Showing papers by "Ralph B. D'Agostino published in 1984"
TL;DR: A predictive instrument for use in a hand-held programmable calculator, which requires only 20 seconds to compute a patient's probability of having acute cardiac ischemia, could reduce the number of CCU admissions in this country by more than 250,000 per year.
Abstract: Each year 1.5 million patients are admitted to coronary-care units (CCUs) for suspected acute ischemic heart disease; for half of these, the diagnosis is ultimately "ruled out." In this study, conducted in the emergency rooms of six New England hospitals ranging in type from urban teaching centers to rural nonteaching hospitals, we sought to develop a diagnostic aid to help emergency room physicians reduce the number of their CCU admissions of patients without acute cardiac ischemia. From data on 2801 patients, we developed a predictive instrument for use in a hand-held programmable calculator, which requires only 20 seconds to compute a patient's probability of having acute cardiac ischemia. In a prospective trial that included 2320 patients in the six hospitals, physicians' diagnostic specificity for acute ischemia increased when the probability value determined by the instrument was made available to them. Rates of false-positive diagnosis decreased without any increase in rates of false-negative diagnosis. Among study patients with a final diagnosis of "not acute ischemia," the number of CCU admissions decreased 30 per cent, without any increase in missed diagnoses of ischemia. The proportion of CCU admissions that represented patients without acute ischemia dropped from 44 to 33 per cent. Widespread use of this predictive instrument could reduce the number of CCU admissions in this country by more than 250,000 per year.
607 citations
TL;DR: No uniformly accepted hypothesis explains the genesis and rupture of intracranial aneurysms, but smoking, particularly heavy smoking, was also more frequent among cases.
Abstract: No uniformly accepted hypothesis explains the genesis and rupture of intracranial aneurysms. We followed 5,184 men and women prospectively for 26 years; 36 cases of aneurysmal subarachnoid hemorrhage (SAH) accounted for 62% of all intracranial hemorrhages. Blood pressure before SAH was higher in these patients than in controls. Definite hypertension (greater than or equal to 160 mm Hg and/or greater than or equal to 95 mm Hg) at entry to the study or at closest exam before SAH was more frequent than in controls. Cigarette smoking, particularly heavy smoking, was also more frequent among cases.
381 citations
TL;DR: The Boston Emergency Medical Service system was studied to determine the effects of Advanced Life Support prehospital trauma care compared to Basic Life Support treatment and it is concluded that the TS is useful for prehospital triage and that appropriate field ALS resuscitation results in more favorable outcomes following major trauma.
Abstract: The Boston Emergency Medical Service system was studied to determine the effects of Advanced Life Support (ALS) prehospital trauma care compared to Basic Life Support (BLS) treatment. The severity of injury and clinical status of patients was defined and monitored using the Trauma Score (TS) described by Champion. The TS on arrival at the hospital increased significantly more for patients receiving field ALS care than for patients transported by BLS ambulances (p = 0.01). ALS resuscitation had most influence on patients with TS 4-13 and did not delay transport time. Furthermore, a positive change in prehospital TS was significantly related to an increased chance of long-term survival for any given severity of injury (p = 0.0002). From these data we conclude that the TS is useful for prehospital triage and that appropriate field ALS resuscitation results in more favorable outcomes following major trauma.
191 citations
TL;DR: Although cardiac nuclear imaging procedures have been demonstrated to be valuable in detecting coronary artery disease or measuring ventricular function, these procedures were rapidly being adopted by the medical community at a time when only limited information about their effectiveness and efficiency are available.
Abstract: A national survey was conducted to examine the extent of adoption and use of nuclear imaging procedures in cardiology in hospitals by 1979 and to develop estimates for 1983. The data are based on the responses of 171 hospitals from a representative 200-hospital sample stratified for region, bed-size, and teaching status. Extrapolating the data, it is estimated that 2,106 hospitals nationally use cardiac nuclear imaging. In 1979, hospitals with at least 200 beds performed an estimated 396,000 cardiac nuclear imaging studies at a cost of $93 million. By 1983, it is estimated that 4,061 hospitals had the capability to perform cardiac nuclear imaging and that national expenditures would exceed $200 million ( noninflated dollars). Although cardiac nuclear imaging procedures have been demonstrated to be valuable in detecting coronary artery disease or measuring ventricular function, these procedures were rapidly being adopted by the medical community at a time when only limited information about their effectiveness and efficiency are available.
5 citations
TL;DR: Using data from 92 EMS systems in three geographically distinct and physically dissimilar regions, the authors found a consistent and significant relationship between the probability of patient survival and cardiac disease severity, age, sex, the presence of a life-threatening arrhythmia, health care resources available to the EMS system, citizen-initiated cardiopulmonary resuscitation, and EMS response time.
Abstract: The authors developed a model that relates survival from myocardial infarction or cardiac arrest to four classes of interactive variables describing the rural community, the patient, Emergency Medical Service (EMS) system inputs, and EMS system process in caring for the suspected cardiac patient. Using data from 92 EMS systems in three geographically distinct and physically dissimilar regions, the authors found a consistent and significant relationship between the probability of patient survival and cardiac disease severity, age, sex, the presence of a life-threatening arrhythmia, health care resources available to the EMS system, citizen-initiated cardiopulmonary resuscitation, EMS response time, and the presence of a paramedic on the ambulance responding to the call. The model affords the opportunity to enumerate those factors with the greatest influence on cardiac survival within the community and to test expected increases in survival gained through incremental changes in these factors.
3 citations
23 Jul 1984
TL;DR: A valid mathematical model that could aid in diagnosing acute ischemic heart disease in the emergency room, thus reducing inappropriate admissions to the coronary care unit and in reducing false positive predictive rates and admissions to coronary care units was developed.
Abstract: A five-year study was undertaken to develop a valid mathematical model that could aid in diagnosing acute ischemic heart disease in the emergency room, thus reducing inappropriate admissions to the coronary care unit. The study was divided into two substudies. In the first, variables significantly predictive of ischemic heart disease were identified and a logistic function was developed and tested. In the second, a six-hospital study, the variables of the first substudy were validated and a final logistic regression was developed and tested prospectively. This model's availability proved to be successful in improving diagnostic accuracy and specificity and in reducing false positive predictive rates and admissions to coronary care units.