Showing papers by "Harlan M. Krumholz published in 2001"
TL;DR: Blood transfusion is associated with a lower short-term mortality rate among elderly patients with acute myocardial infarction if the hematocrit on admission is 30.0 percent or lower and may be effective in patients with a hematOCrit as high as 33.1 percent or higher on admission.
Abstract: Background Anemia may have adverse effects in patients with coronary artery disease. However, the benefit of blood transfusion in elderly patients with acute myocardial infarction and various degrees of anemia is uncertain. Methods We conducted a retrospective study of data on 78,974 Medicare beneficiaries 65 years old or older who were hospitalized with acute myocardial infarction. Patients were categorized according to the hematocrit on admission (5.0 to 24.0 percent, 24.1 to 27.0 percent, 27.1 to 30.0 percent, 30.1 to 33.0 percent, 33.1 to 36.0 percent, 36.1 to 39.0 percent, or 39.1 to 48.0 percent), and data were evaluated to determine whether there was an association between the use of transfusion and 30-day mortality. Results Patients with lower hematocrit values on admission had higher 30-day mortality rates. Blood transfusion was associated with a reduction in 30-day mortality among patients whose hematocrit on admission fell into the categories ranging from 5.0 to 24.0 percent (adjusted odds rati...
915 citations
649 citations
TL;DR: There was a strong and graded association between the severity of depressive symptoms at baseline and the rate of the combined end point of either functional decline or death at six months.
534 citations
TL;DR: Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myocardial infarction, and the potential importance of improving patients' medical care as a step toward reducing their excess mortality is suggested.
Abstract: Background This study investigated whether differences in quality of medical care might explain a portion of the excess mortality associated with mental disorders in the year after myocardial infarction. Methods This study examined a national cohort of 88 241 Medicare patients 65 years and older who were hospitalized for clinically confirmed acute myocardial infarction. Proportional hazard models compared the association between mental disorders and mortality before and after adjusting 5 established quality indicators: reperfusion, aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling. All models adjusted for eligibility for each procedure, demographic characteristics, cardiac risk factors and history, admission characteristics, left ventricular function, hospital characteristics, and regional factors. Results After adjusting for the potential confounding factors, presence of any mental disorder was associated with a 19% increase in 1-year risk of mortality (hazard ratios [HR], 1.19; 95% confidence interval [CI], 1.04-1.36). After adding the 5 quality measures to the model, the association was no longer significant (HR, 1.10; 95% CI, 0.96-1.26). Similarly, while schizophrenia (HR, 1.34; 95% CI, 1.01-1.67) and major affective disorders (HR, 1.11; 95% CI, 1.02-1.20) were each initially associated with increased mortality, after adding the quality variables, neither schizophrenia (HR, 1.23; 95% CI, 0.86-1.60) nor major affective disorder (HR, 1.05; 95% CI, 0.87-1.23) remained a significant predictor. Conclusions Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myocardial infarction. The study suggests the potential importance of improving these patients' medical care as a step toward reducing their excess mortality.
479 citations
TL;DR: Federal guideline standards for ideal weight (BMI 18.7 to <25) may be overly restrictive as they apply to the elderly, and future guidelines should consider the evidence for specific age groups when establishing standards for healthy weight.
Abstract: Background The US Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults set the body mass index (BMI; weight in kilograms divided by the square of height in meters) of 25 as the upper limit of ideal weight for all adults regardless of age. However, the prognostic importance of overweight and obesity in elderly persons (≥65 years) is controversial. We sought to analyze the guidelines in the context of currently available evidence that is relevant to older adults. Methods We searched MEDLINE for all English-language studies of the association between BMI and all-cause or cardiovascular mortality or coronary heart disease events from January 1966 through October 1999. Additional pertinent articles were identified through bibliographies of the MEDLINE articles. We selected studies for detailed review if they reported on the association between BMI and mortality for nonhospitalized subjects who were 65 years or older and had been followed up for at least 3 years. We controlled for age, smoking, and baseline health status. Of the 444 screened articles, 13 were selected to assess the guidelines. We extracted information regarding publication year, study design, population, recruitment period, follow-up duration, number of subjects, sex, age range, inclusion and exclusion criteria, and statistical models, including variables and end points. Results These data do not support the BMI range of 25 to 27 as a risk factor for all-cause and cardiovascular mortality among elderly persons. The results were not substantially different for men and women. Most studies showed a negative or no association between BMI and all-cause mortality. Three studies indicated overweight (BMI ≥27) as a significant prognostic factor for all-cause and cardiovascular mortality among 65- to 74-year-olds, and one study showed a significant positive association between overweight (BMI ≥28) and all-cause mortality among those 75 years or older. Higher BMI values were consistent with a smaller relative mortality risk in elderly persons compared with young and middle-aged populations. Conclusions Federal guideline standards for ideal weight (BMI 18.7 to
443 citations
TL;DR: It is found that younger, but not older, women have higher mortality rates than men of similar age, and an increased long-term risk for death among younger women may well be masked by the combined examination of all age groups.
Abstract: Younger, but not older, women who survive hospitalization for myocardial infarction have a higher long-term mortality rate than men. This finding provides additional evidence that younger women who...
380 citations
TL;DR: Racial differences in the use of cardiac catheterization are similar among patients treated by white physicians and those treated by black physicians, suggesting that this pattern of care is independent of the race of the physician.
Abstract: Background Several studies have reported that black patients are less likely than white patients to undergo cardiac catheterization after acute myocardial infarction. The role of the race of the physician in this pattern is unknown. Methods We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for acute myocardial infarction in 1994 and 1995, to evaluate whether differences between black patients and white patients in the use of cardiac catheterization within 60 days after acute myocardial infarction varied according to the race of their attending physician. Results Our study cohort consisted of 35,676 white and 4039 black patients with acute myocardial infarction who were treated by 17,550 white and 588 black physicians. Black patients had lower rates of cardiac catheterization than white patients, regardless of whether their attending physician was white (rate of catheterization, 38.4 percent vs. 45.7 percent; P<0.001) or black (38.2 percent vs. 49....
302 citations
TL;DR: This study provides a context for understanding efforts to improve care in the hospital setting by describing a taxonomy for classifying and evaluating such efforts and suggests possible elements of successful efforts to increase β-blocker use for patients with AMI.
Abstract: ContextBased on evidence that β-blockers can reduce mortality in patients
with acute myocardial infarction (AMI), many hospitals have initiated performance
improvement efforts to increase prescription of β-blockers at discharge
Determination of the factors associated with such improvements may provide
guidance to hospitals that have been less successful in increasing β-blocker
useObjectivesTo identify factors that may influence the success of improvement efforts
to increase β-blocker use after AMI and to develop a taxonomy for classifying
such effortsDesign, Setting, and ParticipantsQualitative study in which data were gathered from in-depth interviews
conducted in March-June 2000 with 45 key physician, nursing, quality management,
and administrative participants at 8 US hospitals chosen to represent a range
of hospital sizes, geographic regions, and changes in β-blocker use rates
between October 1996 and September 1999Main Outcome MeasuresInitiatives, strategies, and approaches to improve care for patients
with AMIResultsThe interviews revealed 6 broad factors that characterized hospital-based
improvement efforts: goals of the efforts, administrative support, support
among clinicians, design and implementation of improvement initiatives, use
of data, and modifying variables Hospitals with greater improvements in β-blocker
use over time demonstrated 4 characteristics not found in hospitals with less
or no improvement: shared goals for improvement, substantial administrative
support, strong physician leadership advocating β-blocker use, and use
of credible data feedbackConclusionsThis study provides a context for understanding efforts to improve care
in the hospital setting by describing a taxonomy for classifying and evaluating
such efforts In addition, the study suggests possible elements of successful
efforts to increase β-blocker use for patients with AMI
290 citations
TL;DR: Older age was associated with a greater proportion of patients with functional limitations, heart failure, prior coronary disease and renal insufficiency and a lower proportion of male and diabetic patients and the effect of age persisted but was attenuated after adjustment for differences in patient characteristics.
247 citations
TL;DR: Depression is independently associated with a substantial increase in the risk of heart failure among older persons with isolated systolic hypertension, and this association does not appear to be mediated by myocardial infarction.
Abstract: Background: Investigators have shown that depression is associated with an increased risk of coronary heart disease in general and myocardial infarction in particular. However, it is unknown whether depression, independent of its association with myocardial infarction, is a risk factor for heart failure. Methods: This study examined whether depression was a predictor of incident heart failure among 4538 persons aged 60 years and older with isolated systolic hypertension who were enrolled in the Systolic Hypertension in the Elderly Program (SHEP). Depression was defined as a score of 16 or more at baseline on the Center for Epidemiological Studies Depression Scale (CES-D). The relationship between depression and heart failure was assessed using Cox proportional hazards regression. Results: The average follow-up was 4.5 years. Heart failure developed in 138 (3.2%) of 4317 nondepressed persons and in 18 (8.1%) of 221 depressed persons. After controlling for age; sex; race; history of myocardial infarction, diabetes, or angina; blood pressure; cholesterol levels; electrocardiographic abnormalities; smoking; disability; and SHEP treatment group, depressed persons had more than a 2-fold higher risk of developing heart failure compared with nondepressed persons (hazard ratio, 2.59; 95% confidence interval, 1.57-4.27; P,.001). After additional adjustment for the occurrence of myocardial infarction during follow-up, depressed persons remained at elevated risk of heart failure (hazard ratio, 2.82; 95% confidence interval, 1.714.67; P,.001). Conclusions: Depression is independently associated with a substantial increase in the risk of heart failure among older persons with isolated systolic hypertension. This association does not appear to be mediated by myocardial infarction. Arch Intern Med. 2001;161:1725-1730
211 citations
TL;DR: increasing levels of moderate alcohol consumption are associated with a decreasing risk of heart failure among older persons, independent of a number of confounding factors and does not appear to be entirely mediated by a reduction in MI risk.
Abstract: Results Increasing alcohol consumption in the moderate range was associated with decreasing heart failure rates. For persons consuming no alcohol (50.0%), 1 to 20 oz (40.2%), and 21 to 70 oz (9.8%) in the month prior to baseline, crude heart failure rates per 1000 years of follow-up were 16.1, 12.2, and 9.2, respectively. After adjustment for age, sex, race, education, angina, history of MI and diabetes, MI during follow-up, hypertension, pulse pressure, body mass index, and current smoking, the relative risks of heart failure for those consuming no alcohol, 1 to 20 oz, and 21 to 70 oz in the month prior to baseline were 1.00 (referent), 0.79 (95% confidence interval [CI], 0.60-1.02), and 0.53 (95% CI, 0.32-0.88) (P for trend=.02). Conclusions Increasing levels of moderate alcohol consumption are associated with a decreasing risk of heart failure among older persons. This association is independent of a number of confounding factors and does not appear to be entirely mediated by a reduction in MI risk. JAMA. 2001;285:1971-1977 www.jama.com
TL;DR: Beta-blocker therapy after AMI may be beneficial for COPD or asthma patients with mild disease and a survival benefit was not found for elderly AMI patients with more severe pulmonary disease.
TL;DR: White blood cell count within 24 h of admission for an AMI is a strong and independent predictor of in-hospital and 30-day mortality as well as in- hospital clinical events.
TL;DR: The delivery of appropriate care to adults with congenital heart disease (ACHD) is a largely unmet challenge in the U.S. and elsewhere and a structure and process for the organization and delivery of care is proposed.
TL;DR: It is demonstrated that a simple risk model can stratify older patients well by their risk of death one year after discharge for AMI.
TL;DR: Pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension, and is not significantly associated with HF or stroke in the placebo group, nor with incidence of CHD in either the placebo or treatment group.
Abstract: Pulse pressure has been related to higher risk of cardiovascular events in older persons. Isolated systolic hypertension is common among the elderly and is accompanied by elevated pulse pressure. Treatment of isolated systolic hypertension may further increase pulse pressure if diastolic pressure is lowered to a greater extent than systolic pressure. Little is known regarding pulse pressure as a predictor of cardiovascular outcomes in elderly persons with isolated systolic hypertension, and the influence of treatment on the pulse pressure effect. We assessed the relation between pulse pressure, measured throughout the follow-up period, and the incidence of coronary heart disease (CHD), heart failure (HF), and stroke in 4,632 participants in the Systolic Hypertension in the Elderly Program, a 5-year randomized, placebo-controlled clinical trial of treatment of isolated systolic hypertension in older adults. In the treatment group, a 10-mm Hg increase in pulse pressure was associated with a statistically significant 32% increase in risk of HF and a 24% increase in risk of stroke after controlling for systolic blood pressure and other known risk factors, as well as with a 23% increase in risk of HF and a 19% increase in risk of stroke after controlling for diastolic blood pressure and other risk factors. Pulse pressure was not significantly associated with HF or stroke in the placebo group, nor with incidence of CHD in either the placebo or treatment group. These results suggest that pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension.
TL;DR: Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician, suggesting that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.
Abstract: Context Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. Objective To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. Design, Setting, and Patients Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104231 Medicare feefor-service beneficiaries who were hospitalized in US acute care hospitals for an AMI
TL;DR: Typical symptoms are predictive of ACS in younger patients and less predictive in older patients, with younger patients being more likely than older patients to report chest symptoms.
Abstract: BACKGROUND Symptoms, a key element in the patient's decision to seek care, are critical to appropriate triage, and influence decisions to pursue further evaluation and initiation of treatment. Although many studies have described symptoms associated with acute coronary syndromes (ACS), few, if any, have examined symptom predictors of ACS and whether they differ by patients' age. OBJECTIVES To explore symptom predictors of ACS in younger ( or = 70 years) patients. To test the hypothesis that typical symptoms are predictive of ACS in younger patients, but are less predictive in older patients. METHOD Secondary analysis of observational data gathered on 531 patients presenting to the emergency department of a regional cardiac referral center in New England with symptoms suggestive of ACS. RESULTS Bivariate analyses revealed no symptoms significantly (p < .01) associated with ACS in older patients. In younger patients presence of chest symptoms and the total number of typical symptoms reported were significantly (p < .01) associated with ACS. After adjustment for age and gender, typical symptoms that were positive predictors of ACS in younger patients included chest symptoms (OR 2.37, 95% CI 1.32-4.27, p = .004) and arm pain (OR 1.78, 95% CI 1.03-3.09, p = .040). Additionally, the total number of typical symptoms reported (OR 1.68, 95% CI 1.31-2.15, p < .001) was a positive predictor of ACS in younger patients. The atypical symptom of fatigue (OR 2.52, 95% CI 1.10-5.81, p = .029) was a significant positive predictor of ACS, whereas dizziness/faintness (OR .50, 95% CI .26-.91, p = .024) was a significant negative predictor of ACS in younger patients. Logistic regression analysis using the entire sample revealed an interaction between age and number of typical symptoms indicating that younger patients had a 36% greater odds for ACS for each additional typical symptom present compared with older patients (OR 1.36, 95% CI 1.02-1.83, p = .038 for interaction between age and number of typical symptoms reported). The model with the interaction between age and chest symptoms revealed a borderline association (p = .10 for the interaction between age and chest symptoms), with younger patients being more likely than older patients to report chest symptoms. CONCLUSIONS Typical symptoms are predictive of ACS in younger patients and less predictive in older patients.
TL;DR: A dose-response relationship between higher doses and lower mortality is observed, and future studies will need to determine whether this association is causal.
TL;DR: In this paper, the authors found that increasing levels of moderate alcohol consumption are associated with a decreasing risk of heart failure among older persons, independent of a number of confounding factors and does not appear to be entirely mediated by a reduction in MI risk.
Abstract: Results Increasing alcohol consumption in the moderate range was associated with decreasing heart failure rates. For persons consuming no alcohol (50.0%), 1 to 20 oz (40.2%), and 21 to 70 oz (9.8%) in the month prior to baseline, crude heart failure rates per 1000 years of follow-up were 16.1, 12.2, and 9.2, respectively. After adjustment for age, sex, race, education, angina, history of MI and diabetes, MI during follow-up, hypertension, pulse pressure, body mass index, and current smoking, the relative risks of heart failure for those consuming no alcohol, 1 to 20 oz, and 21 to 70 oz in the month prior to baseline were 1.00 (referent), 0.79 (95% confidence interval [CI], 0.60-1.02), and 0.53 (95% CI, 0.32-0.88) (P for trend=.02). Conclusions Increasing levels of moderate alcohol consumption are associated with a decreasing risk of heart failure among older persons. This association is independent of a number of confounding factors and does not appear to be entirely mediated by a reduction in MI risk. JAMA. 2001;285:1971-1977 www.jama.com
TL;DR: A strong association between the use of aspirin and lower mortality in older patients with both heart failure and coronary artery disease is identified and the benefit of aspirin is consistent with that expected from randomized trials of other groups of patients with vascular disease.
Abstract: Objectives We sought (1) to determine how often aspirin is prescribed as a discharge medication among patients 65 years or older and hospitalized with both heart failure and coronary artery disease; (2) to identify patient characteristics associated with the decision to prescribe aspirin; and (3) to evaluate the association between aspirin prescription at discharge and 1-year survival. Methods We performed a retrospective cohort study of consecutive Medicare beneficiary survivors of a hospitalization for heart failure at 18 Connecticut hospitals (up to 200 hospitalizations per hospital) from 1994 to 1995. Results Among the 1110 patients in the study sample who did not have a contraindication to aspirin, aspirin therapy was prescribed for 456 (41%) at discharge. Patients who were prescribed aspirin at discharge had a lower 1-year mortality after discharge than patients who were not prescribed aspirin (odds ratio, 0.71; 95% confidence interval, 0.54-0.94), even after adjustment for baseline differences in demographic, clinical, and treatment characteristics between the 2 groups. Conclusions This study has identified a strong association between the use of aspirin and lower mortality in older patients with both heart failure and coronary artery disease. The benefit of aspirin is consistent with that expected from randomized trials of other groups of patients with vascular disease.
TL;DR: Even with a standardized implementation protocol, consistent results across institutions were not obtained when a clinical guideline for chest pain was implemented beyond its original setting, demonstrating the importance of understanding the local factors that influence guideline implementation.
Abstract: Article-at-a-Glance Rationale Although clinical guidelines have become increasingly popular as a means to reduce variation in care, increase efficiency, and improve patient outcomes, little is known about their effectiveness when they are transported outside their original setting, or about the factors that influence their successful translation into clinical practice. This study assessed whether a clinical guideline for low-risk chest pain patients, implemented with a standardized protocol, could be effectively transported to five hospital settings. Methods In a prospective, interventional trial, a standardized protocol for low-risk chest pain was implemented at each site. A total of 553 consecutively hospitalized low-risk patients with chest pain were enrolled during a 3-month baseline period followed by a standardized 6-month intervention period. During the intervention period, each patient's physician was contacted about eligibility for discharge within the specified 2-day guideline period. Guideline adherence (discharged within 48 hours) and postdischarge patient outcomes were measured. Local guideline champions were interviewed about their implementation experience. Results Guideline adherence during the intervention period ranged from 61% to 100%, with only two sites achieving significant increases of ≥ 10% from the baseline values. Guideline implementation did not affect clinical outcomes or patient satisfaction. Implementation factors such as preexisting hospital environment, implementation team staffing, and the rapid identification and resolution of barriers may influence the successful translation of guidelines into practice. Conclusions Even with a standardized implementation protocol, consistent results across institutions were not obtained when a clinical guideline for chest pain was implemented beyond its original setting. These findings demonstrate the importance of understanding the local factors that influence guideline implementation.
TL;DR: Do Existing Databases Answer Clinical Questions about …
Abstract: Reprinted with permission. Cheitlin MD, Gerstenblith G, and colleagues. Do Existing Databases Answer Clinical Questions about …
TL;DR: In this article, the authors 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.
TL;DR: The goal of this conference was to convene the principal investigators of key databases, and others in the field of geriatric cardiology, to address questions relating to the safety and effectiveness of treatment interventions for several cardiovascular conditions in the elderly.
Abstract: Executive summary
Most randomized, controlled trials evaluating the effectiveness of pharmaceutical, surgical, and device interventions for the prevention and treatment of cardiovascular disease have excluded patients over 75 years of age. Consequently, the use of these therapies in the older population is based on extrapolation of safety and effectiveness data obtained from younger patients. However, there are many registries and observational databases that contain large amounts of data on patients 75 years of age and older, as well as on younger patients. Although conclusions from such data are limited, it is possible to define the characteristics of patients who did well and those who did poorly.
The goal of this conference was to convene the principal investigators of these databases, and others in the field of geriatric cardiology, to address questions relating to the safety and effectiveness of treatment interventions for several cardiovascular conditions in the elderly. Seven committees discussed the following topics:
I.
Risk Factor Modification in the Elderly
II.
Chronic Heart Failure
III.
Chronic Coronary Artery Disease: Role of Revacularization
IV.
Acute Myocardial Infarction
V.
Valve Surgery in the Elderly
VI.
Electrophysiology, Pacemaker, and Automatic Internal Cardioverter Defibrillators Databases
VII.
VII. Carotid Endarterectomy in the Elderly
The chairs of these committees were asked to invite principal investigators of key databases in each of these areas to discuss and prepare a written statement concerning the available safety and efficacy data regarding interventions for these conditions and to identify and prioritize areas for future study. The ultimate goal is to stimulate further collaborative outcomes research in the elderly so as to place the treatment of cardiovascular disease on a more scientific basis.
TL;DR: There is a need to create innovative strategies to optimize the results in the older patient group and the observational studies undertaken with a rigorous methodology should be more frequently used to generate new knowledge and put the established knowledge into practice.
Abstract: In the field of Cardiology, older patients are the most frequently seen in clinical practice. In the USA, 60% of the patients hospitalized with acute myocardial infarction are 65 or older, as are almost 80% of the patients with heart failure. Population in industrialized countries is aging progressively and this fact is particularly pronounced in Spain, where, as calculated, the population pyramid will be inverted in the next 50 years and people over 65 will be a majority group. We know that age is a determinant factor in the prognosis of illness. With age, comorbidity increases, sex distribution changes, mortal complications have a higher incidence, and there are structural and mechanical functional changes. The specific characteristics of this group of patients and their enormous impact in clinical practice have led us to reconsider the medical focus used to approach this very important aspect of public health. Many of the larger randomized clinical trials have included a narrow spectrum of older patients despite the great relevance that the study of this group might have. On the other hand, the extrapolation of the results obtained in younger patients to older patients implies that the average results of the study may be assigned to a heterogeneous population, not taking into consideration the specificities of each subgroup. Therefore, there is a need to create innovative strategies to optimize the results in the older patient group. Even though clinical trials are a very useful tool to establish the effectiveness of a therapy, from a methodological point of view, they should include a higher number of older patients, and the observational studies undertaken with a rigorous methodology should be more frequently used to generate new knowledge and put the established knowledge info practice. Furthermore, observational studies can be particularly important in the development of strategies that allow the translation of information from the clinical trials to daily clinical practice.
TL;DR: The authors found that younger women who survive hospitalization for myocardial infarction have a higher long-term mortality rate than men than older women, but not older, women.
Abstract: Younger, but not older, women who survive hospitalization for myocardial infarction have a higher long-term mortality rate than men. This finding provides additional evidence that younger women who...
TL;DR: The reliability of pneumonia indicators is established and the need for reliability assessment at the quality indicator level, as well as at the component level, is underscored.
TL;DR: The third in a series reporting on Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure is presented in this paper, where baseline quality indicator rates from the National Heart Failure project are discussed.
Abstract: This column is the third in a series reporting on Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first paper1 outlined the history of HCFA quality improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. The second2 reported in more detail the structure of the national inpatient fee-for-service heart failure initiative, known as the National Heart Failure project. It described the development of the quality indicators, the sampling strategy for selecting charts to be reviewed, and the types of local efforts spurred by the project through the activities of each state's HCFA contractor peer review organization. This article discusses baseline quality indicator rates from the National Heart Failure project.