Programmed Outcome Research Teams (PORTs) and implications for clinical practice

The health care burden of unstable angina

Worldwide, UA represents a significant allocation of resources. UA represents a syndrome where not only do many therapies exist, but considerable clinical trial evidence has accumulated. Universal application of effective practice patterns is warranted if we are to successfully reduce the burden of UA. Economic analyses cannot resolve many of the underlying societal issues that affect decision making. Often, the acceptability of an economic burden is dependent on the willingness of both individuals and society to pay. In an interesting study, Chestnut et al evaluated the willingness of 50 patients to pay for avoiding a worsening of their angina symptoms. On average, the patients were willing to pay between $210 and $499 to avoid four to eight additional angina episodes each month. The "rule of rescue" suggests that society is often willing to pay large sums of money to save those in extreme need, such as the 55-year-old man rushed to the emergency department clutching his chest. Only recently has attention been paid to how much this disease entity costs us. Whereas the 1980s and 1990s saw a focus on costs, the next century will increasingly focus on value--obtaining the best health outcome for the dollars spent. Debate has shifted, at least in part, from purely financial costs to medical effectiveness and outcomes management. Continuing assessments of value of interventions and application of evidence based-management strategies permit rational selection of therapy and allow us best to bear the burden of UA.

[Registries of morbimortality in cardiology: methods]

The effectiveness of diagnostic, preventive and therapeutic procedures, whose efficacy has been assessed in clinical trials, should be tested in a real treatment scenario. The procedures used in acute myocardial infarction (AMI) management can be evaluated by means of cohort studies that include all consecutive patients admitted to one or several hospitals. Such studies are called hospital registries. They are simpler to organize and cheaper than clinical trials. On the other hand, the AMI population-based registries allow the establishment of the incidence and mortality rates, as well as case-fatality as they include those patients who die before reaching hospital facilities. In both types of registries a set of variables on co-morbidity, age, sex, severity, and the utilization of procedures along with the course of the disease are systematically recorded in each patient using standard definitions to warrant the internal validity. In hospital registries, the external validity of the results will depend on whether the sample of hospitals represents the population where it was obtained. A good registry should include patients with a wide age range, allow the analysis of specific subgroups of patients such as non-Q wave or first AMI to allow for comparison with other registries. In addition, it should also permit a mid-term follow-up, respect ethical issues, receive appropriate funding and keep a multidisciplinary team involved in its design and development.