) and in 1992-93 (12.6% versus 13.8%, P = 0.39), but the differences were not statistically significant. CONCLUSIONS: Hospitals that instituted critical pathways did not have increased use of proven medical therapies, shorter lengths of stay, or reductions in mortality compared with other hospitals that commonly used alternative approaches to quality improvement among Medicare patients with myocardial infarction.

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PubMed1999

Correlation of the Agency for Health Care Policy and Research congestive heart failure admission guideline with mortality: peer review organization voluntary hospital association initiative to decrease events (PROVIDE) for congestive heart failure.

STUDY OBJECTIVE: We quantify patient risk as related to the presence or absence of the Agency for Health Care Policy and Research (AHCPR) congestive heart failure (CHF) hospital admission criteria. METHODS: This was a retrospective observational cohort study at 12 acute care hospitals examining consecutive patients with the final primary diagnosis of CHF. Trained record abstractors blinded to outcome extracted 386 data elements, including 6 AHCPR admission criteria: (1) pulmonary edema (determined by radiograph) or severe respiratory distress (respiration >40 breaths/min), (2) hypoxia (oxygen saturation <90%) not caused by pulmonary disease, (3) significant edema (>/=+2) or anasarca, (4) symptomatic hypotension (<90 mm Hg systolic blood pressure) or syncope, (5) CHF of recent onset, and (6) clinical evidence (chest pain) of myocardial ischemia. The association between admission criteria and mortality rate (30 days, 6 months, and 1 year) was quantified and risk adjusted by stepwise logistic regression analysis. RESULTS: Of the 1,674 patients with CHF, 1,340 (80%) were admitted to the hospital. Patients not admitted had a lower mortality rate than admitted patients (30-day mortality rate, 2.1% [95% confidence interval [CI] 0.6 to 3.6] versus 11.5% [95% CI 9.8 to 13.2]; odds ratio 0.20 [95% CI 0.09 to 0.45]). Two of the admission criteria did not correlate with a higher mortality rate: CHF of recent onset and myocardial ischemia. Excluding those 2 criteria, the number of admission criteria present correlated with the patient's probability of hospital admission (P <.001), length of hospital stay (P =.014), and 30-day mortality rate (P <.0001). When zero or 1 admission criteria was present, physician clinical judgment did distinguish patients less likely to die in the subsequent 30 days (1.5% [95% CI 0.2 to 2.8] sent home versus 10.2% [95% CI 8.5 to 11.9] admitted). When 2 or more admission criteria were present, physician clinical judgment did not distinguish patients less likely to die in the subsequent 30 days (18.2% [95% CI 0 to 42.0] sent home versus 19.4% [95% CI 13.6 to 25.2] admitted). CONCLUSION: Selected criteria of the AHCPR CHF admission guideline correlate with mortality rate. Combined with physician clinical judgment, they may be useful in the risk stratification of patients with CHF. Selected low-risk patients with CHF identified by the admission criteria who are presently managed in the acute care hospital may be candidates for outpatient management. [Graff L, Orledge J, Radford MJ, Wang Y, Petrillo M, Maag R: Correlation of the Agency for Health Care Policy and Research congestive heart failure admission guideline with mortality: Peer Review Organization Voluntary Hospital Association Initiative to Decrease Events (PROVIDE) for congestive heart failure.

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