Showing papers by "Harlan M. Krumholz published in 2013"
TL;DR: The 2017-18 FAHA/FACC/FAHA Education and Research Grants will be focused on advancing the profession’s understanding of central nervous system disorders and the management of post-traumatic stress disorder.
4,556 citations
TL;DR: This guideline makes more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference (e.g. in PubMed), and more liberalUse of summaryRecommendations.
Abstract: s in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference. In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the IOM cited ACCF/AHA practice guidelines as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated. The recommendations in this guideline are considered current until they are superseded by a focused update or the fulltext guideline is revised. The reader is encouraged to consult the full-text guideline for additional guidance and details about the care of the patient with ST-elevation myocardial infarction (STEMI), because the Executive Summary contains only the recommendations. Guidelines are official policy of both the ACCF and AHA. Jeffrey L. Anderson, MD, FACC, FAHA Chair, ACCF/AHA Task Force on Practice Guidelines O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 533
2,132 citations
TL;DR: The 2017-18 FAHA/FACC/FAHA Education and Research Grants will be focused on advancing the profession’s understanding of central nervous system disorders and the management of post-traumatic stress disorder.
1,681 citations
TL;DR: Patients who were recently hospitalized experience a period of generalized risk for myriad adverse health events, characterized as a post-hospital syndrome, an acquired condition of vulnerability not necessarily linked to the original illness.
Abstract: Patients who were recently hospitalized experience a period of generalized risk for myriad adverse health events. Their condition may be characterized as a post-hospital syndrome, an acquired condition of vulnerability not necessarily linked to the original illness.
958 citations
TL;DR: Among Medicare fee-for-service beneficiaries hospitalized for HF, acute MI, or pneumonia, 30-day readmissions were frequent throughout the month after hospitalization and resulted from a similar spectrum of readmission diagnoses regardless of age, sex, race, or time after discharge.
Abstract: Importance To better guide strategies intended to reduce high rates of 30-day readmission after hospitalization for heart failure (HF), acute myocardial infarction (MI), or pneumonia, further information is needed about readmission diagnoses, readmission timing, and the relationship of both to patient age, sex, and race. Objective To examine readmission diagnoses and timing among Medicare beneficiaries readmitted within 30 days after hospitalization for HF, acute MI, or pneumonia. Design, Setting, and Patients We analyzed 2007-2009 Medicare fee-for-service claims data to identify patterns of 30-day readmission by patient demographic characteristics and time after hospitalization for HF, acute MI, or pneumonia. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare & Medicaid Services' Condition Categories. Readmission timing was determined by day after discharge. Main Outcome Measures We examined the percentage of 30-day readmissions occurring on each day (0-30) after discharge; the most common readmission diagnoses occurring during cumulative periods (days 0-3, 0-7, 0-15, and 0-30) and consecutive periods (days 0-3, 4-7, 8-15, and 16-30) after hospitalization; median time to readmission for common readmission diagnoses; and the relationship between patient demographic characteristics and readmission diagnoses and timing. Results From 2007 through 2009, we identified 329 308 30-day readmissions after 1 330 157 HF hospitalizations (24.8% readmitted), 108 992 30-day readmissions after 548 834 acute MI hospitalizations (19.9% readmitted), and 214 239 30-day readmissions after 1 168 624 pneumonia hospitalizations (18.3% readmitted). The proportion of patients readmitted for the same condition was 35.2% after the index HF hospitalization, 10.0% after the index acute MI hospitalization, and 22.4% after the index pneumonia hospitalization. Of all readmissions within 30 days of hospitalization, the majority occurred within 15 days of hospitalization: 61.0%, HF cohort; 67.6%, acute MI cohort; and 62.6%, pneumonia cohort. The diverse spectrum of readmission diagnoses was largely similar in both cumulative and consecutive periods after discharge. Median time to 30-day readmission was 12 days for patients initially hospitalized for HF, 10 days for patients initially hospitalized for acute MI, and 12 days for patients initially hospitalized for pneumonia and was comparable across common readmission diagnoses. Neither readmission diagnoses nor timing substantively varied by age, sex, or race. Conclusion and Relevance Among Medicare fee-for-service beneficiaries hospitalized for HF, acute MI, or pneumonia, 30-day readmissions were frequent throughout the month after hospitalization and resulted from a similar spectrum of readmission diagnoses regardless of age, sex, race, or time after discharge.
910 citations
TL;DR: WRITING COMMITTEE MEMBERS* Patrick T. O’Gara, MD, FACC, FAHA, Chair†; Frederick G. Kushner,MD, F ACC,FAHA, FSCAI, Vice Chair*†; Deborah D. Kushner-Kushner, PhD, MBA, FACP, FAha‡; Mina K. Linderbaum, MS, CNP-BC.
Abstract: WRITING COMMITTEE MEMBERS* Patrick T. O’Gara, MD, FACC, FAHA, Chair†; Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair*†; Deborah D. Ascheim, MD, FACC†; Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA‡; Mina K. Chung, MD, FACC, FAHA*†; James A. de Lemos, MD, FACC*†; Steven M. Ettinger, MD, FACC*§; James C. Fang, MD, FACC, FAHA*†; Francis M. Fesmire, MD, FACEP* ¶; Barry A. Franklin, PHD, FAHA†; Christopher B. Granger, MD, FACC, FAHA*†; Harlan M. Krumholz, MD, SM, FACC, FAHA†; Jane A. Linderbaum, MS, CNP-BC†; David A. Morrow, MD, MPH, FACC, FAHA*†; L. Kristin Newby, MD, MHS, FACC, FAHA*†; Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP†; Narith Ou, PharmD†; Martha J. Radford, MD, FACC, FAHA†; Jacqueline E. Tamis-Holland, MD, FACC†; Carl L. Tommaso, MD, FACC, FAHA, FSCAI#; Cynthia M. Tracy, MD, FACC, FAHA†; Y. Joseph Woo, MD, FACC, FAHA†; David X. Zhao, MD, FACC*†
535 citations
TL;DR: The magnitude of the effects was modest with individual strategies associated with less than half a percentage point reduction in RSRRs; however, hospitals that implemented more strategies had significantly lower RSRRS (reduction of 0.34 percentage point for each additional strategy).
Abstract: Background—Reducing hospital readmission rates is a national priority; however, evidence about hospital strategies that are associated with lower readmission rates is limited. We sought to identify hospital strategies that were associated with lower readmission rates for patients with heart failure. Methods and Results—Using data from a Web-based survey of hospitals participating in national quality initiatives to reduce readmission (n=599; 91% response rate) during 2010–2011, we constructed a multivariable linear regression model, weighted by hospital volume, to determine strategies independently associated with risk-standardized 30-day readmission rates (RSRRs) adjusted for hospital teaching status, geographic location, and number of staffed beds. Strategies that were associated with lower hospital RSRRs included the following: (1) partnering with community physicians or physician groups to reduce readmission (0.33% percentage point lower RSRRs; P=0.017), (2) partnering with local hospitals to reduce re...
338 citations
TL;DR: Although there was a significant negative linear relationship between RSMRs and RSRRs for heart failure, the shared variance between them was only 2.9% and the results were similar for subgroups defined by hospital characteristics.
Abstract: Importance The Centers for Medicare & Medicaid Services publicly reports hospital 30-day, all-cause, risk-standardized mortality rates (RSMRs) and 30-day, all-cause, risk-standardized readmission rates (RSRRs) for acute myocardial infarction, heart failure, and pneumonia. The evaluation of hospital performance as measured by RSMRs and RSRRs has not been well characterized. Objective To determine the relationship between hospital RSMRs and RSRRs overall and within subgroups defined by hospital characteristics. Design, Setting, and Participants We studied Medicare fee-for-service beneficiaries discharged with acute myocardial infarction, heart failure, or pneumonia between July 1, 2005, and June 30, 2008 (4506 hospitals for acute myocardial infarction, 4767 hospitals for heart failure, and 4811 hospitals for pneumonia). We quantified the correlation between hospital RSMRs and RSRRs using weighted linear correlation; evaluated correlations in groups defined by hospital characteristics; and determined the proportion of hospitals with better and worse performance on both measures. Main Outcome Measures Hospital 30-day RSMRs and RSRRs. Results Mean RSMRs and RSRRs, respectively, were 16.60% and 19.94% for acute myocardial infarction, 11.17% and 24.56% for heart failure, and 11.64% and 18.22% for pneumonia. The correlations between RSMRs and RSRRs were 0.03 (95% CI, −0.002 to 0.06) for acute myocardial infarction, −0.17 (95% CI, −0.20 to −0.14) for heart failure, and 0.002 (95% CI, −0.03 to 0.03) for pneumonia. The results were similar for subgroups defined by hospital characteristics. Although there was a significant negative linear relationship between RSMRs and RSRRs for heart failure, the shared variance between them was only 2.9% (r 2 = 0.029), with the correlation most prominent for hospitals with RSMR Conclusion and Relevance Risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.
330 citations
TL;DR: Severe hypoglycemia was common among patients with type 2 diabetes across all levels of glycemic control and tended to be higher in patients with either near-normal glycemia or very poor gly glucose control.
Abstract: OBJECTIVE We examined the association between HbA 1c level and self-reported severe hypoglycemia in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Type 2 diabetic patients in a large, integrated healthcare system, who were 30–77 years of age and treated with glucose-lowering therapy, were asked about severe hypoglycemia requiring assistance in the year prior to the Diabetes Study of Northern California survey conducted in 2005–2006 (62% response rate). The main exposure of interest was the last HbA 1c level collected in the year preceding the observation period. Poisson regression models adjusted for selected demographic and clinical variables were specified to evaluate the relative risk (RR) of severe hypoglycemia across HbA 1c levels. We also tested whether the HbA 1c -hypoglycemia association differed across potential effect modifiers (age, diabetes duration, and category of diabetes medication). RESULTS Among 9,094 eligible survey respondents (mean age 59.5 ± 9.8 years, mean HbA 1c 7.5 ± 1.5%), 985 (10.8%) reported experiencing severe hypoglycemia. Across HbA 1c levels, rates of hypoglycemia were 9.3–13.8%. Compared with those with HbA 1c of 7–7.9%, the RR of hypoglycemia was 1.25 (95% CI 0.99–1.57), 1.01 (0.87–1.18), 0.99 (0.82–1.20), and 1.16 (0.97–1.38) among those with HbA 1c 1c -hypoglycemia relationship. CONCLUSIONS Severe hypoglycemia was common among patients with type 2 diabetes across all levels of glycemic control. Risk tended to be higher in patients with either near-normal glycemia or very poor glycemic control.
200 citations
TL;DR: Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear, however, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor.
Abstract: Importance With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding. Objective To conduct a multifaceted evaluation of transitional care from a patient-centered perspective. Design Prospective observational cohort study, May 2009 through April 2010. Setting Urban, academic medical center. Participants Patients 65 years and older discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. Main Outcomes and Measures Discharge practices, including presence of follow-up appointment and patient-friendly discharge instructions; patient understanding of diagnosis and follow-up appointment; and patient perceptions of and satisfaction with discharge care. Results The 395 enrolled patients (66.7% of those eligible) had a mean age of 77.2 years. Although 349 patients (95.6%) reported understanding the reason they had been in the hospital, only 218 patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews. Discharge instructions routinely included symptoms to watch out for (98.4%), activity instructions (97.3%), and diet advice (89.7%) in lay language; however, 99 written reasons for hospitalization (26.3%) did not use language likely to be intelligible to patients. Of the 123 patients (32.6%) discharged with a scheduled primary care or cardiology appointment, 54 (43.9%) accurately recalled details of either appointment. During postdischarge interviews, 118 patients (30.0%) reported receiving less than 1 day’s advance notice of discharge, and 246 (66.1%) reported that staff asked whether they would have the support they needed at home before discharge. Conclusions and Relevance Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear. However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor. Patient perceptions and written documentation do not adequately reflect patient understanding of discharge care.
195 citations
TL;DR: Applications of mixed methods in biomedical and health services research are described and a concise overview of key principles to facilitate best practices are provided to facilitate investigators interested in using these methods.
Abstract: Mixed methods studies, in which qualitative and quantitative methods are combined in a single program of inquiry, can be valuable in biomedical and health services research, where the complementary strengths of each approach can yield greater insight into complex phenomena than either approach alone. Although interest in mixed methods is growing among science funders and investigators, written guidance on how to conduct and assess rigorous mixed methods studies is not readily accessible to the general readership of peer-reviewed biomedical and health services journals. Furthermore, existing guidelines for publishing mixed methods studies are not well known or applied by researchers and journal editors. Accordingly, this paper is intended to serve as a concise, practical resource for readers interested in core principles and practices of mixed methods research. We briefly describe mixed methods approaches and present illustrations from published biomedical and health services literature, including in cardiovascular care, summarize standards for the design and reporting of these studies, and highlight four central considerations for investigators interested in using these methods.
TL;DR: In a national sample of Medicare beneficiaries, HF hospitalization after AMI decreased from 1998 to 2010, which may indicate improvements in the management of AMI, and survival after HF following AMI remains poor, and has worsened from 2007 to2010, demonstrating that challenges still remain for the treatment of this high-risk condition after AMi.
Abstract: Background—Previous studies have reported conflicting findings regarding how the incidence of heart failure (HF) after acute myocardial infarction (AMI) has changed over time, and data on contempor...
TL;DR: In this paper, Anderson-Gill regression was used to identify risk factors for the occurrence of all-cause hospital admissions among older persons after heart failure diagnosis, and to determine whether geriatric conditions would emerge as independent risk factors when evaluated in the context of other relevant clinical data.
TL;DR: Between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially, and Medicare data preclude the identification of the causes of the findings and the trends in procedure rates and outcomes cannot be causally linked.
Abstract: Importance There is a need to describe contemporary outcomes of surgical aortic valve replacement (AVR) as the population ages and transcatheter options emerge Objective To assess procedure rates and outcomes of surgical AVR over time Design, Setting, and Participants A serial cross-sectional cohort study of 82 755 924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011 Main Outcomes and Measures Procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates Results The AVR procedure rate increased by 19 (95% CI, 19-20) procedures per 100 000 person-years over the 12-year period ( P Conclusions and Relevance Between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially Medicare data preclude the identification of the causes of the findings and the trends in procedure rates and outcomes cannot be causally linked Nevertheless, the findings may be a useful benchmark for outcomes with surgical AVR for older patients eligible for surgery considering newer transcatheter treatments
TL;DR: Exposure to higher levels of income inequality was associated with increased risk of readmission but not mortality among patients hospitalized with acute myocardial infarction, heart failure, and pneumonia.
Abstract: Objectives To examine the association between income inequality and the risk of mortality and readmission within 30 days of hospitalization. Design Retrospective cohort study of Medicare beneficiaries in the United States. Hierarchical, logistic regression models were developed to estimate the association between income inequality (measured at the US state level) and a patient's risk of mortality and readmission, while sequentially controlling for patient, hospital, other state, and patient socioeconomic characteristics. We considered a 0.05 unit increase in the Gini coefficient as a measure of income inequality. Setting US acute care hospitals. Participants Patients aged 65 years and older, and hospitalized in 2006-08 with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia. Main outcome measures Risk of death within 30 days of admission or rehospitalization for any cause within 30 days of discharge. The potential number of excess deaths and readmissions associated with higher levels of inequality in US states in the three highest quarters of income inequality were compared with corresponding data in US states in the lowest quarter. Results Mortality analyses included 555,962 admissions (4348 hospitals) for acute myocardial infarction, 1,092,285 (4484) for heart failure, and 1,146,414 (4520); readmission analyses included 553,037 (4262), 1,345,909 (4494), and 1,345,909 (4524) admissions, respectively. In 2006-08, income inequality in US states (as measured by the average Gini coefficient over three years) varied from 0.41 in Utah to 0.50 in New York. Multilevel models showed no significant association between income inequality and mortality within 30 days of admission for patients with acute myocardial infarction, heart failure, or pneumonia. By contrast, income inequality was associated with rehospitalization (acute myocardial infarction, risk ratio 1.09 (95% confidence interval 1.03 to 1.15), heart failure 1.07 (1.01 to 1.12), pneumonia 1.09 (1.03 to 1.15)). Further adjustment for individual income and educational achievement did not significantly attenuate these findings. Over the three year period, we estimate an excess of 7153 (2297 to 11,733) readmissions for acute myocardial infarction, 17,991 (3410 to 31,772) for heart failure, and 14,127 (4617 to 23,115) for pneumonia, that are associated with inequality levels in US states in the three highest quarters of income inequality, compared with US states in the lowest quarter. Conclusions Among patients hospitalized with acute myocardial infarction, heart failure, and pneumonia, exposure to higher levels of income inequality was associated with increased risk of readmission but not mortality. In view of the observational design of the study, these findings could be biased, owing to residual confounding.
TL;DR: Younger patients have not experienced comparable declines in HF hospital stay, LOS, and in-hospital mortality as older patients, and Black men remain a vulnerable population for HF hospitalStay.
TL;DR: The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) support their members' goal to improve the prevention and care of cardiovascular diseases through professional education, research, and development of guidelines and standards and by fostering policy that supports optimal patient outcomes.
Abstract: The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) support their members’ goal to improve the prevention and care of cardiovascular diseases through professional education, research, and development of guidelines and standards and by fostering policy that supports optimal patient outcomes. The ACCF and AHA recognize the importance of the use of clinical data standards for patient management, assessment of outcomes, and conduct of research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality-improvement initiatives.
Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform of data elements and definitions applicable to various conditions. Broad agreement on a common vocabulary with reliable definitions used by all is vital to pool and/or compare data across studies to promote interoperability of electronic health records (EHRs) …
TL;DR: In this paper, the authors described substantial disagreement and errors in physicians' angiographic interpretation of coronary stenosis severity, despite the potential implications of these errors. But, they did not discuss the potential consequences of their errors.
Abstract: Background—Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications o...
TL;DR: A wall surrounds much of clinical research data, sequestering knowledge, impeding the free flow of information, and obscuring a clear view of the totality of evidence relevant to many research questions and clinical decisions.
Abstract: IT MAY APPEAR THAT THE CLINICAL RESEARCH ENTERPRISE is functioning well, even thriving. Nearly 30 000 trials globally are recruiting patients, and results from 75 trials are published daily in biomedical journals. However, there is a crisis, with an attendant opportunity, that requires change. A wall surrounds much of these clinical research data, sequestering knowledge, impeding the free flow of information, and obscuring a clear view of the totality of evidence relevant to many research questions and clinical decisions. Nearly half of clinical research trials are never published. Moreover, publications are often incomplete, selectively reporting favorable outcomes and infrequently reporting relevant safety findings. Motivations and explanations for this phenomenon vary, but whether intended or not, selective publication distorts the medical evidence and inhibits the flow of information that is vital to decision making by patients and their clinicians.
TL;DR: High performing hospitals have proportionately fewer 30 day readmissions without differences in readmission diagnoses and timing, suggesting the possible benefit of strategies that lower risk of readmission globally rather than for specific diagnoses or time periods after hospital stay.
Abstract: Objectives To determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions.
TL;DR: About 1 in 70 former inmates are hospitalized for an acute condition within 7 days of release, and 1 in 12 by 90 days, a rate much higher than in the general population.
Abstract: Importance Little is known about the risk of individuals who are released from correctional facilities, a time when there may be discontinuity in care. Objective To study the risk for hospitalizations among former inmates soon after their release from correctional facilities. Design Retrospective cohort study. Participants Data from Medicare administrative claims for 110 419 fee-for-service beneficiaries who were released from a correctional facility from 2002 through 2010 and controls matched by age, sex, race, Medicare status, and residential zip code. Main Outcomes and Measures Hospitalization rates and specifically those for ambulatory care–sensitive conditions 7, 30, and 90 days after release. Results Of 110 419 released inmates, 1559 individuals (1.4%) were hospitalized within 7 days after release; 4285 individuals (3.9%) within 30 days; and 9196 (8.3%) within 90 days. The odds of hospitalization was higher for released inmates compared with those of matched controls (within 7 days: odds ratio [OR], 2.5 [95% CI, 2.3-2.8]; within 30 days: OR, 2.1 [95% CI, 2.0-2.2]; and within 90 days: OR, 1.8 [95% CI, 1.7-1.9]). Compared with matched controls, former inmates were more likely to be hospitalized for ambulatory care–sensitive conditions (within 7 days: OR, 1.7 [95% CI, 1.4-2.1]; within 30 days: OR, 1.6 [95% CI, 1.5-1.8]; and within 90 days: OR, 1.6 [95% CI, 1.5-1.7]). Conclusions and Relevance About 1 in 70 former inmates are hospitalized for an acute condition within 7 days of release, and 1 in 12 by 90 days, a rate much higher than in the general population.
TL;DR: Time to publication for a recent and representative sample of trials published in 2009 was sought and it was found that average time to publication was almost two years.
Abstract: To the Editor:
Prior studies have shown that 25% to 50% of clinical trials are never published.1–4 However, among those published, we know little about the length of time required for publication in the peer-reviewed biomedical literature after study completion. Ioannidis previously demonstrated that a sample of randomized phase 2 and 3 trials conducted between 1986 and 1996 required nearly 2.5 years for publication,5 while our more recent study of National Institutes of Health (NIH)-funded trials found that average time to publication was almost two years.4 We sought to determine time to publication for a recent and representative sample of trials published in 2009.
TL;DR: Trends in rates of hospitalization and outcomes were consistent across demographic subgroups and declined consistently in the subgroup with a principal diagnosis of endocarditis, highlighting the high burden ofendocarditis among older adults.
TL;DR: ICU admission rates for HF varied markedly across hospitals and lacked association with in-hospital risk-standardized mortality, suggesting judicious ICU use could reduce resource consumption without diminishing patient outcomes.
Abstract: Background—Despite increasing attention on reducing relatively costly hospital practices while maintaining the quality of care, few studies have examined how hospitals use the intensive care unit (ICU), a high-cost setting, for patients admitted with heart failure (HF). We characterized hospital patterns of ICU admission for patients with HF and determined their association with the use of ICU-level therapies and patient outcomes. Methods and Results—We identified 166 224 HF discharges from 341 hospitals in the 2009–2010 Premier Perspective database. We excluded hospitals with <25 HF admissions, patients <18 years old, and transfers. We defined ICU as including medical ICU, coronary ICU, and surgical ICU. We calculated the percent of patients admitted directly to an ICU. We compared hospitals in the top quartile (high ICU admission) with the remaining quartiles. The median percentage of ICU admission was 10% (interquartile range, 6%–16%; range, 0%–88%). In top-quartile hospitals, treatments requiring an I...
TL;DR: Discharge summary quality is inadequate in many domains and may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes, however, improving discharge summaryTimeliness may also improve content and transmission.
Abstract: BACKGROUND
Discharge summaries are essential for safe transitions from hospital to home.
OBJECTIVE
To conduct a comprehensive quality assessment of discharge summaries.
DESIGN
Prospective cohort study.
SUBJECTS
Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia.
MEASURES
Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC).
RESULTS
A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content.
CONCLUSIONS
Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission. Journal of Hospital Medicine 2013;8:436–443. © 2013 Society of Hospital Medicine
TL;DR: Two systematic reviews on rhBMP-2 in this issue are based on patient-level data from all clinical trials conducted by Medtronic, which were shared through the YODA Project.
Abstract: Two systematic reviews on rhBMP-2 in this issue are based on patient-level data from all clinical trials conducted by Medtronic, which were shared through the YODA Project—an unprecedented step in ...
TL;DR: To the Editor: Diuretics are a mainstay of treatment in both chronic and acute decompensated heart failure (HF) and studies during the 1990s and early 2000s show that roughly 90% of HF patients receive at least 1 class of diuretics.
TL;DR: Proactive attention to women's concerns related to sexual function and the safety of sexual activity following an MI could improve post‐MI outcomes for women and their partners.
Abstract: Background Little is known about recovery of female sexual function following an acute myocardial infarction (MI). Interventions to improve sexual outcomes in women are limited.
Methods and Results Semistructured, qualitative telephone interviews were conducted with 17 partnered women (aged 43 to 75 years) purposively selected from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status Registry to deepen knowledge of recovery of female sexual function following an acute myocardial infarction (MI) and to improve sexual outcomes in women. Sixteen women had a monogamous relationship with a male spouse; 1 had a long-term female partner. Most women resumed sexual activity within 4 weeks of their MI. Sexual problems and concerns were prevalent, including patient and/or partner fear of “causing another heart attack.” Few women received counseling about sexual concerns or the safety of returning to sex. Most women who discussed sex with a physician initiated the discussion themselves. Inquiry about strategies to improve sexual outcomes elicited key themes: need for privacy, patient-centeredness, and information about the timing and safe resumption of sexual activity. In addition, respondents felt that counseling should be initiated by the treating cardiologist, who “knows whether your heart is safe,” and then reinforced by the care team throughout the rehabilitation period.
Conclusions Partnered women commonly resume sexual activity soon after an MI with fear but without directed counseling from their physicians. Proactive attention to women's concerns related to sexual function and the safety of sexual activity following an MI could improve post-MI outcomes for women and their partners.
TL;DR: Two articles in this issue of JAMA, focused on coronary angiography, reinforce the need to ensure that practice variation is not evidence of care that is not truly patient centered and demonstrate the differences in the rates of coronaryAngiography in the 2 regions with 2 very different payment systems were associated with differences in patient selection.
Abstract: Practice variation in clinical care for preference-sensitive decisions should be a call to action to optimize clinical decision making. Preference-sensitive decisions are those that involve considerable tradeoffs and do not have an option that is clearly superior in all respects.1 Practice variations, which may be influenced by factors that are extrinsic to the patient, occur among physicians, hospitals, health care organizations, regions, and health care systems.1 The variations in practice should disturb physicians not merely because they may indicate wasteful practices but because of the possibility that such variations do not optimally serve the best interests of patients. The health care system should allow variation in practice, provided that variation is based on patient clinical differences and preferences rather than on other factors such as payment method, geography, or system proclivities. Of the 10 rules for the redesign of health care from the Institute of Medicine’s Crossing the Quality Chasm,2 4 reflect the need tooptimizemedicaldecisionmakingandinvolvepatients, includingcustomizationbasedonpatients’needsandvalues,thepatient as the source of control, shared knowledge and the free flow of information, and evidence-based decisionmaking.Despitetheseaspirations, physicians’ actions may fall short. Too often, patients do not know key facts that are critical to making decisions.3,4 Despite the interest of patients to participate in decisions,5 clinicians are often unaware of patient preferences, cannot predict them, and weigh risks and benefits differently than their patients.6,7 Perhaps it is time to recognize the current practice variation as a potential indicator of a weakness of the current approach to decision making. Medical students diligently learn about disease and illness, but there is little education about the science of decision making,particularlyhowtoelicitpreferencesfrompatients,present information, avoid cognitive bias, and ensure that the final choices are aligned with the patient’s values and goals. Perhaps not surprisingly, current practice patterns often do not involve the patient. Fowler and colleagues,8 in a survey of Medicare beneficiaries, found that among patients undergoing coronary artery stenting, only 16% were asked about their treatment preferences. Moreover, many physicians are unaware of thewaysthatlocalculture,explicitandtacit incentives,andmarketing might influence their interpretation of data, affect recommendations, and ultimately shape practice patterns. Two articles in this issue of JAMA, focused on coronary angiography, reinforce the need to ensure that practice variation is not evidence of care that is not truly patient centered.9,10 Coronary angiography is ideal for the study of practice variations and decisions because the evidence, guidelines, and appropriateness criteria provide substantial opportunity for discretionary judgment,whichoughttobebasedonthepatient’scharacteristicsand preferences. The study by Ko and colleagues9 compared the use of coronary angiography among 54 933 patients in Ontario and 18 114 in New York State. In prior work, these authors demonstrated that the population rate of coronary angiography in New York State was twice that of Ontario.11 The current study demonstrates that the differences in the rates of coronary angiography in the 2 regions with 2 very different payment systems were associated with differences in patient selection and resulted in differences in the diagnostic yield of the test. The study by Matlock and colleagues10 demonstrated that procedure rates were higher in fee-for-service than in Medicare Advantage (for angiography, 25.9 vs 16.5 per 1000 person-years; for percutaneous coronary intervention, 9.8 vs 6.8 per 1000 person-years, respectively, with similar rates for coronary artery bypass graft surgery (3.4 vs 3.1 per1000person-years).Theinvestigatorsalsoobserved3-to4-fold differences in rates of angiography and percutaneous coronary intervention among regions for both payment types. Regions that perform fewer procedures may reduce cost but do not necessarily optimize care. In an earlier report by Ko et al,12 regions with fewer procedures had a lower percentage of inappropriate procedures, based on criteria from the American CollegeofCardiology/AmericanHeartAssociationclassifications,but also a lower percentage of appropriate procedures. The findings highlightthechallengeindeterminingtheidealratebecauserates donotconveywellwhetherthebestdecisionwasmadeeachtime. Although descriptions of variation, its determinants, and its consequences are useful, perhaps even more emphasis should now be placed on producing innovations that optimize decision making and ensure that any variation is based on differences among the patients and not on the tendencies of the health care practitioners, organizations, or payment systems. Although ongoing efforts to improve the value of health care delivery may reduce some of the variation due to payment incentives, much less attention has focused on ways to ensure that discretionary decisions incorporate the preferences of well-informed patients. Here are some potential next steps. First, set standards for high-quality decisions, develop metrics for assessing the quality of decisions, promote performance, and encourage quality improvement activities.13 If high-quality decisions are valued, methods are needed to define their properties and measure them. These measurements can help clinicians become accountable for the conduct of decision making and protect against approaches that steer patients according to the interestsofothers.Elwynandcolleagues14 haveproposedamodelthat Related articles pages 155 and 163 Opinion