Showing papers by "Harlan M. Krumholz published in 2010"
1,797 citations
TL;DR: Among patients recently hospitalized for heart failure, telemonitoring did not improve outcomes, and the results indicate the importance of a thorough, independent evaluation of disease-management strategies before their adoption.
Abstract: Methods We randomly assigned 1653 patients who had recently been hospitalized for heart failure to undergo either telemonitoring (826 patients) or usual care (827 patients). Telemonitoring was accomplished by means of a telephone-based interactive voiceresponse system that collected daily information about symptoms and weight that was reviewed by the patients’ clinicians. The primary end point was readmission for any reason or death from any cause within 180 days after enrollment. Secondary end points included hospitalization for heart failure, number of days in the hospital, and number of hospitalizations. Results The median age of the patients was 61 years; 42.0% were female, and 39.0% were black. The telemonitoring group and the usual-care group did not differ significantly with respect to the primary end point, which occurred in 52.3% and 51.5% of patients, respectively (difference, 0.8 percentage points; 95% confidence interval [CI], −4.0 to 5.6; P = 0.75 by the chi-square test). Readmission for any reason occurred in 49.3% of patients in the telemonitoring group and 47.4% of patients in the usualcare group (difference, 1.9 percentage points; 95% CI, −3.0 to 6.7; P = 0.45 by the chi-square test). Death occurred in 11.1% of the telemonitoring group and 11.4% of the usual care group (difference, −0.2 percentage points; 95% CI, −3.3 to 2.8; P = 0.88 by the chi-square test). There were no significant differences between the two groups with respect to the secondary end points or the time to the primary end point or its components. No adverse events were reported. Conclusions Among patients recently hospitalized for heart failure, telemonitoring did not improve outcomes. The results indicate the importance of a thorough, independent evaluation of disease-management strategies before their adoption. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00303212.)
1,124 citations
TL;DR: For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in30-day readmission rates were observed.
Abstract: Context Whether decreases in the length of stay during the past decade for patients with heart failure (HF) may be associated with changes in outcomes is unknown. Objective To describe the temporal changes in length of stay, discharge disposition, and short-term outcomes among older patients hospitalized for HF. Design, Setting, and Participants An observational study of 6 955 461 Medicare fee-for-service hospitalizations for HF between 1993 and 2006, with a 30-day follow-up. Main Outcome Measures Length of hospital stay, in-patient and 30-day mortality, and 30-day readmission rates. Results Between 1993 and 2006, mean length of stay decreased from 8.81 days (95% confidence interval [CI], 8.79-8.83 days) to 6.33 days (95% CI, 6.32-6.34 days). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) in 1993 to 4.3% (95% CI, 4.2%-4.4%) in 2006, whereas 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Discharges to home or under home care service decreased from 74.0% to 66.9% and discharges to skilled nursing facilities increased from 13.0% to 19.9%. Thirty-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%; all P Conclusion For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in 30-day readmission rates were observed.
588 citations
TL;DR: National mean and RSRR distributions among Medicare beneficiaries discharged after hospitalization for heart failure have not changed in recent years, indicating that there was neither improvement in hospital readmission rates nor in hospital variations in rates over this time period.
Abstract: Background— In July 2009, Medicare began publicly reporting hospitals’ risk-standardized 30-day all-cause readmission rates (RSRRs) among fee-for-service beneficiaries discharged after hospitalization for heart failure from all the US acute care nonfederal hospitals. No recent national trends in RSRRs have been reported, and it is not known whether hospital-specific performance is improving or variation in performance is decreasing.Methods and Results— We used 2004–2006 Medicare administrative data to identify all fee-for-service beneficiaries admitted to a US acute care hospital for heart failure and discharged alive. We estimated mean annual RSRRs, a National Quality Forum-endorsed metric for quality, using 2-level hierarchical models that accounted for age, sex, and multiple comorbidities; variation in quality was estimated by the SD of the RSRRs. There were 570 996 distinct hospitalizations for heart failure in which the patient was discharged alive in 4728 hospitals in 2004, 544 550 in 4694 hospitals...
436 citations
TL;DR: Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality.
Abstract: BACKGROUND The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists. METHODS We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality. RESULTS There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia. CONCLUSIONS Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality.
288 citations
TL;DR: High RSRs persist for AMI and HF and clinically meaningful variation exists for RSMRs and RSRRs for both conditions and the results suggest continued opportunities for improvement in patient outcomes for HF and AMI.
Abstract: Background—Patient outcomes provide a critical perspective on quality of care. The Centers for Medicare and Medicaid Services (CMS) is publicly reporting hospital 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) for patients hospitalized with acute myocardial infarction (AMI) and heart failure (HF). We provide a national perspective on hospital performance for the 2010 release of these measures. Methods and Results—The hospital RSMRs and RSRRs are calculated from Medicare claims data for fee-for-service Medicare beneficiaries, 65 years or older, hospitalized with AMI or HF between July 1, 2006, and June 30, 2009. The rates are calculated using hierarchical logistic modeling to account for patient clustering, and are risk-adjusted for age, sex, and patient comorbidities. The median RSMR for AMI was 16.0% and for HF was 10.8%. Both measures had a wide range of hospital performance with an absolute 5.2% difference between hospitals in the 5th versus 95th percen...
169 citations
TL;DR: Cardiac imaging procedures lead to substantial radiation exposure and effective doses for many patients in the U.S. health care markets, and radiation exposure increased with age and were generally higher among men.
165 citations
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TL;DR: In this article, the authors provided a national perspective on hospital performance for 30-day risk-standardized mortality rates and riskstandardized readmission rates for patients hospitalized with acute myocardial infarction and heart failure.
Abstract: This article provides a national perspective on hospital performance for 30-day risk-standardized mortality rates and risk-standardized readmission rates for patients hospitalized with acute myocardial infarction and heart failure.
156 citations
TL;DR: AMI hospitalization rates fell markedly in the Medicare fee-for-service population between 2002 and 2007, however, black men and women appeared to have had a slower rate of decline compared with their white counterparts.
Abstract: Background— Amid recent efforts to reduce cardiovascular risk, whether rates of acute myocardial infarction (AMI) in the United States have declined for elderly patients is unknown. Methods and Res...
155 citations
TL;DR: Dementia and mobility disability were among the top predictors of short- and long-term mortality, withamong the top 6 largest absolute standardized estimates in the final model for 30-day mortality, and among theTop 7 largest standardized estimates for 5-year mortality.
141 citations
TL;DR: A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol-based target approaches and results were robust, even with assumptions favoring a treat-to-target approach.
Abstract: In their population-level simulation, Hayward and colleagues compared giving fixed doses of statins based on a person's 5-year risk for coronary artery disease (CAD) (“tailored treatment”) with app...
TL;DR: Percutaneous coronary intervention was associated with greater freedom from angina compared with medical therapy, but this benefit was largely attenuated in contemporary studies.
Abstract: In this meta-analysis of angina relief with percutaneous coronary intervention (PCI) versus medical therapy in patients with coronary artery disease, pooled data from 14 randomized trials 1 to 7 ye...
TL;DR: Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
Abstract: Context Little is known about how health insurance status affects decisions to seek care during emergency medical conditions such as acute myocardial infarction (AMI). Objective To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI. Design, Setting, and Patients Multicenter, prospective study using a registry of 3721 AMI patients enrolled between April 11, 2005, and December 31, 2008, at 24 US hospitals. Health insurance status was categorized as insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews. Main Outcome Measure Prehospital delay times (≤2 hours, >2-6 hours, or >6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models. Results Of 3721 patients, 2294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (P Conclusion Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
TL;DR: What does patient centeredness mean in the 21st century when medical care will inevitably entail more evidencebased decision making; electronic records with guidelinedrivendecisionsupports; and personalizedgenomic,proteomic, and metabolomic analyses driving decision making?
Abstract: PATIENT CENTEREDNESS HAS BECOME A DESIDERATUM OF health care reform. The Institute of Medicine (IOM) nameditasoneof its6coreattributesofahigh-quality healthcaresystem. TheCommonwealthFund’sCommission on a High Performance Health System, as well as the theory behind medical homes, emphasizes patient-centered care. These calls are the contemporary expression of Francis Peabody’s imperative that “the care of the patient is in caring for the patient . . . to engage deeply with patients . . . see the sorrows of severe illness, the hardships and resources of the family, and the circumstances of our patients’ lives.” But what does patient centeredness mean in the 21st century when medical care will inevitably entail more evidencebased decision making; electronic records with guidelinedrivendecisionsupports; andpersonalizedgenomic,proteomic, and metabolomic analyses driving decision making?
TL;DR: Same-hospitalreadmission rate is an unreliable and biased indicator of all-hospital readmission rate with limited value as a benchmark for quality of care processes.
Abstract: Background: The Centers for Medicare & Medicaid Services (CMS) readmission measure is based on all-cause readmissions to any hospital within 30 days of discharge. Whether a measure based on same-hospital readmission, an outcome that is easier for hospitals and some systems to track, could serve as a proxy for the all-hospital measure is not known. Objectives: Evaluate whether same-hospital readmission rate is a good surrogate for all-hospital readmission rate. Research Design: The study population was derived from the Medicare inpatient, outpatient, and carrier (physician) Standard Analytic Files. Thirty-day risk-standardized readmission rates (RSRRs) for heart failure (HF) for both all-hospital readmission and same-hospital readmission were assessed by using hierarchical logistic regression models. Subjects: The sample consisted of 501,234 hospitalizations in 4674 hospitals with at least 1 hospitalization. Measures: Thirty-day readmission was defined as occurrence of at least 1 hospitalization in any US acute care hospital for any cause within 30 days of discharge after an index hospitalization. Same-hospital readmission was considered if the patient was admitted to the hospital that produced the original discharge within 30 days. Results: Overall, 80.9% of all HF readmissions occurred in the same-hospital, whereas 19.1% of readmissions occurred in a different hospital. The mean difference between all- versus same-hospital RSRR was 4.7 ± 1.0%, ranging from 0.9% to 10.5% across these hospitals with 25th, 50th, and 75th percentiles of 4.1%, 4.7%, and 5.2%, respectively, and was variable across the range of average RSRR. Conclusion: Same-hospital readmission rate is an unreliable and biased indicator of all-hospital readmission rate with limited value as a benchmark for quality of care processes.
TL;DR: Among hospitalized patients with cardiac arrest, use of AEDs was not associated with improved survival, after matching patients to the individual units in each hospital where the cardiac arrest occurred, and with a propensity score analysis.
Abstract: Context Automated external defibrillators (AEDs) improve survival from out-of-hospital cardiac arrests, but data on their effectiveness in hospitalized patients are limited. Objective To evaluate the association between AED use and survival for in-hospital cardiac arrest. Design, Setting, and Patients Cohort study of 11 695 hospitalized patients with cardiac arrests between January 1, 2000, and August 26, 2008, at 204 US hospitals following the introduction of AEDs on general hospital wards. Main Outcome Measure Survival to hospital discharge by AED use, using multivariable hierarchical regression analyses to adjust for patient factors and hospital site. Results Of 11 695 patients, 9616 (82.2%) had nonshockable rhythms (asystole and pulseless electrical activity) and 2079 (17.8%) had shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia). AEDs were used in 4515 patients (38.6%). Overall, 2117 patients (18.1%) survived to hospital discharge. Within the entire study population, AED use was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16.3% vs 19.3%; adjusted rate ratio [RR], 0.85; 95% confidence interval [CI], 0.78-0.92; P Conclusion Among hospitalized patients with cardiac arrest, use of AEDs was not associated with improved survival.
TL;DR: VIRGO is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psychosocial risk factors.
Abstract: Background—Among individuals with ischemic heart disease, young women with an acute myocardial infarction (AMI) represent an extreme phenotype associated with an excess mortality risk. Although women younger than 55 years of age account for less than 5% of hospitalized AMI events, almost 16 000 deaths are reported annually in this group, making heart disease a leading killer of young women. Despite a higher risk of mortality compared with similarly aged men, young women have been the subject of few studies. Methods and Results—Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI. VIRGO will enroll 2000 women, 18 to 55 years of age, with AMI and a comparison cohort of 1000 men with AMI from more than 100 participating hospitals. The aims of the study are to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psy...
TL;DR: The focus of the 2010 report is to provide a state-of-the-art perspective on the construction, collection, and emerging directions of performance measurement as a means to improve healthcare quality.
Abstract: Since the publication of the initial American College of Cardiology (ACC)/American Heart Association (AHA) Methodology for the Selection and Creation of Performance Measures,1 there has been an explosion in the development and application of performance measures. Although initially envisioned as a means for physician-led quality-improvement efforts, performance measures have been primarily used as tools for accountability and performance-based reimbursement instead. Given the centrality of and experience with performance measures for quantifying healthcare quality, the American College of Cardiology Foundation (ACCF)/AHA Task Force on Performance Measures sought to update its methodology so that ongoing efforts to measure performance could benefit from emerging insights. The original methodology, proposed in 2005,1 remains the foundation for developing process performance measures. The principal recommendations of the 2005 report are summarized in Table 1. The 2010 report does not address detailed issues of analysis,3 pay for performance,4 or nonfinancial rewards for better performance5 because these topics have been addressed in other statements. The focus of the 2010 report is to provide a state-of-the-art perspective on the construction, collection, and emerging directions of performance measurement as a means to improve healthcare quality.
View this table:
Table 1.
ACCF/AHA Attributes of Performance Measures
Figure 1.
An overview of the steps in providing care by domain. Reprinted from Spertus et al.1
Performance measures that articulate discrete processes of care, as opposed to structural aspects of care or outcomes, are distinctly different from both clinical practice guidelines and appropriate use criteria because they represent a subset of the clinical guidelines for which the evidence is sufficiently strong: typically where the highest-quality evidence of benefit unequivocally exceeds risk (Class I recommendation, Level of Evidence: A),8 failure to provide the therapy to an eligible patient meaningfully reduces the likelihood that the patient will experience the best possible outcome. In this report, …
TL;DR: In this article, the authors present an approach for the review and approval of a document written by a writing committee of a writing workshop at the University of South Australia (USA).
Abstract: TABLE OF CONTENTSPreamble ……………………………….280 Introduction ………………………281 1.1. Methodology and Evidence Review … . .2811.2. Organization of the Writing Committee …2831.3. Document Review and Approval …… .2831.4. Scope of the Guideline ……………283 1.4.1. Critical Issues …………… . .2831.5. Glossary of Terms and
TL;DR: The focus of the 2010 report is to provide a state-of-the-art perspective on the construction, collection, and emerging directions of performance measurement as a means to improve healthcare quality.
TL;DR: Long delay times are common and have not changed over time for patients with non-STEMI and because patients cannot differentiate whether symptoms are due to STEMI or non- STEMI, early presentation is desirable in both instances.
Abstract: confidence interval [CI], 1.08-1.30), 0.91 (95% CI, 0.831.00), 0.77 (95% CI, 0.69-0.88), and 0.90 (95% CI, 0.811.00), respectively. Conclusions: Long delay times are common and have not changed over time for patients with non-STEMI. Becausepatientscannotdifferentiatewhethersymptomsare due to STEMI or non-STEMI, early presentation is desirable in both instances.
TL;DR: After the diabetes drug rosiglitazone was linked to an increased risk of MI, the FDA issued a boxed warning for the drug, which led to decreases in the rate of use, but some use persisted, and the level of use varied by location.
Abstract: After the diabetes drug rosiglitazone was linked to an increased risk of MI, the FDA issued a boxed warning for the drug. The warning led to decreases in the rate of rosiglitazone use, but some use persisted, and the level of use varied by location.
TL;DR: In conclusion, substantial variation in hospital outcomes for patients with AMI remains unexplained by measurements of hospital characteristics including SES patient profile.
Abstract: Hospitals vary by twofold in their hospital-specific 30-day risk-stratified mortality rates (RSMRs) for Medicare beneficiaries with acute myocardial infarction (AMI). However, we lack a comprehensive investigation of hospital characteristics associated with 30-day RSMRs and the degree to which the variation in 30-day RSMRs is accounted for by these characteristics, including the socioeconomic status (SES) profile of hospital patient populations. We conducted a cross-sectional national study of hospitals with ≥15 AMI discharges from July 1, 2005 to June 20, 2008. We estimated a multivariable weighted regression using Medicare claims data for hospital-specific 30-day RSMRs, American Hospital Association Survey of Hospitals for hospital characteristics, and the United States Census data reported by Neilsen Claritas, Inc., for zip-code level estimates of SES status. Analysis included 2,908 hospitals with 513,202 AMI discharges. Mean hospital 30-day RSMR was 16.5% (SD 1.7 percentage points). Our multivariable model explained 17.1% of the variation in hospital-specific 30-day RSMRs. Teaching status, number of hospital beds, AMI volume, cardiac facilities available, urban/rural location, geographic region, ownership type, and SES profile of patients were significantly (p
TL;DR: Absence of a USOC was associated with being untreated for hypertension and hypercholesterolemia, even among individuals with insurance, suggesting that efforts to improve chronic disease management should also facilitate access to a regular source of care.
01 May 2010
TL;DR: A blueprint for improving the dissemination of best practices by national quality improvement campaigns is proposed, to highlight the evidence base and relative simplicity of recommended practices and align campaigns with strategic goals of adopting organizations.
Abstract: Aimed at fostering the broad adoption of effective health care interventions, this report proposes a blueprint for improving the dissemination of best practices by national quality improvement campaigns. The blueprint's eight key strategies are to: 1) highlight the evidence base and relative simplicity of recommended practices; 2) align campaigns with strategic goals of adopting organizations; 3) increase recruitment by integrating opinion leaders into the enrollment process; 4) form a coalition of credible campaign sponsors; 5) generate a threshold of participating organizations that maximizes network exchanges; 6) develop practical implementation tools and guides for key stakeholder groups; 7) create networks to foster learning opportunities; and 8) incorporate monitoring and evaluation of milestones and goals. The impact of quality campaigns also depends on contextual factors, including the nature of the innovation itself, external environmental incentives, and features of adopting organizations.
TL;DR: To determine the relationship between admission systolic blood pressure (SBP) and mortality in older patients hospitalized for heart failure (HF) and among various subgroups, a large number of patients were diagnosed with HF.
Abstract: Aims
To determine the relationship between admission systolic blood pressure (SBP) and mortality in older patients hospitalized for heart failure (HF) and among various subgroups.
Methods and results
We evaluated the independent association between initial SBP and 30-day and 1-year mortality, and potential interactions by age, gender, race, previous hypertension, and left ventricular dysfunction using multivariable logistic regression in the National Heart Failure Project, a database of Medicare patients >65 years old recruited from 1998 through 2001. Among 56 942 patients, mean admission SBP was 147.0 ± 92.3 mmHg, 15% presenting with SBP >180 mmHg. Systolic blood pressure showed an inverse relationship with 30-day and 1-year mortality rates in all subgroups analysed. Using admission SBP of 120–149 mmHg as the reference, the adjusted odds ratios (95% confidence intervals) for 1-year mortality were 2.18 (1.77–2.69) for SBP <90 mmHg, 1.57 (1.47–1.69) for SBP 90–119 mmHg, 0.71 (0.67–0.76) for SBP 150–179 mmHg, 0.63 (0.57–0.68) for SBP 180–209 mmHg, and 0.51 (0.44–0.59) for SBP ≥210 mmHg.
Conclusion
Higher SBP on admission is associated with significant lower 30-day and 1-year mortality in patients hospitalized for HF. The relationship is strong, graded, independent of other clinical factors and consistent among subgroups.
TL;DR: Ad hoc PCI provides less opportunity for patients and their physicians to thoughtfully consider a range of clinically equivalent treatment options after the coronary anatomy is known, and highlights the potential hazards of merging diagnostic tests and therapeutic procedures.
Abstract: AD HOC IS A LATIN PHRASE, LITERALLY MEANING “FOR this.” It typically implies a solution designed for a particular problem or task—that is, something not broadly generalizable. When the term was introduced more than 2 decades ago to cardiologists in the context of percutaneous coronary intervention (PCI), it suggested the unique circumstances that justified combining coronary angiography and PCI into the same setting. This approach was uncommon in the early years of PCI when most procedures were performed days to weeks after the initial diagnostic test. Initially, the hesitation to perform ad hoc PCI resulted from technical challenges. Older imaging systems limited the ability of cardiologists to rapidly and accurately review angiograms. In addition, operating rooms and cardiac surgeons had to be on stand-by whenever PCI was performed because of the threat of acute closure of the coronary artery and other life-threatening complications. Over the years, these issues have largely been resolved, however, by advances in imaging systems and procedural techniques, such as the introduction of coronary stents. As a result, ad hoc PCI is now routinely performed, and its use has increased considerably in recent years. In New York state, for example, more than 80% of PCIs are currently performed ad hoc and, in many cases, this makes perfect sense. During acute coronary syndromes, including STelevation myocardial infarction, the ability to perform PCI immediately after coronary angiography saves lives and improves outcomes. In elective cases, ad hoc PCI avoids the cost and inconvenience associated with a second procedure and arterial puncture. Yet now that it is clear that ad hoc PCI can be performed, a more fundamental question arises: Should it? Recent clinical trials, such as COURAGE and SYNTAX, have fueled concerns about the widespread use of PCI. For many patients with stable coronary disease, PCI does not improve survival when compared with optimal medical therapy. For patients with more severe disease for whom coronary artery bypass grafting is considered, PCI does as well as surgery for 1-year survival, but leads to more repeat procedures and the need for prolonged antiplatelet medications. Although findings from these trials are largely undisputed, the use of ad hoc PCI raises challenges for incorporating their lessons into routine practice. Specifically, ad hoc PCI provides less opportunity for patients and their physicians to thoughtfully consider a range of clinically equivalent treatment options after the coronary anatomy is known. By making the diagnostic test an automatic gateway to the therapeutic procedure, pressure is placed on the cardiologist and patient to make immediate decisions that may favor PCI even in elective settings. In one study, for instance, patients with stronger indications for coronary artery bypass grafting were more likely to be recommended surgery after coronary angiography when it was performed at hospitals without the ability to perform ad hoc PCI. At the other extreme are ongoing concerns about how frequently PCI is performed when medical therapy appears suitable. Part of this results from the well-described “oculo-stenotic” reflex, ie, the tendency to treat blockages, even when clinically silent, based on benefits attributed to PCI that are not supported by the literature. There are other issues to consider as well. In their seminal article, Myler and colleagues highlighted 2 specific challenges with ad hoc PCI. First, they noted that obtaining adequate informed consent for ad hoc PCI may be difficult. Patients typically receive conscious sedation during coronary angiography, prompting most centers to adopt an approach in which risks of PCI are simultaneously discussed before the coronary anatomy is known. However, risks of PCI differ substantially from the diagnostic test and may vary from patient to patient based on lesion characteristics and location. A generic consent obtained prior to coronary angiography fails to capture these subtleties. In addition, Myler et al pointed out possible concerns about the ethics of self-referral. At its core, this issue highlights the potential hazards of merging diagnostic tests (ie, coronary angiography) and therapeutic procedures (ie, PCI) into the same setting. If the cardiologist who performs and interprets the coronary angiogram will also perform the PCI,
TL;DR: In older patients with diabetes after AMI, discontinuation of antihyperglycemic therapy is common and associated with higher mortality rates.
Abstract: Background— Patients with diabetes are frequently admitted for acute myocardial infarction (AMI) on antihyperglycemic agents but may be discharged without glucose-lowering therapy. We examined the frequency of this practice and evaluated the associated outcomes of readmission and mortality. Methods and Results— We conducted a retrospective study of 24 953 Medicare beneficiaries with diabetes discharged after hospitalization for AMI. We examined the frequency of discontinuation of antihyperglycemic agents on discharge among those patients admitted on a diabetic regimen. The independent association between discharge on versus off antihyperglycemic therapy and outcomes at 1 year was assessed in multivariable Cox proportional hazards models, adjusting for patient, physician, and hospital variables. The primary outcome was time to death within 1 year of discharge; secondary outcomes were time to first rehospitalization within 1 year for AMI, heart failure, and all causes. There were 8751 patients admitted on a...
TL;DR: The magnitude of benefit from comprehensively regionalizing AMI care to PCI hospitals appears to vary greatly across HRRs, and these findings support a tailored regionalization policy that targets areas with the greatest outcome differences between PCI and local non-PCI hospitals.
Abstract: Background There are increasing calls for regionalization of acute myocardial infarction (AMI) care in the United States to hospitals with the capacity to perform percutaneous coronary intervention (PCI). Whether regionalization will improve outcomes depends in part on the magnitude of existing differences in outcomes between PCI and non-PCI hospitals within the same health care region. Methods A 100% sample of claims from Medicare fee-for-service beneficiaries 65 years or older hospitalized for AMI between January 1, 2004, and December 31, 2006, was used to calculate hospital-level, 30-day risk-standardized mortality rates (RSMRs). The RSMRs between PCI and local non-PCI hospitals were compared within local health care regions defined by hospital referral regions (HRRs). Results A total of 523 119 AMI patients was admitted to 1382 PCI hospitals, and 194 909 AMI patients were admitted to 2491 non-PCI hospitals in 295 HRRs with at least 1 PCI and 1 non-PCI hospital. Although PCI hospitals had lower RSMRs than non-PCI hospitals (mean, 16.1% vs 16.9%; P Conclusions The magnitude of benefit from comprehensively regionalizing AMI care to PCI hospitals appears to vary greatly across HRRs. These findings support a tailored regionalization policy that targets areas with the greatest outcome differences between PCI and local non-PCI hospitals.
TL;DR: Krumholz and Hayward as mentioned in this paper argue that preventive cardiology should be based as much as possible on strategies that are known to improve patient outcomes rather than focusing on biomarkers.
Abstract: Harlan Krumholz and Rodney Hayward argue that preventive cardiology should be based as much as possible on strategies that are known to improve patient outcomes rather than focusing on biomarkers