Determinants of Physicians’ Preferences for Alternative Treatments in Women with Early Breast Cancer

To learn about factors, that influence a physician's decision making, a mail survey was conducted asking physicians about their preferences for radical mastectomy vs. local excision plus irradiation, and for adjuvant chemotherapy vs. no adjuvant treatment for two hypothetical women with operable, clinical stage I breast cancer - one 35 years old and the other 60 years old. Two hundred and sixty-one physicians from varied specialties in Connecticut and Massachusetts returned the questionnaire. Approximately half of the respondents would accept either mastectomy or limited surgery plus radiation therapy for either patient. Adjuvant chemotherapy was recommended by 97% of respondents for the younger patient and by 66% for the older patient. Several factors appeared to be related to therapeutic preferences. An individual physician's attitude towards patient involvement in decision making was the most important predictor of surgical preference for both the patients, whereas the role of specialty (i.e., surgeons vs. other providers) was more important for the surgical management of the older patient. For the decision involving adjuvant chemotherapy, specialty, hospital size, and presence of radiotherapy equipment on site were important predictors. Factors other than survival (such as disease-free interval and cosmetic results) were viewed as important standards of effectiveness by some physicians.

Nursing informatics education in the United States: proposed undergraduate curriculum

Nursing informatics education is undergoing dramatic change as nursing informatics skills and knowledge expand and roles in practice proliferate. In the United States, Federal government initiatives and the activities of national nursing organizations are moving nursing informatics forward in preparation for the new millennium. This paper presents a history of nursing informatics education in the US, as it has emerged from a focus on computer literacy to a new model of information processing, cognitive science and computer science. The paper suggests specific computing skills and informatics concepts which should be integrated into nursing informatics courses or undergraduate nursing programs. Initiatives and goals of the National Agenda for Informatics in Nursing Education and Practice are presented.

Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare

BACKGROUND

There is concern that care provided in the Veterans Health Administration (VA) may be of poorer quality than non-VA health care. We compared use of medications after acute myocardial infarction in the VA with that in non-VA healthcare settings under fee-for-service (FFS) Medicare financing.

METHODS AND RESULTS

We used clinical data from 2486 VA and 29 249 FFS men >65 years old discharged with a confirmed diagnosis of acute myocardial infarction from 81 VA hospitals and 1530 non-VA hospitals. We reported odds ratios (ORs) for use of thrombolytics, beta-blockers, ACE inhibitors, or aspirin among ideal candidates adjusted for age, sample design (hospital academic affiliation, availability of cardiac procedures, and volume), and within-hospital clustering. Ideal VA candidates were more likely to undergo thrombolytic therapy at arrival (OR [VA relative to Medicare] 1.40 [1.05, 1.74]) or to receive ACE inhibitors (OR 1.67 [1.12, 2.45]) or aspirin (OR 2.32 [1.81, 3.01]) at discharge and equally likely to receive beta-blockers (OR 1.09 [1.03, 1.40]) at discharge.

CONCLUSIONS

Ideal candidates in VA were at least as likely as those in FFS to receive medical therapies of known benefit for acute myocardial infarction.

Pitfalls in assessing the quality of care for patients with cardiovascular disease

PURPOSE

There are no clinical performance measures for cardiovascular diseases that span the continuum of hospital through postdischarge ambulatory care. We tested the feasibility of developing and implementing such measures for patients with acute myocardial infarction, congestive heart failure, or hypertension.

SUBJECTS AND METHODS

After reviewing practice guidelines and the medical literature, we developed potential measures related to therapy, diagnostic evaluation, and communication. We tested the feasibility of implementing the selected measures for 518 patients with myocardial infarction, 396 with heart failure, and 601 with hypertension who were enrolled in four major U.S. managed care plans at six geographic sites, using data from administrative claims, medical records, and patient surveys.

RESULTS

Difficulties in obtaining timely data and small numbers of cases adversely affected measurement. We encountered 6- to 12-month delays, disagreement between principal discharge diagnosis as coded in administrative and records data (for 9% of myocardial infarction and 21% of heart failure patients), missing medical records (20% for both myocardial infarction and heart failure patients), and problems in identifying physicians accountable for care. Low rates of performing key diagnostic tests (e.g., ejection fraction) excluded many cases from measures of appropriate therapy that were conditional on test results. Patient survey response rates were low.

CONCLUSIONS

Constructing meaningful clinical performance measures is straightforward, but implementing them on a large scale will require improved data systems. Lack of standardized data captured at the point of clinical care and low rates of eligibility for key measures hamper measurement of quality of care.

Quality of ambulatory care after myocardial infarction among Medicare patients by type of insurance and region

PURPOSE

To evaluate use of effective cardiac medications and rehabilitation after myocardial infarction in the ambulatory setting in health maintenance organizations (HMOs) and fee-for-service care, and by region.

SUBJECTS AND METHODS

We surveyed elderly Medicare patients during 1996 and 1997 in California (n = 516), Florida (n = 304), and the Northeast (n = 220; Massachusetts, New York, and Pennsylvania) approximately 18 months after myocardial infarction. We assessed use of cardiac medications and rehabilitation for HMO (n = 520) and fee-for-service (n = 520) patients matched by age, sex, month of infarct, and region.

RESULTS

Across all regions, similar proportions of HMO and fee-for-service patients were using aspirin (72%, n = 374 vs. 74%, n = 387), beta-blockers (38%, n = 195 vs. 32%, n = 168), angiotensin-converting enzyme inhibitors (31%, n = 159 vs. 29%, n = 148), cholesterol-lowering agents (28%, n = 146 vs. 30%, n = 157), and calcium channel blockers (31%, n = 162 vs. 31%, n = 159; all P >0.07), except in California where more HMO patients received beta-blockers (36%, n = 93 vs. 26%, n = 66, P = 0.01). In adjusted analyses, use of these drugs did not differ significantly between HMO and fee-for-service patients. Substantial regional differences were evident in the use of beta-blockers (Northeast 46%, n = 102; Florida 34%, n = 102; California 31%, n = 159) and cholesterol-lowering agents (California 35%, n = 182; Florida 24%, n = 73; Northeast 22%, n = 48; each P <0.001). Fee-for-service patients were more likely than HMO patients to receive cardiac rehabilitation in unadjusted (32%, n = 167, vs. 22%, n = 141, P = 0.001) and adjusted analyses.

CONCLUSIONS

Both HMO and fee-for-service patients would likely benefit from greater use of beta-blockers and cholesterol-lowering agents. Professional fees for cardiac rehabilitation may promote increased use among fee-for-service patients. Future studies should assess the quality of ambulatory cardiac care in different types of HMOs and the reasons for geographic variations in cardiac drug use.

Fine-Needle Aspiration Biopsy of Nonpalpable Breast Lesions in a Multicenter Clinical Trial: Results from the Radiologic Diagnostic Oncology Group V

PURPOSE

To determine the diagnostic accuracy of ultrasonographically (US) and stereotactically guided fine-needle aspiration biopsy (FNAB) in the diagnosis of nonpalpable breast lesions.

MATERIALS AND METHODS

At 18 institutions, 442 women who underwent 22-25-gauge imaging-guided FNAB were enrolled. Definitive surgical, core-needle biopsy, and/or follow-up information was available for 423 (95.7%) of these women. The reference standard was established from additional clinical and imaging information for an additional six (1.4%) women who did not undergo further histopathologic evaluation. The FNAB protocol was standardized at all institutions, and all specimens were reread by one of two expert cytopathologists.

RESULTS

When insufficient samples were included in the analysis and classified as positive, the sensitivity and specificity of FNAB were 85%-88% and 55.6%-90.5%, respectively; accuracy ranged from 62.2% to 89.2%. The diagnostic accuracy of FNAB was significantly better for detection of masses than for detection of calcifications (67.3% vs. 53.8%, P =.006) and with US guidance than with stereotactic guidance (77.2% vs. 58.9%; P =.002).

CONCLUSION

FNAB of nonpalpable breast lesions has limited value given the high insufficient sample rate and greater diagnostic accuracy of other interventions, including core-needle biopsy and needle-localized open surgical biopsy.

Impact of underuse, overuse, and discretionary use on geographic variation in the use of coronary angiography after acute myocardial infarction

BACKGROUND

Geographic variation in the use of medical procedures has been well documented. However, it is not known whether this variation is due to differences in use when procedures are indicated, discretionary, or contraindicated.

OBJECTIVES

To examine whether use of coronary angiography after acute myocardial infarction (AMI) according to appropriateness criteria varied across geographic regions and whether underuse, overuse, or discretionary use accounted for variation in overall use.

DESIGN

Retrospective cohort study using data from the Cooperative Cardiovascular Project.

SETTING

Ninety-five hospital referral regions.

PATIENTS

There were 44,294 Medicare patients hospitalized with AMI during 1994 or 1995, classified according to appropriateness for angiography.

MAIN OUTCOME MEASURE

Variation in use of angiography, as measured by the difference between high and low rates of use across regions.

RESULTS

Across regions, variation in the use of angiography was similar for indications judged necessary; appropriate, but not necessary; or uncertain. Variation was lowest for indications judged unsuitable (difference between high rate and low rate across regions = 16.3%; 95% CI = 12.6%; 20.6%). The primary cause of variation in the overall rate of angiography was due to use for indications judged appropriate, but not necessary or uncertain. When variation associated with these indications was accounted for, the difference between the resulting high and low overall rates was 10.8% (9.4%, 12.4%). In contrast, variation in the overall rate remained high when underuse in necessary situations or overuse in unsuitable situations was accounted for.

CONCLUSIONS

Across regions, practice was more similar for patients categorized unsuitable for angiography than for patients with other indications. Variation in overall use of angiography appeared to be driven by utilization for discretionary indications rather than by underuse or overuse. If equivalent rates across geographic areas are judged desirable, then greater effort must be directed toward defining care for patients with discretionary indications.

Angiography of potential cardiac donors

OBJECTIVES

This retrospective review of organ donor records was designed to evaluate the practice of donor angiography in one organ procurement organization and determine the outcomes of angiography and its impact on the timing of the organ donation process.

BACKGROUND

Concerns about transmission of atherosclerosis from donor to recipient have been heightened by the increasing prevalence of older donors. Guidelines that advocate the use of angiography in specific settings have been published, but no formal large-scale review has been performed.

METHODS

For the period January 1993 through June 1997, we reviewed all New England Organ Bank records of donors between the ages of 40 and 65 including any from whom at least one solid organ was procured. Data abstracted included the presence of risk factors, timing of the evaluation process and angiographic findings.

RESULTS

Coronary angiography was performed in 119 donors aged 40 and older; 64.7% of these hearts were transplanted. Thirty-eight hearts were transplanted from donors not subjected to angiography and outcomes were poorer compared with donors who underwent angiography. Advanced donor age was the only significant predictor of coronary artery disease. The duration of the procurement process was not prolonged by the performance of angiography.

CONCLUSIONS

Donor coronary angiography does not complicate the donation process. Older donor age is the most powerful predictor of coronary artery disease and may explain prior observations of poorer outcome with older donor hearts. These factors should be considered when angiography is performed as part of the heart donor evaluation.

Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994-1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6% (15.1, 20.1)] and smallest for those rated uncertain [8.8% (6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.

Primary versus secondary ovarian malignancy: imaging findings of adnexal masses in the Radiology Diagnostic Oncology Group Study

PURPOSE

To analyze ultrasonographic (US), computed tomographic (CT), and magnetic resonance (MR) imaging features of primary and secondary ovarian malignant neoplasms to determine if there is any significant difference in their appearance.

MATERIALS AND METHODS

Analysis of the multi-institutional Radiology Diagnostic Oncology Group data revealed 86 patients with primary ovarian carcinoma and 24 patients with a secondary ovarian neoplasm. Numerous imaging features that had been recorded for the adnexal masses with each imaging modality were reviewed and compared between primary and secondary malignant ovarian neoplasms.

RESULTS

Of the imaging features assessed with all three modalities, multilocularity as determined at US (P =.02) or MR imaging (P: =.01) was the only significant feature. At US, 30 (37%) of 81 primary ovarian cancers were multilocular, whereas only three (12%) of 24 metastatic neoplasms were multilocular. At MR imaging, 40 (74%) of 54 primary ovarian cancers were multilocular, whereas only five (36%) of 14 metastatic neoplasms were multilocular. Neither a predominately solid appearance nor bilaterality was significantly different between primary and secondary neoplasms.

CONCLUSION

For malignant ovarian masses, multilocularity at MR imaging or US favors the diagnosis of primary ovarian malignancy rather than secondary neoplasm, but it is difficult to accurately distinguish between primary and secondary ovarian malignancies.

Advances in biomedical imaging

In the 21st century, diseases will be diagnosed and treated using increasingly less invasive, more sophisticated imaging and image-guided procedures. During the past 100 years, the field of biomedical imaging has developed from Roentgen's original discovery of the x-ray to the imaging tools of today, such as magnetic resonance imaging, computed tomography, positron emission tomography, and ultrasonography. The benefits of using these sophisticated noninvasive imaging tools are already evident: more accurate and timely diagnosis of disease has translated into improved patient care. Recent advances in imaging research have shown the potential to change many aspects of clinical medicine within the next decade. Major new areas of research focus on development of the molecular, functional, cellular, and genetic imaging tools of the future, aided by new information technology and image fusion/integration capabilities. Image-guided therapy is growing rapidly, with advances in computer science, technology, and noninvasive treatment methods, such as focused ultrasonography. Undoubtedly, these and other new imaging techniques will enhance the ability to accurately diagnose and recognize disease and allow understanding of the molecular mechanisms of diseases and their respective responses to therapy. Given this explosion in new technologies, the next 25 years promise to result in dramatic changes in diagnostic imaging, particularly with respect to detection and recognition of disease.

Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients

BACKGROUND

Some have the opinion that patients cared for in Veterans Health Administration (VHA) hospitals receive care of poorer quality than those cared for in non-VHA institutions. To assess the quality of care in VHA hospitals, we compared the outcome of acute myocardial infarction among patients in VHA and non-VHA institutions while controlling for potential confounders, including coexisting conditions and severity of illness.

METHODS

We studied 2486 veterans discharged from 81 VHA hospitals and 29,249 Medicare patients discharged from 1530 non-VHA hospitals, restricting our samples to men at least 65 years of age who were discharged with confirmed acute myocardial infarction. We compared coexisting conditions, severity of illness, and 30-day and 1-year mortality in the two samples.

RESULTS

VHA patients were significantly more likely than Medicare patients to have a recorded history of hypertension (64.3 percent vs. 57.3 percent), chronic obstructive pulmonary disease or asthma (30.9 percent vs. 23.5 percent), diabetes (34.8 percent vs. 29.0 percent), stroke (20.4 percent vs. 14.2 percent), or dementia (7.2 percent vs. 4.8 percent) (P<0.001 for all comparisons). According to both multivariate logistic regression and an analysis using 2265 matched pairs of VHA and Medicare patients, there were no significant differences in 30-day or 1-year mortality. The matched-pairs analysis found that the difference in mortality at 30 days (the mortality rate among Medicare patients minus the mortality rate among VHA patients), averaged over the 5-year age groups, was -0.8 percent (95 percent confidence interval, -2.8 percent to 1.3 percent), and the difference in mortality at 1 year was -1.3 percent (95 percent confidence interval, -3.9 percent to 1.3 percent).

CONCLUSIONS

VHA patients had more coexisting conditions than Medicare patients. Nevertheless, we found no significant difference in mortality between VHA and Medicare patients, a result that suggests a similar quality of care for acute myocardial infarction.

Appropriateness of coronary angiography after myocardial infarction among Medicare beneficiaries. Managed care versus fee for service

BACKGROUND

Previous studies have documented that cardiac procedures are performed less frequently in patients enrolled in managed-care plans than in those with fee-for-service coverage. However, it is not known whether this difference is due to less frequent use of cardiac procedures when they are indicated or to less frequent use when they are not indicated.

METHODS

We compared the use of coronary angiography after acute myocardial infarction among Medicare beneficiaries who had traditional fee-for-service coverage with the use among Medicare beneficiaries enrolled in managed-care plans. The analysis was adjusted for differences in demographic and clinical characteristics of the patients and for characteristics of the hospitals to which they were admitted. We studied more than 50,000 beneficiaries in seven states and evaluated their care according to guidelines proposed by the American College of Cardiology and the American Heart Association (ACC-AHA).

RESULTS

Among the 44 percent of patients in both groups who had ACC-AHA class I indications (those for which angiography is useful and effective), more fee-for-service beneficiaries than managed-care enrollees underwent angiography (46 percent vs. 37 percent, P<0.001). The rate of angiography was very low among patients with class I indications who were admitted to hospitals without angiography facilities (31 percent in the fee-for-service group and 15 percent in the managed-care group, P<0.001). Among patients with class III indications (those for which angiography is not effective), the rate of use was low in both groups (approximately 13 percent).

CONCLUSIONS

In situations in which angiography is thought to be useful, it is used less often among Medicare beneficiaries enrolled in managed-care plans than among those with fee-for-service coverage. Moreover, rates of use among patients with class I indications are fairly low in both groups, suggesting that there is room for improving the care of elderly patients with myocardial infarction, especially those admitted to hospitals without angiography facilities.

Staging of advanced ovarian cancer: comparison of imaging modalities--report from the Radiological Diagnostic Oncology Group

PURPOSE

To compare ultrasonography (US), magnetic resonance (MR) imaging, and computed tomography (CT) for diagnosing and staging advanced ovarian cancer.

MATERIALS AND METHODS

US, CT, and MR imaging were performed in 280 patients. Images were read by three radiologists from each of the five hospitals. Image analysis included determination of malignancy within the peritoneum (11 sites), lymph nodes (10 sites), and hepatic parenchyma. The standard of reference was based on surgical and histopathologic findings. Statistical methods used were receiver operating characteristic (ROC) curve analysis, pairwise comparison of areas under the ROC curves (A(z)), analysis of sensitivity and specificity pairs, and assessment of agreement between the degree of suspicion and standard of reference.

RESULTS

There were 118 patients with malignant tumors; 73 (62%) had stage III or IV disease. Metastases were found in the peritoneum in 70 (59%), nodes in 20 (17%), and liver in seven (6%) cases. In the peritoneum, MR imaging and CT (A(z) = 0.96 for both) were more accurate than US (A(z) = 0.86), especially in the subdiaphragmatic spaces and hepatic surfaces. MR imaging and CT were more sensitive than US (95%, 92%, and 69%, respectively) for peritoneal metastases. MR imaging was more accurate than CT for detection of lymph node metastases (A(z) = 0.76 vs 0.57, P =.04). In the liver, the A(z) values for the three modalities were 0.77-0.94.

CONCLUSION

CT and MR imaging are equally accurate, and either modality can be used to stage advanced ovarian cancer.

Survival after acute myocardial infarction in patients with end-stage renal disease: results from the cooperative cardiovascular project

Cardiovascular disease (CVD) is the most common cause of death in patients with end-stage renal disease (ESRD). The optimal management strategy in this population is unknown. We studied 640 patients with ESRD and acute myocardial infarction during 1994 to 1995 as part of the Health Care Financing Administration's Cooperative Cardiovascular Project. The majority of patients were treated with medical therapy alone, 46 patients (7%) were treated with percutaneous transluminal coronary angioplasty (PTCA), and 29 patients (5%) underwent coronary artery bypass grafting (CABG). Patient characteristics and comorbid conditions were similar among the three groups. The overall 1-year mortality rate was 53%. Advanced age, low or high body mass index, history of peripheral vascular disease or stroke, the inability to walk independently, and several indicators of cardiac dysfunction were associated with an increased relative risk (RR) for death. Survival curves differed significantly by treatment modality, with 1-year survival rates of 45%, 54%, and 69% in the medical therapy alone, PTCA, and CABG groups, respectively (P = 0.03). After adjustment for confounding variables, the RR for death was less (but not significantly so) in the CABG group (RR, 0.6; 95% confidence interval, 0.3 to 1.1). There are no randomized clinical trial data to guide therapy of CVD in patients with ESRD. On the basis of these and other available data, CABG may be the optimal therapy for CVD in ESRD. In light of the exceptionally poor outcomes observed for patients treated with medical therapy alone, it may be premature to dismiss PTCA as a therapeutic option in this population.

Diagnosis and staging of ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis--report of the Radiology Diagnostic Oncology Group

PURPOSE

To determine the optimal imaging modality for diagnosis and staging of ovarian cancer.

MATERIALS AND METHODS

Two hundred eighty women suspected to have ovarian cancer were enrolled in a prospective study before surgery. Doppler ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging were used to evaluate the mass; conventional US, CT, and MR imaging were used to stage spread.

RESULTS

All three modalities had high accuracy (0.91) for the overall diagnosis of malignancy. In the ovaries, the accuracy of MR imaging (0.91) was higher than that of CT and significantly higher than that of Doppler US (0.78). In the extraovarian pelvis and in the abdomen, conventional US, CT, and MR imaging had similar accuracies (0.87-0.95). In differentiation of disease confined to the pelvis from abdominal spread, the specificity of conventional US (96%) was higher than that of CT and significantly higher than that of MR imaging (88%), whereas the sensitivities of MR imaging (98%) and CT (92%) were significantly higher than that of conventional US (75%).

CONCLUSION

MR imaging is superior to Doppler US and CT in diagnosis of malignant ovarian masses. There is little variation among conventional US, CT, and MR imaging as regards staging.

Understanding variability in physician ratings of the appropriateness of coronary angiography after acute myocardial infarction

We examined variability in ratings of the appropriateness of coronary angiography for 890 clinical scenarios (indications) after an acute myocardial infarction (AMI) from a nine-member multispecialty panel as a function of panel characteristics and the attributes of the clinical indications. We documented a substantial degree of reliability in the ratings. However, key differences among the experts in terms of both their overall propensity to score high and their beliefs regarding the impact of clinical factors on appropriateness were identified. Age, cardiac complications, post-AMI angina, and noninvasive test results were the clinical factors most strongly related to appropriateness ratings for coronary angiography. Further research on the effectiveness of coronary angiography in older patients and in patients with shock, pulmonary edema, and silent ischemia is needed to improve our knowledge about the appropriateness of this procedure in these patients.

Rating the appropriateness of coronary angiography--do practicing physicians agree with an expert panel and with each other?

BACKGROUND

Evaluations of the appropriateness of medical care are important to monitor the quality of care and to contain costs and enhance safety by reducing inappropriate care. Experts' views are usually incorporated into evaluations of appropriateness. However, practicing physicians may not concur with these views, and physicians' clinical backgrounds may influence their beliefs.

METHODS

We asked 1058 internists, family practitioners, and cardiologists in California, Florida, New York, Pennsylvania, and Texas to rate the appropriateness of coronary angiography after acute myocardial infarction for 20 common indications. Nine clinical experts also rated these indications using an established consensus method.

RESULTS

For 17 of the 20 indications, median ratings of surveyed physicians and the expert panel agreed within 1 unit on a 9-unit scale. Patients' older age had a negative effect on ratings by the expert panel but not on ratings by surveyed physicians. In multivariable analyses of surveyed physicians, cardiologists rated angiography as significantly more appropriate than did primary care physicians for complicated indications, and for uncomplicated indications cardiologists who performed invasive procedures gave higher appropriateness ratings for angiography than did cardiologists who did not perform such procedures and primary care physicians. For uncomplicated indications, physicians from hospitals providing coronary angioplasty and bypass surgery rated angiography as more appropriate than physicians from other hospitals. Physicians from New York and those employed by health maintenance organizations rated angiography as less appropriate than other physicians.

CONCLUSIONS

Surveyed physicians agreed with clinical experts about the appropriateness of coronary angiography after myocardial infarction for most indications, indicating that well-designed expert panels can closely reflect the views of practicing physicians. Variations in beliefs among practicing physicians suggest that evaluations of medical practice should incorporate the views of a range of relevant types of physicians.

Eliciting expert opinion using the Delphi technique: identifying performance indicators for cardiovascular disease

Combining opinion from expert panels is becoming a more common method of selecting criteria to define quality of health care. The Rand Corporation pioneered this method is the 1950s and 1960s in the context of forecasting technological events. Since then, numerous organizations have adopted the methodology to develop local and national policy. In the context of quality of care, opinion is typically elicited from a sample of experts regarding the appropriateness or importance of a medical treatment for several well-defined clinical cohorts. The information from the experts is then combined in order to create a standard or performance measure of care. This article describes how to use the panel process to elicit information from diverse panels of experts. Methods are demonstrated using the data from five distinct panels convened as part of the Harvard Q-SPAN-CD study, a nationally-funded project whose goal is to identify a set of cardiovascular-related performance measures.

Predicting mortality after coronary artery bypass surgery: what do artificial neural networks learn? The Steering Committee of the Cardiac Care Network of Ontario

OBJECTIVE

To compare the abilities of artificial neural network and logistic regression models to predict the risk of in-hospital mortality after coronary artery bypass graft (CABG) surgery.

METHODS

Neural network and logistic regression models were developed using a training set of 4,782 patients undergoing CABG surgery in Ontario, Canada, in 1991, and they were validated in two test sets of 5,309 and 5,517 patients having CABG surgery in 1992 and 1993, respectively.

RESULTS

The probabilities predicted from a fully trained neural network were similar to those of a "saturated" regression model, with both models detecting all possible interactions in the training set and validating poorly in the two test sets. A second neural network was developed by cross-validating a network against a new set of data and terminating network training early to create a more generalizable model. A simple "main effects" regression model without any interaction terms was also developed. Both of these models validated well, with areas under the receiver operating characteristic curves of 0.78 and 0.77 (p > 0.10) in the 1993 test set. The predictions from the two models were very highly correlated (r=0.95).

CONCLUSIONS

Artificial neural networks and logistic regression models learn similar relationships between patient characteristics and mortality after CABG surgery.

Comparison of CT and MR imaging in staging of neck metastases

PURPOSE

To compare the abilities of magnetic resonance (MR) imaging and computed tomography (CT) in detection of lymph node metastasis from head and neck squamous cell carcinoma.

MATERIALS AND METHODS

MR imaging and CT were performed with standard protocols in patients with known carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx. Histopathologic examination was performed to validate imaging findings. Between 1991 and 1994, 213 patients undergoing 311 neck dissections were accrued at three institutions.

RESULTS

For the upper jugular and spinal accessory regions, the areas under the receiver operating characteristic curves for combined information on size and internal abnormality were 0.80 for CT and 0.75 for MR imaging. Sensitivities, specificities, negative predictive values (NPVs), and positive predictive values (PPVs) were calculated for various size criteria with and without internal abnormality information. With use of a 1-cm size or an internal abnormality to indicate a positive node, CT had an NPV of 84% and a PPV of 50%, and MR imaging had an NPV of 79% and a PPV of 52%. CT achieved an NPV of 90%, correlating with a PPV of 44%, with use of 5-mm size as an indicator of a positive node.

CONCLUSION

CT performed slightly better than MR imaging for all interpretative criteria. However, a high NPV was achieved only when a low size criterion was used and was therefore associated with a relatively low PPV.

Rate of insufficient samples for fine-needle aspiration for nonpalpable breast lesions in a multicenter clinical trial: The Radiologic Diagnostic Oncology Group 5 Study. The RDOG5 investigators

BACKGROUND

Radiologic Diagnostic Oncology Group 5 is a multicenter clinical trial designed to evaluate fine-needle aspiration (FNA) of nonpalpable breast lesions performed by multiple operators using the same protocol.

METHODS

Four hundred and nineteen women with mammographically detected nonpalpable breast lesions were enrolled on the trial at 18 institutions. Group A institutions randomized women to stereotactically guided FNA (SFNA) followed by stereotactically guided core needle biopsy (SCNB), or SCNB only. Group B institutions randomized women to SFNA and SCNB, SCNB, or ultrasonographically guided FNA followed by ultrasonographically guided core needle biopsy (USCNB), or USCNB only. A total of 377 women were eligible for analysis.

RESULTS

FNA yielded 128 insufficient samples for the 377 patients (33.95%; 95% confidence interval, 29.2-38.7%). The rate of insufficient samples varied by type of lesion with calcified lesions associated with a significantly higher rate of insufficient sampling than masses (P < 0.001). The radiologist's level of suspicion of the lesion was not a statistically significant predictor of insufficient samples for mass lesions, but was a predictor for calcified lesions. For the 336 lesions for which histologic information was available, insufficient samples occurred in significantly more benign than malignant lesions.

CONCLUSIONS

The high rate of insufficient samples for FNA of nonpalpable breast lesions in this multicenter trial makes its use impractical in this setting. Because of this factor, the study was terminated early.

Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians

BACKGROUND

Both cardiologists and generalist physicians care for patients with acute myocardial infarction, but little is known about their patients' characteristics, treatments, and outcomes.

METHODS

We identified attending and consulting physicians, patient characteristics, drugs, procedures, and mortality from clinical and administrative records of 1620 Medicare beneficiaries aged 65 to 79 years who were treated for acute myocardial infarction at 285 hospitals in Texas during 1990.

RESULTS

Patients treated by attending cardiologists were younger, had prior congestive heart failure less frequently, and were initially treated in hospitals offering coronary angioplasty or bypass surgery more often than patients treated by attending generalist physicians (for each, P<.004). Adjusting for patient and hospital characteristics, cardiologists were more likely than generalist physicians to prescribe thrombolytic therapy and aspirin (P<.05) but not beta-adrenergic blocking agents (beta-blockers). Cardiologists used coronary angiography and angioplasty more often (P<.003), but not echocardiography or exercise testing. Adjusted 1-year mortality did not differ significantly between patients of attending cardiologists and generalist physicians (odds ratio, 1.01; 95% confidence interval, 0.76-1.35) or between patients of generalist physicians with and without a consulting cardiologist (odds ratio, 0.83; 95% confidence interval, 0.60-1.16). However, patients initially admitted to hospitals offering coronary angioplasty and bypass surgery had lower adjusted 1-year mortality than patients admitted to other hospitals (odds ratio, 0.68; 95% confidence interval, 0.47-0.98).

CONCLUSIONS

Compared with generalist physicians, cardiologists used some, but not all, effective drugs more frequently, as well as coronary angiography and angioplasty. Although these differences were not associated with lower adjusted mortality among cardiologists' patients, cardiologists were more likely to treat patients in hospitals with better outcomes. Future studies should identify organizational factors that improve outcomes of myocardial infarction.

Prostate cancer: relative effects of demographic, clinical, histologic, and MR imaging variables on the accuracy of staging

PURPOSE

To determine the effects on the accuracy of staging prostate gland cancer of diagnostic prediction rules based on demographic, clinical, histologic, and magnetic resonance (MR) image variables.

MATERIALS AND METHODS

A total of 200 cases from four medical centers were evaluated by nine radiologists experienced in MR imaging. The accuracies of the four diagnostic variables (age, prostate specific antigen level, Gleason tumor grade, and MR imaging findings) were measured, both singly and combined in a particular sequence, by calculating the area index of the receiver operating characteristic curve.

RESULTS

The accuracy of staging with single variables (age, 0.58; prostate specific antigen level, 0.74; Gleason grade 0.73, MR image findings, 0.74) increased as the variables were optimally merged. The first two variables combined to yield an accuracy of 0.74; the first three combined to yield an accuracy of 0.81; and all four variables resulted in an accuracy of 0.86. In a clinically important subset of 69 cases for which antigen level and Gleason grade together were inconclusive for the purposes of staging, the addition of MR imaging findings resulted in an increase in accuracy from 0.55 to 0.73.

CONCLUSION

Optimal merging of diagnostic test results yields an improvement in the accuracy of prostate cancer staging.

Use of cardiac procedures and outcomes in elderly patients with myocardial infarction in the United States and Canada

BACKGROUND

Acute myocardial infarction is a leading cause of morbidity and mortality in the United States and Canada. We performed a population-based study to compare the use of cardiac procedures and outcomes after acute myocardial infarction in elderly patients in the two countries.

METHODS

We compared the use of invasive cardiac procedures and the mortality rates among 224,258 elderly Medicare beneficiaries in the United States and 9444 elderly patients in Ontario, Canada, each of whom had a new acute myocardial infarction in 1991.

RESULTS

The U.S. patients were significantly more likely than the Canadian patients to undergo coronary angiography (34.9 percent vs. 6.7 percent, P< 0.001), percutaneous transluminal coronary angioplasty (11.7 percent vs. 1.5 percent, P<0.001), and coronary-artery bypass surgery (10.6 percent vs. 1.4 percent, P<0.001) during the first 30 days after the index infarction. These differences in the use of cardiac procedures narrowed but persisted through 180 days of follow-up. The 30-day mortality rates were slightly but significantly lower for the U.S. patients than for the Canadian patients (21.4 percent vs. 22.3 percent, P=0.03). However, the one-year mortality rates were virtually identical (34.3 percent in the United States vs. 34.4 percent in Ontario, P= 0.94).

CONCLUSIONS

Short-term mortality after an acute myocardial infarction was slightly lower in the United States than in Ontario, but these differences did not persist through one year of follow-up. The strikingly higher rates of use of cardiac procedures in the United States, as compared with Canada, do not appear to result in better long-term survival rates for elderly U.S. patients with acute myocardial infarction.

Rapid method for rigorous assessment of radiologic imaging technologies

Rapid and rigorous technology evaluation is important for improving quality and cost in health care, particularly for swiftly changing, highly technologic fields like radiology. Currently, however, evaluations are generally seriously deficient in quality, and rigorous evaluations typically require 4 years or more. Therefore, the authors developed an appropriate methodology. Its principal characteristics include study of outcomes, clinical relevance, multi-institutional design, intensive communication, experienced data management and statistical centers, sophisticated analysis, careful attention to the protocol and reference standard, on-site managers, and extensive pretesting and refinement. The authors successfully tested the methodology in a seven-institution study. Completed in 1 1/4 years, the study achieved active participation of treating physicians, which much enhanced the clinical relevance of the end points studied. The data supported extensive analyses, which included the effect of imaging on treatment plans, an important outcome measure. The authors report the (limited) difficulties encountered and identify changes to ameliorate them. Thus revised, the methodology can serve as a model for future technology assessments.

Coronary artery bypass graft surgery in Ontario and New York State: which rate is right? Steering Committee of the Cardiac Care Network of Ontario

BACKGROUND

Previous studies have shown that the rate of coronary artery bypass graft (CABG) surgery is much higher in New York State than in Ontario.

OBJECTIVE

To compare the service context and clinical characteristics of patients having CABG surgery in New York and Ontario.

DESIGN

Retrospective analysis of data from cardiac surgery registries in New York and Ontario.

PATIENTS

All 16,690 patients in New York and 5517 patients in Ontario who had isolated CABG surgery in 1993.

MEASUREMENTS

Clinical characteristics of patients having CABG surgery and rates of CABG surgery by coronary anatomy.

RESULTS

The overall age-adjusted rate of isolated CABG surgery was 1.79 times (95% CI, 1.74 to 1.85) greater in New York than in Ontario. Patients who had CABG surgery in New York were more likely to be elderly and female and to have recently had myocardial infarction (P < 0.001), whereas patients who had CABG surgery in Ontario were more likely to have had left ventricular dysfunction and severe coronary artery disease (two-vessel disease with proximal left anterior descending disease, three-vessel disease, or left main disease) (P < 0.001). The relative rate of CABG surgery for left main disease was 2.53 times (CI, 2.35 to 2.73) greater in New York than in Ontario but was 8.97 times (CI, 8.01 to 10.06) greater for patients with limited coronary artery disease (one-vessel or two-vessel disease without proximal left anterior descending disease).

CONCLUSIONS

The higher rates of CABG surgery in New York are associated with higher rates of CABG surgery among the elderly, women, and patients who recently had myocardial infarction. Potential underservicing in Ontario is suggested by a lower rate of CABG surgery for left main disease; however, the higher rate of CABG surgery in New York is also associated with a strikingly higher rate of surgery in patients with limited coronary disease. Such trade-offs highlight the difficulty of defining an optimal rate of CABG surgery.

CT and MR imaging in the local staging of primary malignant musculoskeletal neoplasms: Report of the Radiology Diagnostic Oncology Group

PURPOSE

To assess the relative accuracies of computed tomography (CT) and magnetic resonance (MR) imaging in the local staging of primary malignant bone and soft-tissue tumors.

MATERIALS AND METHODS

At four institutions, 367 eligible patients (aged 6-89 years) with malignant bone or soft-tissue neoplasms in selected anatomic sites were enrolled. Patients underwent both CT and MR imaging within 4 weeks before surgery. In each patient, CT scans were interpreted independently by two radiologists and MR images by two other radiologists at the enrolling institution. The CT and MR images were then interpreted together by two of those radiologists and subsequently reread at the other institutions. Imaging and histopathologic findings were compared and were supplemented when needed with surgical findings. Receiver operating characteristic curve analysis and descriptive statistical analysis were performed.

RESULTS

Cases were analyzable in 316 patients: 183 had primary bone tumors; 133 had primary soft-tissue tumors. There was no statistically significant difference between CT and MR imaging in determining tumor involvement of muscle, bone, joints, or neurovascular structures. The combined interpretation of CT and MR images did not statistically significantly improve accuracy. Interreader variability was similar for both modalities.

CONCLUSION

CT and MR imaging are equally accurate in the local staging of malignant bone and soft-tissue neoplasms in the specific anatomic sites studied.

Staging prostate cancer with MR imaging: a combined radiologist-computer system

PURPOSE

To test the accuracy of a combined radiologist-computer system in the diagnosis with magnetic resonance (MR) imaging of cancer of the prostate gland.

MATERIALS AND METHODS

The combined system was developed and tested by four specialists in prostate MR imaging and five radiologists expert in body MR imaging. Each group read MR images obtained in 100 proved cases of prostate cancer. The images were obtained from two sources, and all were obtained with an endorectal surface coil. Prostate MR specialists ranked imaging features of cases to develop a checklist for image interpretation. Features with greatest diagnostic value were incorporated in the combined system. Accuracy measures were derived from the area index of the receiver operating characteristic curve for the combined system and compared with those of radiologists working alone.

RESULTS

Body MR radiologists had a mean baseline accuracy of 0.67; mean accuracy of their combined system was 0.80. The prostate MR specialists, when they rated the features in each case, had a mean accuracy of 0.81; the accuracy of their combined system was 0.87.

CONCLUSIONS

A combined radiologist-computer system substantially improved accuracy of body MR radiologists in the diagnosis of prostate cancer. High levels of accuracy were also achieved by the system with prostate MR specialists.

CT and MR imaging in the staging of colorectal carcinoma: report of the Radiology Diagnostic Oncology Group II

PURPOSE

To prospectively evaluate the relative accuracy of computed tomography (CT) and magnetic resonance (MR) imaging in the staging of colorectal carcinoma.

MATERIALS AND METHODS

CT and MR studies were independently interpreted in a group of 478 patients with colorectal carcinoma in a study conducted from 1989 to 1993. The accuracy of each modality was assessed in a subset of 365 patients with primary tumors with respect to staging of local extent of tumor, status of local-regional lymph nodes, and the presence of liver metastases.

RESULTS

In the staging of local extent of tumor, CT is more accurate than MR imaging, particularly in the definition of penetration of the muscularis propria by rectal cancer (74% vs 58%). Accuracies of CT and MR imaging were equivalent in depiction of transmural extent in colon cancers. CT and MR imaging exhibited accuracies of 62% and 64% in assessment of lymph node involvement with sensitivities of 48% and 22%, respectively. The accuracy of MR imaging and of CT (85% for each) are better for evaluation of liver metastases; lower sensitivities (62% and 70%, respectively) than specificities (97% and 94%, respectively) were demonstrated for both modalities.

CONCLUSION

CT was more accurate than MR imaging in detection and characterization of transmural penetration of rectal tumors. Recent technologic advances in MR imaging may affect these results.

Using admission characteristics to predict short-term mortality from myocardial infarction in elderly patients. Results from the Cooperative Cardiovascular Project

OBJECTIVE

To develop a prediction model of death within 30 days of hospital admission for Medicare patients with acute myocardial infarction that would permit use of risk-adjusted mortality rates as hospital quality measures.

DESIGN

Retrospective cohort study using data created from medical charts and administrative files.

SETTING

All acute care hospitals in Alabama, Connecticut, Iowa, or Wisconsin.

PATIENTS

A cohort of 14,581 patients with acute myocardial infarction covered by Medicare in 1993.

RESULTS

The unadjusted 30-day mortality rate was 21%, ranging from 18% in Connecticut to 23% in Alabama. The 4 largest contributors to variability in mortality rates were mean arterial pressure, age, respiratory rate, and serum urea nitrogen level. The area under the receiver operator characteristic curve was 0.79 in a developmental sample of 10 936 patients and 0.78 in a validation sample of 3645 patients. Based on admission variables, we were able to explain 27% of the variability in 30-day mortality rates. During the index admission, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and thrombolytic agents were used in 72%, 39%, 32%, and 15% of patients, respectively. Explained variation increased by 6 percentage points to 33% when drug therapies and revascularization procedures performed during the index admission were added to the model predictors.

CONCLUSIONS

Short-term mortality remains high for elderly patients with acute myocardial infarction, and a large percentage of variation remains unexplained after controlling for admission severity. Part of the unexplained variability can be explained by the location of the admitting hospital; some of the remaining unexplained variation may reflect differences in quality of care or unmeasured differences in disease severity. Researchers should develop quality indicators based on process measures for acute myocardial infarction and should incorporate these measures into mortality models to determine whether quality accounts for variation in 30-day mortality rates beyond that explained by clinical status at admission.

Variation in the use of cardiac procedures after acute myocardial infarction

BACKGROUND

There are large geographic differences in the frequency with which coronary angiography and revascularization are performed. We attempted to assess whether differences in case mix or in the treatment of specific groups of patients may explain this variability. We also assessed the consequences of various patterns of treatment.

METHODS

We studied patients covered by Medicare who were 65 to 79 years of age and were admitted to 478 hospitals with acute myocardial infarctions during 1990 in New York (1852 patients), where the rate of use of cardiac procedures is low, and in Texas (1837 patients), where the rate of use of such procedures is high. We compared the patterns of treatment of clinically similar groups of patients in the two states. We also compared mortality rates and measures of the health-related quality of life.

RESULTS

Coronary angiography was performed more often in Texas than in New York (45 percent vs. 30 percent, P < 0.001). The frequency of use in Texas was significantly higher than that in New York for all the clinical subgroups of patients analyzed except those at greatest risk for reinfarction. Over a two-year period, the adjusted likelihood of death was lower in New York than in Texas (hazard ratio, 0.87; 95 percent confidence interval, 0.78 to 0.98). Patients from Texas were 41 percent more likely to report angina (P = 0.002) and 62 percent more likely to say they could not perform activities requiring energy expenditure of 5 or more metabolic equivalents than patients from New York approximately two years after infarction (P < 0.001).

CONCLUSIONS

Physicians in Texas were more likely to perform angiography than physicians in New York for patients whose conditions allowed more discretion in the use of cardiac procedures. On average, there appears to be no advantage with respect to mortality or health-related quality of life to performing the procedures at the higher rate used in Texas.

Variations in the utilization of coronary angiography for elderly patients with an acute myocardial infarction. An analysis using hierarchical logistic regression

This article reports a study of variations in the utilization of angiography for Medicare recipients who had an acute myocardial infarction. The study cohort consisted of 1987 Medicare beneficiaries who had a recent acute myocardial infarction. Variations were examined from three perspectives: patient characteristics, regional practice patterns, and on-site availability of the procedure. Factors associated with variation within and among states were incorporated into the analysis using hierarchical logistic regression models. The probability of angiography during the first 90 days after an acute myocardial infarction was estimated as a function of patient age, gender, race, and comorbidity for patients in 51 states (including the District of Columbia). Interstate differences were examined in relation to geographic region and on-site availability of angiography. Observed rates of angiography ranged between 13.8% and 38.3% (median, 24.7%). Variation was nearly threefold based on estimated state probabilities of angiography for a patient with characteristics set at the national average. Observed and estimated rates were lower in northeastern states than in other parts of the United States. States with more extensive onsite availability of angiography tended to have higher angiography rates after adjusting for patient characteristics and geographic region. Adjusted angiography rates were on average higher for younger patients, males, and nonblacks. There was substantial interstate variation in race differences, with states in the Southeast generally having the largest differences. The adjusted black-to-nonblack odds ratio ranged from a low of 0.41 to a high of 0.94. Interstate variation in age and gender differences was moderate. The work reported in this article illustrates the potential of hierarchical regression modeling as a framework for the analysis of variations and some methodologic issues connected with its implementation. Our results show that large variations in the utilization of procedures can exist, despite uniform insurance coverage and a relatively homogeneous patient cohort. Aggressive use of angiography was highly variable across states as was the degree of access to the procedure for blacks and nonblacks. The state rate of on-site availability of angiography facilities was an important predictor of utilization. Increased on-site availability of angiography, however, was not associated with a reduction of differences in access to the procedure.

The influence of socioeconomic status on change in health status after hospitalization

We reviewed patients' hospital records and surveyed patients after hospital discharge to determine whether the experience of being hospitalized differentially affected the health status of persons with different socioeconomic backgrounds (as measured by income level and education level) and to determine whether the association between socioeconomic status (SES) and change in health status varied depending upon the reason for hospital admission. We studied patients admitted to six university-affiliated teaching hospitals in Massachusetts and California for chest pain (N = 797) and surgery (N = 1165). We compared the health status scores of patients for a variety of outcomes: basic activities of daily living, instrumental activities of daily living, social activities, mental well-being, work performance and housework performance. Lower-SES patients entered the hospital with worse health status than higher-SES patients. Change in health status, statistically adjusted for case-mix, varied by reason for admission. Patients with chest pain generally reported either no improvement or a decline in functioning with the amount of decline equivalent for low- and high-SES patients. Surgical patients reported improvement in functioning following hospitalization. For several measures, lower-income surgical patients reported greater improvement than did higher-income patients, but still did not reach the same level of health status as higher-income patients.

The influence of race on the use of surgical procedures for treatment of peripheral vascular disease of the lower extremities

OBJECTIVE

To assess whether rates of amputation and leg-sparing surgery for peripheral vascular disease of the lower extremities differ between African-American and white patients.

DESIGN

Retrospective cohort study using Medicare claims data for 1989 and 1990.

SETTING

A total of 3313 hospitals in the United States.

PATIENTS

Random sample of 19,236 Medicare Part A enrollees who underwent amputation and/or leg-sparing surgery for peripheral vascular disease.

MAIN OUTCOME MEASURES

Adjusted odds of toe and/or foot amputation, below-knee amputation, above-knee amputation, lower extremity arterial vascularization, and percutaneous transluminal angioplasty for African American relative to whites, controlling for case-mix, region, and hospital characteristics.

RESULTS

African-American patients were significantly more likely than white patients to undergo above-knee, below-knee, and toe and/or foot amputation and significantly less likely to undergo lower-extremity arterial revascularization and percutaneous transluminal angioplasty. These associations occurred for diabetic patients and nondiabetic patients but were more pronounced among patients who did not have diabetes.

CONCLUSIONS

Potential explanations include unmeasured factors such as severity of disease and the technical expertise available at hospitals or other factors such as lack of compliance with medical treatment and race-specific treatment decisions by providers. Whatever the cause, interventions aimed toward reducing the number of amputations among African Americans are needed. Further work is required to determine where such interventions should be targeted.

Development and validation of a claims based index for adjusting for risk of mortality: the case of acute myocardial infarction

We developed a comorbidity index on a cohort of 162,699 Medicare beneficiaries who had an acute myocardial infarction (AMI) in 1987 and validate it on two national cohorts: (1) a cohort of 164,427 Medicare beneficiaries who had an AMI in 1988 and (2) a cohort of 10,466 patients admitted to Veterans Administration Hospitals (VAH) for AMI in 1988-1991. The impact of each sensitivity was expressed as; (1) the risk of mortality for those with the comorbidity, (2) the adjustment to the log odds for 2 year mortality and (3) the age-based likelihood of 2 year mortality. Models were validated by calculated the area under an ROC curve obtained by fitting a logistic regression model to each validation population. The two year mortality rate for 30-day survivors was approximately 30% in each of the 3 cohorts. The 5 most prevlent comorbidities coded in the developmental cohort were heart failure (34%), chronic angina (27%), minor arrythmias (25%) and uncomplicated hypertension (18%). Cancer was the most powerful predictor of 2 year mortality, impacting mortality the same as a 18.3 year age increase. Saturation (having all secondary diagnoses in the discharge summary filled) resulted in a 9.2 year age increase. Validation in the 1988 Medicare and in the Veterans Administration Hospitals cohorts resulted in areas of 73% and 72% under the respective ROC curves. Our methods can serve as a prototype for others wishing to assess comorbidity in other targeted subgroups.

Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction

BACKGROUND

The respective roles of generalist and specialist physicians in the care of patients is currently a matter of debate. Information is limited about the knowledge and practices of generalist and specialist physicians regarding conditions that both groups treat, such as myocardial infarction.

METHODS

We therefore surveyed 1211 cardiologists, internists, and family practitioners in the states of New York and Texas about four treatments demonstrated by randomized clinical trials to be associated with improved survival after myocardial infarction (thrombolytic therapy, immediate and long-term use of aspirin, and long-term use of beta-blockers) and two treatments for which such evidence is lacking (diltiazem for patients with pulmonary congestion and prophylactic lidocaine). We asked physicians about the effect of each treatment on survival and the likelihood that they would prescribe each class of drugs.

RESULTS

For the four beneficial treatments, the cardiologists believed more strongly than the internists and family physicians that survival was improved by the treatment, and they were more likely to prescribe these drugs (P < 0.001). For example, 94.1 percent of cardiologists said they were very likely to prescribe thrombolytic agents to treat an acute myocardial infarction, as compared with 82.0 percent of internists and 77.3 percent of family practitioners. Conversely, for the two treatments for which trials showed no evidence of a survival benefit, cardiologists were less likely than internists and family practitioners to think there was such a benefit and less likely to prescribe the drugs (P < 0.001). For example, 4.7 percent of cardiologists reported that they were very likely to use prophylactic lidocaine, as compared with 13.1 percent of internists, and 16.5 percent of family practitioners. When we used logistic regression to adjust for potential confounders, all the differences between the cardiologists and the internists and family practitioners remained significant (P < 0.02).

CONCLUSIONS

Internists and family practitioners are less aware of or less certain about key advances in the treatment of myocardial infarction than are cardiologists. This finding underscores the need to improve the dissemination of information from clinical trials to generalist physicians, particularly if they are to have an enlarged role in the evolving health care system.

Staging of prostate cancer: results of Radiology Diagnostic Oncology Group project comparison of three MR imaging techniques

PURPOSE

To assess accuracy of three different magnetic resonance (MR) imaging techniques, including the endorectal coil, in staging prostate cancer.

MATERIALS AND METHODS

MR imaging was performed in 213 patients with prostate cancer with a conventional body coil, with fat suppression and a body coil, and with an endorectal coil. Radiologists identified tumor invasion into periprostatic tissues, neurovascular bundles, and seminal vesicles. Each technique was evaluated separately, and in a subset of 74 patients the three techniques were evaluated together. Images obtained with the two body-coil techniques were read in combination with images obtained with the endorectal coil (combination A) and alone (combination B).

RESULTS

Overall accuracy for conventional body-coil, fat-suppressed body-coil, and endorectal-coil MR was 61%, 64%, and 54%, respectively. Overall group accuracy for combinations A and B was 57% and 61%. Considerable interreader variability was found for combination A.

CONCLUSION

No technique was highly accurate for staging early prostate cancer. Individual radiologists did achieve a high degree of staging accuracy with the endorectal-coil and body-coil combination.