COVID-19 pandemic effects: Examining prenatal internalizing symptoms and infant temperament

For pregnant women, the COVID-19 pandemic has resulted in unprecedented stressors, including uncertainty regarding prenatal care and the long-term consequences of perinatal infection. However, few studies have examined the role of this adverse event on maternal wellbeing and infant socioemotional development following the initial wave of the pandemic when less stringent public health restrictions were in place. The current study addressed these gaps in the literature by first comparing prenatal internalizing symptoms and infant temperament collected after the first wave of the pandemic to equivalent measures in a pre-pandemic sample. Second, associations between prenatal pandemic-related stress and infant temperament were examined. Women who were pregnant during the COVID-19 pandemic endorsed higher pregnancy-specific anxiety relative to the pre-pandemic sample. They also reported greater infant negative emotionality and lower positive affectivity and regulatory capacity at 2 months postpartum. Prenatal infection stress directly predicted infant negative affect. Both prenatal infection and preparedness stress were indirectly related to infant negative emotionality through depression symptoms during pregnancy and at 2 months postpartum. These results have implications for prenatal mental health screening procedures during the pandemic and the development of early intervention programs for infants born to mothers during this adverse event.

Perinatal hair cortisol concentrations linked to psychological distress and unpredicted birth complications

Maternal well-being and stress during the perinatal period have been hypothesized to influence birth outcomes and the postnatal development of offspring. In the present study, we explored whether hair cortisol concentration (HCC) was related to symptoms of psychological distress during the perinatal period and with unpredicted birth complications (UBCs). Surveys measuring symptoms of perceived stress, state/trait anxiety, and depression were collected from 53 participants (mean age = 31.1, SD = 4.04; 83% Caucasian, 17% other races) during the third trimester and again at two and six months after birth, 24.5% of which reported UBCs. In a subset of participants, we measured HCC in hair samples collected during the third trimester (27-39 weeks) and six months after birth. Compared to participants reporting normal births, those reporting UBCs had significantly elevated composite stress, anxiety, and depression (SAD) scores two months after birth, but scores decreased by six months postpartum. During the third trimester, HCC was positively associated with reported SAD scores, and HCC was elevated in participants reporting birth complications. Logistic regression showed HCC, but not SAD scores, predicted UBCs (p = 0.023, pseudo R2= 19.7%). Repeated measures MANOVA showed HCC varied over the perinatal period depending on both SAD scores reported at two months postpartum and the experience of UBCs; but when SAD scores reported at six months postpartum were included in the model, the association between HCC and SAD scores and the influence of UBCs was diminished. Although generalizability is limited by our relatively small, homogeneous sample, findings support a positive association between reported psychological distress and HCC during pregnancy and at two months postpartum. We also report a novel finding that chronically elevated cortisol concentrations during pregnancy were related to the risk of UBCs and remain elevated through the early postpartum period, suggesting the importance of monitoring both psychological distress and HCC during the perinatal period.

Associations between mothers' and fathers' depression and anxiety prior to birth and infant temperament trajectories over the first year of life: Evidence from diagnoses and symptom severity

BACKGROUND

Developmental shifts in infant temperament predict distal outcomes including emerging symptoms of psychopathology in childhood. Thus, it is critical to gain insight into factors that shape these developmental shifts. Although parental depression and anxiety represent strong predictors of infant temperament in cross-sectional research, few studies have examined how these factors influence temperament trajectories across infancy.

METHODS

We used latent growth curve modeling to examine whether mothers' and fathers' anxiety and depression, measured in two ways - as diagnostic status and symptom severity - serve as unique predictors of developmental shifts in infant temperament from 3 to 12 months. Participants included mothers (N = 234) and a subset of fathers (N = 142). Prior to or during pregnancy, both parents were assessed for lifetime diagnoses of depression and anxiety as well as current severity levels. Mothers rated their infants' temperament at 3, 6, and 12 months of age.

RESULTS

Mothers' depression and anxiety primarily predicted initial levels of temperament at 3 months. Controlling for mothers' symptoms, fathers' depression and anxiety largely related to temperament trajectories across infancy. Lifetime diagnoses and symptom severities were associated with distinct patterns.

LIMITATIONS

Infant temperament was assessed using a parent-report measure. Including an observational measure would provide a more comprehensive picture of the infants' functioning.

CONCLUSIONS

These results indicate that mothers' and fathers' mental health are uniquely associated with infant temperament development when measured using diagnostic status and/or symptom severity. Future studies should examine whether these temperament trajectories mediate intergenerational transmission of risk for depression and anxiety.

Using machine learning to understand age and gender classification based on infant temperament

Age and gender differences are prominent in the temperament literature, with the former particularly salient in infancy and the latter noted as early as the first year of life. This study represents a meta-analysis utilizing Infant Behavior Questionnaire-Revised (IBQ-R) data collected across multiple laboratories (N = 4438) to overcome limitations of smaller samples in elucidating links among temperament, age, and gender in early childhood. Algorithmic modeling techniques were leveraged to discern the extent to which the 14 IBQ-R subscale scores accurately classified participating children as boys (n = 2,298) and girls (n = 2,093), and into three age groups: youngest (< 24 weeks; n = 1,102), mid-range (24 to 48 weeks; n = 2,557), and oldest (> 48 weeks; n = 779). Additionally, simultaneous classification into age and gender categories was performed, providing an opportunity to consider the extent to which gender differences in temperament are informed by infant age. Results indicated that overall age group classification was more accurate than child gender models, suggesting that age-related changes are more salient than gender differences in early childhood with respect to temperament attributes. However, gender-based classification was superior in the oldest age group, suggesting temperament differences between boys and girls are accentuated with development. Fear emerged as the subscale contributing to accurate classifications most notably overall. This study leads infancy research and meta-analytic investigations more broadly in a new direction as a methodological demonstration, and also provides most optimal comparative data for the IBQ-R based on the largest and most representative dataset to date.

Assessing the reliability of self-reported weight for the management of heart failure: application of fraud detection methods to a randomised trial of telemonitoring

Background

Since clinical management of heart failure relies on weights that are self-reported by the patient, errors in reporting will negatively impact the ability of health care professionals to offer timely and effective preventive care. Errors might often result from rounding, or more generally from individual preferences for numbers ending in certain digits, such as 0 or 5. We apply fraud detection methods to assess preferences for numbers ending in these digits in order to inform medical decision making.

Methods

The Telemonitoring to Improve Heart Failure Outcomes trial tested an approach to telemonitoring that used existing technology; intervention patients (n = 826) were asked to measure their weight daily using a digital scale and to relay measurements using their telephone keypads. First, we estimated the number of weights subject to end-digit preference by dividing the weights by five and comparing the resultant distribution with the uniform distribution. Then, we assessed the characteristics of patients reporting an excess number of weights ending in 0 or 5, adjusting for chance reporting of these values.

Results

Of the 114,867 weight readings reported during the trial, 18.6% were affected by end-digit preference, and the likelihood of these errors occurring increased with the number of days that had elapsed since trial enrolment (odds ratio per day: 1.002, p < 0.001). At least 105 patients demonstrated end-digit preference (14.9% of those who submitted data); although statistical significance was limited, a pattern emerged that, compared with other patients, they tended to be younger, male, high school graduates and on more medications. Patients with end-digit preference reported greater variability in weight, and they generated an average 2.9 alerts to the telemonitoring system over the six-month trial period (95% CI, 2.3 to 3.5), compared with 2.3 for other patients (95% CI, 2.2 to 2.5).

Conclusions

As well as overshadowing clinically meaningful changes in weight, end-digit preference can lead to false alerts to telemonitoring systems, which may be associated with unnecessary treatment and alert fatigue. In this trial, end-digit preference was common and became increasingly so over time. By applying fraud detection methods to electronic medical data, it is possible to produce clinically significant information that can inform the design of initiatives to improve the accuracy of reporting.

Trial registration

ClinicalTrials.gov registration number NCT00303212 March 2006.

Do Non-Clinical Factors Improve Prediction of Readmission Risk?: Results From the Tele-HF Study

OBJECTIVES

This study sought to determine whether a model that included self-reported socioeconomic, health status, and psychosocial characteristics obtained from patients recently discharged from hospitalizations for heart failure substantially improved 30-day readmission risk prediction compared with a model that incorporated only clinical and demographic factors.

BACKGROUND

Existing readmission risk models have poor discrimination and it is unknown whether they would be markedly improved by the inclusion of patient-reported information.

METHODS

As part of the Tele-HF (Telemonitoring to Improve Heart Failure Outcomes) trial, we conducted medical record abstraction and telephone interviews in a sample of 1,004 patients recently hospitalized for heart failure to obtain clinical, functional, and psychosocial information within 2 weeks of discharge. Candidate risk factors included 110 variables divided into 2 groups: demographic and clinical variables generally available from the medical record; and socioeconomic, health status, adherence, and psychosocial variables from patient interview.

RESULTS

The 30-day readmission rate was 17.1%. Using the 3-level risk score derived from the restricted medical record variables, patients with a score of 0 (no risk factors) had a readmission rate of 10.9% (95% confidence interval [CI]: 8.2% to 14.2%), and patients with a score of 2 (all risk factors) had a readmission rate of 32.1% (95% CI: 22.4% to 43.2%), a C-statistic of 0.62. Using the 5-level risk score derived from all variables, patients with a score of 0 (no risk factors) had a readmission rate of 9.6% (95% CI: 6.1% to 14.2%), and patients with a score of 4 (all risk factors) had a readmission rate of 55.0% (95% CI: 31.5% to 76.9%), a C-statistic of 0.65.

CONCLUSIONS

Self-reported socioeconomic, health status, adherence, and psychosocial variables are not dominant factors in predicting readmission risk for patients with heart failure. Patient-reported information improved model discrimination and extended the predicted ranges of readmission rates, but the model performance remained poor. (Telemonitoring to Improve Heart Failure Outcomes [Tele-HF]; NCT00303212).

Abstract P25: Factors Associated with Patients' Adoption and Adherence to a Heart Failure Telemonitoring System

Background: Despite numerous studies of telemonitoring (TM), the use of technology to monitor patients remotely, information about patients' adoption and adherence to using such technologies is scarce. The objective of this study was to determine the patient characteristics associated with: 1) initiating use of TM and 2) adherence to using daily TM over 6 months.

Methods: We evaluated all 826 patients enrolled in the TM arm of the Tele-HF multicenter RCT. TM consisted of a telephone-based interactive voice response system whereby patients reported symptoms and weight daily for 6 months. The adherence rate was calculated as the # of weeks the patient used the TM system at least 3 days/week over 6-month study period. Multivariable hierarchical regression was used to identify factors independently associated with initiation of and adherence to TM.

Results: The mean ± SD age of patients was 61.1 ± 15.3 years (range 19-90), 44% were women, and 50% were of minority race. Overall, 14% (119/ 826) never initiated use of TM. In the multivariable analysis, younger patients (age < 65) and patients with higher satisfaction with care were more likely to initiate TM (p-values ≤ .03) (Figure). Among the 707 patients who initiated TM, adherence averaged 90% in week 1 and 55% in week 26. Younger patients and those with lower health literacy had lower rates of adherence to using TM over 6 months (p-values ≤ .004).

Conclusion: Age, satisfaction with care and health literacy were associated with utilization of a TM system for the management of HF. Understanding more about how patient nonclinical factors impact use of new technologies such as TM, may improve the design and effectiveness of TM strategies.

An administrative claims measure suitable for profiling hospital performance based on 30-day all-cause readmission rates among patients with acute myocardial infarction

BACKGROUND

National attention has increasingly focused on readmission as a target for quality improvement. We present the development and validation of a model approved by the National Quality Forum and used by the Centers for Medicare & Medicaid Services for hospital-level public reporting of risk-standardized readmission rates for patients discharged from the hospital after an acute myocardial infarction.

METHODS AND RESULTS

We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with acute myocardial infarction. The model was derived using Medicare claims data for a 2006 cohort and validated using claims and medical record data. The unadjusted readmission rate was 18.9%. The final model included 31 variables and had discrimination ranging from 8% observed 30-day readmission rate in the lowest predictive decile to 32% in the highest decile and a C statistic of 0.63. The 25th and 75th percentiles of the risk-standardized readmission rates across 3890 hospitals were 18.6% and 19.1%, with fifth and 95th percentiles of 18.0% and 19.9%, respectively. The odds of all-cause readmission for a hospital 1 SD above average were 1.35 times that of a hospital 1 SD below average. Hospital-level adjusted readmission rates developed using the claims model were similar to rates produced for the same cohort using a medical record model (correlation, 0.98; median difference, 0.02 percentage points).

CONCLUSIONS

This claims-based model of hospital risk-standardized readmission rates for patients with acute myocardial infarction produces estimates that are excellent surrogates for those produced from a medical record model.

Variation in recovery: Role of gender on outcomes of young AMI patients (VIRGO) study design

BACKGROUND

Among individuals with ischemic heart disease, young women with an acute myocardial infarction (AMI) represent an extreme phenotype associated with an excess mortality risk. Although women younger than 55 years of age account for less than 5% of hospitalized AMI events, almost 16 000 deaths are reported annually in this group, making heart disease a leading killer of young women. Despite a higher risk of mortality compared with similarly aged men, young women have been the subject of few studies.

METHODS AND RESULTS

Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI. VIRGO will enroll 2000 women, 18 to 55 years of age, with AMI and a comparison cohort of 1000 men with AMI from more than 100 participating hospitals. The aims of the study are to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psychosocial risk factors; to determine whether there are sex differences in the quality of care received by young AMI patients; and to determine how these factors contribute to sex differences in outcomes (including mortality, hospitalization, and health status). Blood serum and DNA for consenting participants will be stored for future studies.

CONCLUSIONS

VIRGO will seek to identify novel and prognostic factors that contribute to outcomes in this young AMI population. Results from the study will be used to develop clinically useful risk-stratification models for young AMI patients, explain sex differences in outcomes, and identify targets for intervention.

Telemonitoring in patients with heart failure

BACKGROUND

Small studies suggest that telemonitoring may improve heart-failure outcomes, but its effect in a large trial has not been established.

METHODS

We randomly assigned 1653 patients who had recently been hospitalized for heart failure to undergo either telemonitoring (826 patients) or usual care (827 patients). Telemonitoring was accomplished by means of a telephone-based interactive voice-response system that collected daily information about symptoms and weight that was reviewed by the patients' clinicians. The primary end point was readmission for any reason or death from any cause within 180 days after enrollment. Secondary end points included hospitalization for heart failure, number of days in the hospital, and number of hospitalizations.

RESULTS

The median age of the patients was 61 years; 42.0% were female, and 39.0% were black. The telemonitoring group and the usual-care group did not differ significantly with respect to the primary end point, which occurred in 52.3% and 51.5% of patients, respectively (difference, 0.8 percentage points; 95% confidence interval [CI], -4.0 to 5.6; P=0.75 by the chi-square test). Readmission for any reason occurred in 49.3% of patients in the telemonitoring group and 47.4% of patients in the usual-care group (difference, 1.9 percentage points; 95% CI, -3.0 to 6.7; P=0.45 by the chi-square test). Death occurred in 11.1% of the telemonitoring group and 11.4% of the usual care group (difference, -0.2 percentage points; 95% CI, -3.3 to 2.8; P=0.88 by the chi-square test). There were no significant differences between the two groups with respect to the secondary end points or the time to the primary end point or its components. No adverse events were reported.

CONCLUSIONS

Among patients recently hospitalized for heart failure, telemonitoring did not improve outcomes. The results indicate the importance of a thorough, independent evaluation of disease-management strategies before their adoption. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00303212.).

An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure

BACKGROUND

Readmission soon after hospital discharge is an expensive and often preventable event for patients with heart failure. We present a model approved by the National Quality Forum for the purpose of public reporting of hospital-level readmission rates by the Centers for Medicare & Medicaid Services.

METHODS AND RESULTS

We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with heart failure. The model was derived with the use of Medicare claims data for a 2004 cohort and validated with the use of claims and medical record data. The unadjusted readmission rate was 23.6%. The final model included 37 variables, had discrimination ranging from 15% observed 30-day readmission rate in the lowest predictive decile to 37% in the upper decile, and had a c statistic of 0.60. The 25th and 75th percentiles of the risk-standardized readmission rates across 4669 hospitals were 23.1% and 24.0%, with 5th and 95th percentiles of 22.2% and 25.1%, respectively. The odds of all-cause readmission for a hospital 1 standard deviation above average was 1.30 times that of a hospital 1 standard deviation below average. State-level adjusted readmission rates developed with the use of the claims model are similar to rates produced for the same cohort with the use of a medical record model (correlation, 0.97; median difference, 0.06 percentage points).

CONCLUSIONS

This claims-based model of hospital risk-standardized readmission rates for heart failure patients produces estimates that may serve as surrogates for those derived from a medical record model.

Telemonitoring for patients with chronic heart failure: a systematic review

BACKGROUND

Telemonitoring, the use of communication technology to remotely monitor health status, is an appealing strategy for improving disease management.

METHODS AND RESULTS

We searched Medline databases, bibliographies, and spoke with experts to review the evidence on telemonitoring in heart failure patients. Interventions included: telephone-based symptom monitoring (n = 5), automated monitoring of signs and symptoms (n = 1), and automated physiologic monitoring (n = 1). Two studies directly compared effectiveness of 2 or more forms of telemonitoring. Study quality and intervention type varied considerably. Six studies suggested reduction in all-cause and heart failure hospitalizations (14% to 55% and 29% to 43%, respectively) or mortality (40% to 56%) with telemonitoring. Of the 3 negative studies, 2 enrolled low-risk patients and patients with access to high quality care, whereas 1 enrolled a very high-risk Hispanic population. Studies comparing forms of telemonitoring demonstrated similar effectiveness. However, intervention costs were higher with more complex programs (8383 dollars per patient per year) versus less complex programs (1695 dollars per patient per year).

CONCLUSION

The evidence base for telemonitoring in heart failure is currently quite limited. Based on the available data, telemonitoring may be an effective strategy for disease management in high-risk heart failure patients.

Strategies for reducing the door-to-balloon time in acute myocardial infarction

BACKGROUND

Prompt reperfusion treatment is essential for patients who have myocardial infarction with ST-segment elevation. Guidelines recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon time) during primary percutaneous coronary intervention should be 90 minutes or less. However, few hospitals meet this objective. We sought to identify hospital strategies that were significantly associated with a faster door-to-balloon time.

METHODS

We surveyed 365 hospitals to determine whether each of 28 specific strategies was in use. We used hierarchical generalized linear models and data on patients from the Centers for Medicare and Medicaid Services to determine the association between hospital strategies and the door-to-balloon time.

RESULTS

In multivariate analysis, six strategies were significantly associated with a faster door-to-balloon time. These strategies included having emergency medicine physicians activate the catheterization laboratory (mean reduction in door-to-balloon time, 8.2 minutes), having a single call to a central page operator activate the laboratory (13.8 minutes), having the emergency department activate the catheterization laboratory while the patient is en route to the hospital (15.4 minutes), expecting staff to arrive in the catheterization laboratory within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes), having an attending cardiologist always on site (14.6 minutes), and having staff in the emergency department and the catheterization laboratory use real-time data feedback (8.6 minutes). Despite the effectiveness of these strategies, only a minority of hospitals surveyed were using them.

CONCLUSIONS

Several specific hospital strategies are associated with a significant reduction in the door-to-balloon time in the management of myocardial infarction with ST-segment elevation.

Health related quality of life after mitral valve repairs and replacements

BACKGROUND

The decision to replace or repair mitral valves is often a difficult decision, and outcomes from the patients' perspective should guide decision-making. We investigated whether the change in health related quality of life (HRQOL) after mitral valve surgery is different after valve repairs compared with replacements.

METHODS

We prospectively studied 25 patients with mitral valve replacement and 45 patients with valve repairs performed in 1998-99. We measured HRQOL at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-item Health Survey (SF-36) questionnaire. We compared mean HRQOL scores of the groups with age-adjusted U.S. population scores. We used analysis of covariance to determine a change in HRQOL within groups (repair or replacement) and if the change in HRQOL was different between the groups.

RESULTS

We found few differences between the groups, with more men and simultaneous coronary artery bypass graft surgery in the valve repair group and more prior operation in the valve replacement group. HRQOL improved after surgery in most domains, and was comparable to age-adjusted U.S. norms in the valve repair group. In the multivariable analysis, mitral valve repair recipients reported higher social functioning compared with patients who received valve replacement (p = 0.04). We did not find other statistically significant differences. However, the adjusted improvements in the component scales of physical functioning (PCS) and mental functioning (MCS) were substantial in the valve repair group (mean changes: PCS = 6.8, p = 0.003; MCS = 8.1, p = 0.014) and less pronounced in the replacement group (mean changes: PCS = 3.6, p = 0.09; MCS = 4.3, fsp = 0.16).

CONCLUSIONS

While many considerations influence the decision to repair or replace mitral valves, these findings suggest that repair may be better from the health status perspective. Further studies are necessary to validate this finding.

An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with an acute myocardial infarction

BACKGROUND

A model using administrative claims data that is suitable for profiling hospital performance for acute myocardial infarction would be useful in quality assessment and improvement efforts. We sought to develop a hierarchical regression model using Medicare claims data that produces hospital risk-standardized 30-day mortality rates and to validate the hospital estimates against those derived from a medical record model.

METHODS AND RESULTS

For hospital estimates derived from claims data, we developed a derivation model using 140,120 cases discharged from 4664 hospitals in 1998. For the comparison of models from claims data and medical record data, we used the Cooperative Cardiovascular Project database. To determine the stability of the model over time, we used annual Medicare cohorts discharged in 1995, 1997, and 1999-2001. The final model included 27 variables and had an area under the receiver operating characteristic curve of 0.71. In a comparison of the risk-standardized hospital mortality rates from the claims model with those of the medical record model, the correlation coefficient was 0.90 (SE=0.003). The slope of the weighted regression line was 0.95 (SE=0.007), and the intercept was 0.008 (SE=0.001), both indicating strong agreement of the hospital estimates between the 2 data sources. The median difference between the claims-based hospital risk-standardized mortality rates and the chart-based rates was <0.001 (25th and 75th percentiles, -0.003 and 0.003). The performance of the model was stable over time.

CONCLUSIONS

This administrative claims-based model for profiling hospitals performs consistently over several years and produces estimates of risk-standardized mortality that are good surrogates for estimates from a medical record model.

An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure

BACKGROUND

A model using administrative claims data that is suitable for profiling hospital performance for heart failure would be useful in quality assessment and improvement efforts.

METHODS AND RESULTS

We developed a hierarchical regression model using Medicare claims data from 1998 that produces hospital risk-standardized 30-day mortality rates. We validated the model by comparing state-level standardized estimates with state-level standardized estimates calculated from a medical record model. To determine the stability of the model over time, we used annual Medicare cohorts discharged in 1999-2001. The final model included 24 variables and had an area under the receiver operating characteristic curve of 0.70. In the derivation set from 1998, the 25th and 75th percentiles of the risk-standardized mortality rates across hospitals were 11.6% and 12.8%, respectively. The 95th percentile was 14.2%, and the 5th percentile was 10.5%. In the validation samples, the 5th and 95th percentiles of risk-standardized mortality rates across states were 9.9% and 13.9%, respectively. Correlation between risk-standardized state mortality rates from claims data and rates derived from medical record data was 0.95 (SE=0.015). The slope of the weighted regression line from the 2 data sources was 0.76 (SE=0.04) with intercept of 0.03 (SE=0.004). The median difference between the claims-based state risk-standardized estimates and the chart-based rates was <0.001 (25th percentile=-0.003; 75th percentile=0.002). The performance of the model was stable over time.

CONCLUSIONS

This administrative claims-based model produces estimates of risk-standardized state mortality that are very good surrogates for estimates derived from a medical record model.

Achieving Rapid Door-To-Balloon Times

BACKGROUND

Fewer than half of patients with ST-elevation acute myocardial infarction (STEMI) are treated within guideline-recommended door-to-balloon times; however, little information is available about the approaches used by hospitals that have been successful in improving door-to-balloon times to meet guidelines. We sought to characterize experiences of hospitals with outstanding improvement in door-to-balloon time during 1999-2002.

METHODS AND RESULTS

We performed a qualitative study using in-depth interviews (n=122) with clinical and administrative staff at 11 hospitals that were participating with the National Registry of Myocardial Infarction and had median door-to-balloon times of < or =90 minutes during 2001-2002, representing substantial improvement since 1999. Data were organized with the use of NUD-IST 4 (Sage Publications Software) and were analyzed by the constant comparative method of qualitative data analysis. Eight themes characterized hospitals' experiences: commitment to an explicit goal to improve door-to-balloon time motivated by internal and external pressures; senior management support; innovative protocols; flexibility in refining standardized protocols; uncompromising individual clinical leaders; collaborative teams; data feedback to monitor progress and identify problems and successes; and an organizational culture that fostered resilience to challenges or setbacks in improvement efforts.

CONCLUSIONS

Several themes characterized the experiences of hospitals that had achieved notable improvements in their door-to-balloon times. By distilling the complex and diverse experiences of organizational change into its essential components, this study provides a foundation for future efforts to elevate clinical performance in the hospital setting.

Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?

OBJECTIVES

We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally.

BACKGROUND

Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA).

METHODS

We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals.

RESULTS

Top performers were those with median door-to-balloon times of < or =90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG.

CONCLUSIONS

Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.

Knowledge of blood pressure levels and targets in patients with coronary artery disease in the USA

Little is known about patient awareness of nationally recommended blood pressure targets, especially among patients with cardiac disease. To examine this issue, we interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their systolic and diastolic blood pressure levels as well as corresponding national targets. We used bivariate and multivariate analyses to determine if any patient demographic or clinical characteristics were associated with blood pressure knowledge. Only 66.1% of patients could recall their own systolic and diastolic blood pressure levels. Only 48.9% of all patients could correctly name targets for these values. Knowledge of target blood pressure levels was particularly poor among patients who were female (odds ratio (OR) 0.69; 95% confidence interval (CI) 0.49-0.98), aged > or =60 years (OR 0.70, CI 0.51-0.97), without any college education (OR 0.48, CI 0.35-0.65), without a documented history of hypertension (OR 0.57, CI 0.39-0.84), and with known diabetes (OR 0.46, CI 0.33-0.66). Patients in the highest risk group, according to Joint National Committee guidelines stratification, were no more knowledgeable about their blood pressure levels and targets than lower risk patients. A significant proportion of patients hospitalized with coronary artery disease do not know their own blood pressure levels or targets. Current blood pressure education efforts appear inadequate, particularly for certain patient subgroups in which hypertension is an important modifiable risk factor.

A Randomized Outpatient Trial of a Decision-Support Information Technology Tool

BACKGROUND

Decision-support information technology is often adopted to improve clinical decision making, but it is rarely rigorously evaluated. Congress mandated the evaluation of Problem-Knowledge Couplers (PKC Corp, Burlington, Vt), a decision-support tool proposed for the Department of Defense's new health information network.

METHODS

This was a patient-level randomized trial conducted at 2 military practices. A total of 936 patients were allocated to the intervention group and 966 to usual care. Couplers were applied before routine ambulatory clinic visits. The primary outcome was quality of care, which was assessed based on the total percentage of any of 24 health care quality process measures (opportunities to provide evidence-based care) that were fulfilled. Secondary outcomes included medical resources consumed within 60 days of enrollment and patient and provider satisfaction.

RESULTS

There were 4639 health care opportunities (2374 in the Coupler group and 2265 in the usual-care group), with no difference in the proportion of opportunities fulfilled (33.9% vs 30.7%; P = .12). Although there was a modest improvement in performance on screening/preventive measures, it was offset by poorer performance on some measures of acute care. Coupler patients used more laboratory and pharmacy resources than usual-care patients (logarithmic mean difference, 71 dollars). No difference in patient satisfaction was observed between groups, and provider satisfaction was mixed.

CONCLUSION

This study provides no strong evidence to support the utility of this decision-support tool, but it demonstrates the value of rigorous evaluation of decision-support information technology.

Quality Improvement Efforts and Hospital Performance

BACKGROUND

Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited.

OBJECTIVE

We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI).

RESEARCH DESIGN

This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999.

SUBJECTS

A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included.

MEASURES

Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type.

RESULTS

The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4-89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17-3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64-37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97-5.30, P = 0.07).

CONCLUSIONS

Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance.

Patients with depressive symptoms have lower health status benefits after coronary artery bypass surgery

BACKGROUND

Depression is an established independent prognostic factor for mortality, readmission, and cardiac events after CABG surgery. However, limited data exist on whether depression influences functional outcomes after CABG.

METHODS AND RESULTS

We followed 963 patients who underwent first CABG between February 1999 and February 2001. At baseline and at 6 months after CABG, we interviewed patients to assess depressive symptoms using the Geriatric Depression Scale (GDS) and physical function using the Short Form-36 Physical Component Scale (PCS). The patient's physical function was considered improved if the PCS score increased > or =5 points at 6 months. Patients with high GDS scores were younger, were more often female, and had worse physical function and higher comorbidity than patients with low GDS scores. Rates of improvement in physical function were 60.1% for a GDS score <5 (below 75th percentile), 49.8% for a GDS score between 5 and 9 (75th to 90th percentile), and 39.7% for a GDS score > or =10 (> or =90th percentile; P=0.002 for the trend). Depressive symptoms remained a significant independent predictor of lack of functional improvement after adjustment for severity of coronary artery disease, angina class, baseline PCS score, and medical history. A GDS score > or =10 was a stronger inverse risk factor for functional improvement after CABG than such traditional measures of disease severity as previous myocardial infarction, heart failure on admission, history of diabetes, and left ventricular ejection fraction.

CONCLUSIONS

Higher levels of depressive symptoms at the time of CABG are a strong risk factor for lack of functional benefits 6 months after CABG.

Knowledge of Cholesterol Levels and Targets in Patients With Coronary Artery Disease

Little is known about the extent to which patients are aware of nationally-recommended cholesterol and lipid subfraction targets. The authors interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their low-density lipoprotein, high-density lipoprotein, and total cholesterol levels as well as corresponding national targets. Only 8%, 8%, and 43% of patients could recall their low-density lipoprotein, high-density lipoprotein, and total cholesterol values, respectively. Only 5%, 2%, and 50% could correctly name targets for these values. Knowledge of cholesterol targets was particularly poor among women, nonwhites, and patients without any college education. Patients with multiple cardiac risk factors and patients with a previous history of cardiovascular disease were no more knowledgeable about their cholesterol targets than those without these conditions. These findings suggest that current cholesterol education efforts appear inadequate, particularly for women, nonwhites, and patients without any college education.

Hospital-level performance improvement: beta-blocker use after acute myocardial infarction

BACKGROUND

National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics.

METHODS AND RESULTS

We used data (n = 335,244 patients with AMI discharged from 682 hospitals) from the National Registry of Myocardial Infarction (NRMI) and from the American Hospital Association Annual Survey of Hospitals and hierarchical modeling to examine the associations between hospital characteristics and hospital-level rates of change in beta-blocker use during 1996-1999. On average, hospital rates of beta-blocker use for patients with AMI increased 5.9 percentage points (standard deviation, 9.7 percentage points) from the premidpoint time period (April 1996-February 1998) to the postmidpoint time period (March 1998-September 1999) of the study. The range in hospital-level changes in beta-blocker rates was substantial, from a decline of -50.0 percentage points to an increase of +35.7 percentage points. AMI volume and teaching status, geographic region, and initial beta-blocker use rates were associated with rate of improvement, but the magnitude of these effects was modest.

CONCLUSIONS

The study reveals marked hospital-level variation in improvement in beta-blocker use after AMI. Several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of beta-blockers.

Social support as a predictor of participation in cardiac rehabilitation after coronary artery bypass graft surgery

PURPOSE

Cardiac rehabilitation promotes recovery and enhances quality of life after a coronary artery bypass graft (CABG), but participation in such rehabilitation is low. The role of social support in promoting participation has been suggested by prior studies, but is not clearly defined. The purpose of this study was to investigate the role of social support as an independent predictor of participation in cardiac rehabilitation.

METHODS

This study examined 944 patients who underwent first isolated CABG between May 1999 and February 2001, then were followed for 6 months after surgery. Social support before CABG and 6 weeks after CABG was assessed using the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Inventory (ESSI) and evaluated for its association with participation in cardiac rehabilitation.

RESULTS

Of 944 patients, 524 (56%) reported participation in rehabilitation. The participants were younger, better educated, more often employed, and less financially strained. The participants also had a lower prevalence of cardiovascular disease risk factors and better physical function. According to unadjusted analysis, the patients with low social support (ESSI </= 22) before surgery were less likely to participate in rehabilitation than the other patients (52% vs 59%; risk ratio [RR], 0.89; 95% confidence interval [CI], 0.78-0.99). However, adjustment for demographic factors, medical history, cardiovascular disease risk factors, physical and psychological function, and hospital complications attenuated this association (adjusted RR, 0.92; 95% CI, 0.78-1.07). A low ESSI score measured 6 weeks after CABG similarly did not significantly affect participation in rehabilitation (adjusted RR, 0.96; 95% CI, 0.81-1.11).

CONCLUSIONS

Contrary to what is believed generally, social support may not be a strong determinant of participation in rehabilitation after CABG. Correlates of social support such as gender, socioeconomic status, and comorbidity burden may have a more important role in cardiac rehabilitation participation than social support itself. When marital status was examined as a main predictive variable, the analyses yielded similar results (unadjusted RR, 0.72; 95% CI, 0.58-0.86; RR adjusted for the same covariates, 0.80; 95% CI, 0.60-1.02).

Data feedback efforts in quality improvement: lessons learned from US hospitals

BACKGROUND

Data feedback is a fundamental component of quality improvement efforts, but previous studies provide mixed results on its effectiveness. This study illustrates the diversity of hospital based efforts at data feedback and highlights successful strategies and common pitfalls in designing and implementing data feedback to support performance improvement.

METHODS

Open ended interviews with 45 clinical and administrative staff in eight US hospitals in 2000 concerning their perceptions about the effectiveness of data feedback in supporting performance improvement efforts were analysed. The hospitals were chosen to represent a range of sizes, geographical regions, and beta blocker improvement rates over a 3 year period. Data were organized and analyzed in NUD-IST 4 using the constant comparative method of qualitative data analysis.

RESULTS

Although the data feedback efforts at the hospitals were diverse, the interviews suggested that seven key themes may be important: (1) data must be perceived by physicians as valid to motivate change; (2) it takes time to develop the credibility of data within a hospital; (3) the source and timeliness of data are critical to perceived validity; (4) benchmarking improves the meaningfulness of data feedback; (5) physician leaders can enhance the effectiveness of data feedback; (6) data feedback that profiles an individual physician's practices can be effective but may be perceived as punitive; (7) data feedback must persist to sustain improved performance. Embedded in several themes was the view that the effectiveness of data feedback depends not only on the quality and timeliness of the data, but also on the organizational context in which such efforts are implemented.

CONCLUSIONS

Data feedback is a complex and textured concept. Data feedback strategies that might be most effective are suggested, as well as potential pitfalls in using data to promote performance improvement.

Clinical trial of an educational intervention to achieve recommended cholesterol levels in patients with coronary artery disease

BACKGROUND

Despite national efforts to improve cholesterol management for patients with coronary artery disease, many patients are not reaching recommended cholesterol target levels. We sought to determine whether a nurse-based educational intervention, designed to educate patients with confirmed coronary artery disease about personal low-density lipoprotein (LDL) cholesterol target levels and encourage partnership with physicians, could increase adherence with National Cholesterol Education Program target levels (LDL cholesterol level < or =100 mg/dL).

METHODS

Patients hospitalized with confirmed coronary artery disease were randomized to undergo a nurse-based educational intervention (375 patients) or usual care (381 patients) for a 12-month period after hospitalization. The primary outcome was the proportion of patients at the LDL cholesterol target level 1 year after hospitalization. The secondary outcome was the proportion of patients with accurate knowledge of LDL cholesterol target levels.

RESULTS

The groups were similar at baseline in demographic and clinical characteristics, percent at LDL cholesterol target level (43.9% and 41.1%, respectively), and percent with knowledge of LDL cholesterol target levels (both 5%). The proportion of patients at LDL cholesterol target levels at 1 year did not differ between the intervention (70.2%) and usual care group (67.4%, P =.46). At the conclusion of the trial, patient knowledge about LDL cholesterol target level was higher for the intervention group than the usual care group (19.6% and 6.7%, respectively, P =.001), but this was not associated with improved cholesterol management.

CONCLUSIONS

Our nurse-based educational intervention did not result in a significant increase in the proportion of patients who reached target LDL cholesterol levels 1 year after hospitalization. Although the intervention improved patient knowledge of LDL cholesterol target levels, overall rates of LDL cholesterol knowledge remained low, and it was not associated with improved cholesterol management.

Sex differences in health status after coronary artery bypass surgery

BACKGROUND

Although previous studies have shown functional improvements in patients who undergo coronary artery bypass graft (CABG) surgery, data are conflicting on whether the gains achieved by women are similar to or less than those achieved by men.

METHODS AND RESULTS

We compared physical and psychological functional gains and readmission rates between 777 men and 295 women who underwent first CABG consecutively between February 1999 and February 2001. Physical function and mental health were measured by means of the Short Form 36-Item Health Survey (SF-36). At 6 months, both men and women showed, on average, a significant improvement in physical function and mental health, but men improved significantly more than women. After adjustment for baseline characteristics, the mean score improvement in women was half that of men for physical function (7.3 versus 14.0, P=0.0002) and 25% less than that of men for mental health (-3.0 versus 8.9, P=0.026). The absolute rates of adverse outcomes, such as hospital readmission, worsening functional status, and worsening mental health, were significantly higher in women (32.6%, 25.7%, and 17.5%, respectively) than in men (21.2%, 11.1%, and 12.6%, respectively) and remained significantly different in multivariable analysis.

CONCLUSIONS

CABG surgery is associated with lower functional gains and higher readmission rates in women compared with men 6 months after operation.

Age does not limit quality of life improvement in cardiac valve surgery

OBJECTIVES

We sought to determine the association of age with the change in quality of life (QOL) after valve surgery.

BACKGROUND

Improvement in QOL is one of the principal goals of valve surgery. These procedures are being done with increasing frequency for older patients.

METHODS

We prospectively studied 148 patients with aortic valve procedures and 72 patients with mitral valve procedures. Patients' QOL was measured at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-Item (SF-36) Health Survey (response rate 90%). The association of age with change in QOL was measured by multiple regression analysis and based on two meta-scores of the SF-36: the Mental Component Summary (MCS) and the Physical Component Summary (PCS).

RESULTS

Overall improvement in most domains of the SF-36, including the MCS and the PCS scores, was substantial. Improvement in the MCS score was not influenced by age in either aortic (0.09 score point improvement per 10-year age increments; p = 0.9) or mitral (0.90 score point improvement per 10-year age increments; p = 0.3) patients. Similarly, improvement in the PCS score did not vary by age in aortic patients (-1.00 score points per 10-year age increments; p = 0.2) and only slightly varied by age in mitral patients (-1.90 score points per 10-year age increments, p = 0.02). In the latter, despite statistical significance, the association was not substantial or clinically important.

CONCLUSIONS

Among patients referred for cardiac valve surgery, age does not appear to limit the QOL benefits of surgery.

What are hospitals doing to increase beta-blocker use?

BACKGROUND

Despite the many proposed methods for improving quality, little is known about which methods are being applied in practice across the United States or their perceived effectiveness.

METHODS

A descriptive, cross-sectional analysis of data from a telephone survey of quality improvement staff in 234 randomly selected hospitals participating in the National Registry of Myocardial Infarction was conducted to examine the prevalence and perceived effectiveness of various quality improvement interventions directed at increasing beta-blocker use after acute myocardial infarction.

RESULTS

The mean and median number of quality improvement interventions directed at beta-blocker use in the past 4 years was 5.0 per hospital. The most commonly reported effort was performance reporting about beta-blocker use (87.9%), although only 26.7% used physician-specific performance reporting. More than half the hospitals implemented clinical pathways (58.1%), standing orders (56.8%), or care coordinators (50.4%). Care coordinators (63.4%) and computer support systems (61.6%) were most frequently rated as "very effective." Clinical pathways (24.2%), counseling physicians who had poor performance (26.9%), and reminder forms (23.0%) were most frequently rated as not effective.

CONCLUSIONS

Substantial variation in the types of quality improvement efforts implemented to increase beta-blocker use and perceived effectiveness were evident.

Characteristics of Physician Leaders Working to Improve the Quality of Care in Acute Myocardial Infarction

BACKGROUND

The influence of physician leaders on their colleagues in local medical communities has been recognized for several decades. However, the literature indicates that little is known about the specific characteristics of physician leaders involved in improving quality in today's hospital environment. A taxonomy of the characteristics of the physician quality leader from the perspective of physicians and nonphysicians was developed.

SUBJECTS AND METHODS

Information about physician leaders working to improve acute myocardial infarction (AMI) was gathered from in-depth interviews with 45 key physicians and nursing, quality management, and administrative staff at eight hospitals. Data were analyzed using the constant comparative method of qualitative data analysis.

RESULTS

The physician leader characteristics were described in four main categories: personal commitment, professional credibility, quality improvement behaviors and skills, and institutional linkages. Each physician leader possessed different combinations of the characteristics from the four categories, revealing the complexity of the physician leader role.

CONCLUSION

Understanding the key characteristics of physician leaders is a critical step in helping hospitals choose and develop physician leaders who can effectively bring about meaningful quality improvement.

Gender differences in recovery after coronary artery bypass surgery

OBJECTIVES

This study was designed to examine whether female gender is associated with poorer recovery after coronary artery bypass graft (CABG) surgery.

BACKGROUND

The risks and benefits associated with CABG surgery in women are not as well established as they are in men, and there are concerns that women may have worse outcomes. The recovery period after CABG (the first four to eight weeks after the surgery) is a vulnerable time, with higher risks of complications and hospital readmission. There is little information on patients' experiences during this phase, particularly among women.

METHODS

We prospectively followed 1,113 patients (804 men and 309 women) who underwent first CABG consecutively between February 1999 and February 2001. Patients were interviewed at baseline and between six and eight weeks after surgery. Clinical data were abstracted from medical records.

RESULTS

Compared with men, women were older and more often had unstable angina and congestive heart failure, lower physical function (PF), and more depressive symptoms in the month before surgery. At six to eight weeks after CABG surgery, after adjustment for baseline characteristics, the rate of hospital readmission was 20.5% in women and 11.0% in men (p = 0.005), and the mean number of physical symptoms and side effects was 2.5 in women and 2 in men (p = 0.0009). Whereas, on average, PF remained unchanged in men (an increase in score of 0.3 points, 95% confidence interval [CI], -1.1 to 1.8) and depressive symptoms improved (a decrease of 0.2 depressive symptoms, 95% CI, -0.4 to -0.04), women showed, on average, a 13-point decline in physical function (95% CI, -15.8 to -10.4) and an increase of 0.5 in depressive symptoms (95% CI, 0.1 to 0.9).

CONCLUSIONS

After CABG surgery, women have a more difficult recovery compared with men, which is not explained by illness severity, presurgery health status, or other patient characteristics.

The roles of senior management in quality improvement efforts: what are the key components?

With increasing attention directed at quality problems and medical errors in healthcare organizations, the ability of senior management to promote and sustain effective quality improvement efforts is paramount to their organizational success. We sought to define key roles and activities that comprise senior managers' involvement in improvement efforts directed at physicians' prescription of beta-blockers after acute myocardial infarction (AMI). We also developed a taxonomy to organize the diverse roles and activities of managers in quality improvement efforts and proposed key elements that might be most central to successful improvement efforts. Results are based on a qualitative study of 8 hospitals across the country and included in-depth interviews with 45 clinical and administrative staff from these hospitals. The findings help identify a checklist that senior managers may use to assess their own and others' participation in quality improvement efforts in their institutions. By reinforcing their current involvement or by identifying potential gaps in their involvement in quality improvement efforts, practitioners may enhance their effectiveness in promoting and sustaining quality in clinical care.

Randomized trial of an education and support intervention to prevent readmission of patients with heart failure

OBJECTIVES

We determined the effect of a targeted education and support intervention on the rate of readmission or death and hospital costs in patients with heart failure (HF).

BACKGROUND

Disease management programs for patients with HF including medical components may reduce readmissions by 40% or more, but the value of an intervention focused on education and support is not known.

METHODS

We conducted a prospective, randomized trial of a formal education and support intervention on one-year readmission or mortality and costs of care for patients hospitalized with HF.

RESULTS

Among the 88 patients (44 intervention and 44 control) in the study, 25 patients (56.8%) in the intervention group and 36 patients (81.8%) in the control group had at least one readmission or died during one-year follow-up (relative risk = 0.69, 95% confidence interval [CI]: 0.52, 0.92; p = 0.01). The intervention was associated with a 39% decrease in the total number of readmissions (intervention group: 49 readmissions; control group: 80 readmissions, p = 0.06). After adjusting for clinical and demographic characteristics, the intervention group had a significantly lower risk of readmission compared with the control group (hazard ratio = 0.56, 95% CI: 0.32, 0.96; p = 0.03) and hospital readmission costs of $7,515 less per patient.

CONCLUSIONS

A formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with HF.

A qualitative study of increasing beta-blocker use after myocardial infarction: Why do some hospitals succeed?

CONTEXT

Based on evidence that beta-blockers can reduce mortality in patients with acute myocardial infarction (AMI), many hospitals have initiated performance improvement efforts to increase prescription of beta-blockers at discharge. Determination of the factors associated with such improvements may provide guidance to hospitals that have been less successful in increasing beta-blocker use.

OBJECTIVES

To identify factors that may influence the success of improvement efforts to increase beta-blocker use after AMI and to develop a taxonomy for classifying such efforts.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative study in which data were gathered from in-depth interviews conducted in March-June 2000 with 45 key physician, nursing, quality management, and administrative participants at 8 US hospitals chosen to represent a range of hospital sizes, geographic regions, and changes in beta-blocker use rates between October 1996 and September 1999.

MAIN OUTCOME MEASURES

Initiatives, strategies, and approaches to improve care for patients with AMI.

RESULTS

The interviews revealed 6 broad factors that characterized hospital-based improvement efforts: goals of the efforts, administrative support, support among clinicians, design and implementation of improvement initiatives, use of data, and modifying variables. Hospitals with greater improvements in beta-blocker use over time demonstrated 4 characteristics not found in hospitals with less or no improvement: shared goals for improvement, substantial administrative support, strong physician leadership advocating beta-blocker use, and use of credible data feedback.

CONCLUSIONS

This study provides a context for understanding efforts to improve care in the hospital setting by describing a taxonomy for classifying and evaluating such efforts. In addition, the study suggests possible elements of successful efforts to increase beta-blocker use for patients with AMI.

Association of patients' perception of health status and exercise electrocardiogram, myocardial perfusion imaging, and ventricular function measures

BACKGROUND

Patients' viewpoint of their health status is increasingly used as an important outcome measure of the success of treatments. Because clinicians rarely formally measure patients' health-related quality of life, the question arises whether noninvasive testing for ischemia can provide similar information regarding physical functioning and general health perception.

METHODS

We measured physical functioning and general health status with the Medical Outcomes Study Short Form (SF-36) survey in 195 consecutive patients (68% male, mean age 55.6 +/- 11.1 years) referred for exercise testing with myocardial perfusion imaging. The survey was completed immediately before the exercise test.

RESULTS

In the multivariate analysis, the strongest predictor of physical functioning and general health perception was metabolic equivalents. However, the best model, including demographic, clinical, and test variables, predicted only 14% of the variation in physical functioning and 10% of the variability in general health perception.

CONCLUSIONS

The variation in physical functioning and general health perception, as measured by the SF-36, among patients referred for exercise testing is not predicted well by the results of the test. As expected, several test results are significantly associated with physical functioning and general health perception; however, there was substantial overlap among individual patients, suggesting that the parameters are poor surrogates for the actual assessment of the domains. If these domains are deemed important to tracking patient outcomes, then they should supplement the current assessments of these patients.

Failure to improve left ventricular function after coronary revascularization for ischemic cardiomyopathy is not associated with worse outcome

Background-Preoperative identification of viable myocardium in patients with ischemic cardiomyopathy is considered important because CABG can result in recovery of left ventricular (LV) function. However, the hypothesis that lack of improvement of LV function after CABG is associated with poorer patient outcome is untested. Methods and Results-Outcome was compared in patients with ischemic LV dysfunction (LVEF </=0.30) with and without improvement in LVEF after CABG. Of 135 consecutive patients, 128 (95%) survived CABG and 104 (77%) had pre- and post-CABG LVEF assessment. Of these 104 patients, 68 (65%) had >0.05 increase in LVEF (group A) and 36 (35%) had no significant change, or </=0.05 decrease in LVEF (group B) compared with pre-CABG LVEF. No significant differences existed in age, gender, comorbidities, baseline symptoms, baseline LVEF, or intraoperative variables between groups A and B. Group A increased LVEF from 0.24+/-0.05 to 0.39+/-0.1 (P<0.005). In Group B, LVEF did not change significantly postoperatively, 0.24+/-0.05 to 0.23+/-0.06 (P=NS). Postoperative improvement in angina and heart failure scores were similar between the 2 groups. Survival free of cardiac death was similar for both groups (93% in group A and 94% in group B, P=NS) at a mean follow-up of 32+/-23 months. Conclusions-Lack of improvement of global LVEF after CABG is not associated with poorer outcome compared with that of patients with improved LVEF, presumably because effective revascularization of ischemic myocardium, even without improvement in ventricular function, protects against future infarction and death.

Trends in costs of percutaneous transluminal coronary angioplasty

OBJECTIVE

To evaluate recent trends in the cost of percutaneous transluminal coronary angioplasty (PTCA), particularly the impact of newer technology and changing patient profile.

STUDY DESIGN

Retrospective study with a 6-month follow up.

PATIENTS AND METHODS

We compared the data on two groups of 100 consecutive patients admitted for elective PTCA at Yale-New Haven Hospital in 1995 and 1996. Hospital records, cineangiograms, and hospital cost accounting system were reviewed, and 6-month clinical outcomes were obtained from telephone interviews and medical chart review.

RESULTS

Demographic and clinical characteristics did not differ between the 1995 and 1996 groups of patients, nor was a difference detected in in-hospital and 6-month clinical outcomes between 1995 and 1996. Angiographic features of treated lesions were different between the two groups, with a significantly higher frequency of type C and totally occluded lesions in 1996 (p = 0.002 and p = 0.04, respectively). The total hospital costs were higher in 1996 compared with 1995 ($11,799 +/- $6189 vs $10,087 +/- $5608; p = 0.04). This difference persisted after adjustment for changes in patient population. The major factor responsible for escalating costs was a 45% increase in catheterization laboratory costs ($8575 +/- $4524 in 1996 vs $5916 +/- $3030 in 1995; P < 0.0001). In contrast, the noncatheterization costs decreased substantially during this period, largely as a result of an approximately 33% decrease in length of stay (3.75 +/- 2.66 days in 1995 vs 2.57 +/- 1.99 days in 1996; P = 0.0005). In a multiple linear regression model, the most important determinants of cost were lesion characteristics, stent use, and radiographic contrast volume.

CONCLUSIONS

Despite cost reduction efforts, the costs of PTCA are rising because of increased consumption of resources in the catheterization laboratory.

Exercise testing with myocardial perfusion imaging in patients with normal baseline electrocardiograms: cost savings with a stepwise diagnostic strategy

BACKGROUND

It has been suggested that in patients with a normal resting electrocardiogram (ECG), exercise radionuclide myocardial perfusion imaging (MPI) does not add significant incremental diagnostic information to exercise ECG.

METHODS AND RESULTS

Of 840 consecutive patients referred for physical exercise MPI, 313 (37%) had normal resting ECGs. There were 189 men and 124 women with a mean age of 54+/-11.9 years. Exercise MPI was performed with either TI-201 or 99mTc-labeled sestamibi. Overall concordance between exercise ECG result and MPI result was 79% (kappa agreement = .54). One hundred eighty-four patients had normal exercise ECG; 181 (98.4%) of these also had normal exercise MPI. In 271 patients with low (< or =20%) to intermediate (21% to 70%) pre-exercise likelihood of coronary artery disease (CAD), concordance between normal exercise ECG and normal MPI was 100%. In the high likelihood (> or =71%) group 3 (15 %) patients with normal exercise ECG had abnormal exercise MPI. Of 129 patients with abnormal exercise ECG, 67 (52%) patients also had abnormal MPI, but 62 (48%) patients had normal MPI. Complete follow-up was obtained in 89% of patients at 9 months. Only 1 hard cardiac event occurred: nonfatal myocardial infarction. Twenty-one (8%) patients had subsequent coronary revascularization or admission with unstable angina. Although both abnormal stress ECG and abnormal exercise MPI were significantly (P < .0001) associated with hard and "soft" events, the association of abnormal exercise MPI was significantly stronger. Because all patients with a low and intermediate likelihood of CAD who had normal exercise ECG also had normal exercise MPI, we propose a stepwise diagnostic testing strategy whereby exercise MPI imaging is performed only in patients with a low to intermediate likelihood of CAD when the exercise ECG is abnormal. When the exercise ECG is performed first, and exercise MPI is performed only when the exercise ECG is abnormal, substantial (38%) cost savings can be achieved. In patients with a high likelihood of CAD, the exercise ECG may be falsely negative, and exercise MPI is preferred.

CONCLUSION

In patients with normal resting ECGs a stepwise diagnostic strategy can reduce costs of exercise testing without compromising diagnostic yield when pretest likelihood of coronary artery disease is taken into consideration.

Prognostic value of noninvasive testing one year after orthotopic cardiac transplantation

OBJECTIVES

We sought to evaluate the prognostic value of routine noninvasive testing--stress thallium-201 imaging, rest two-dimensional echocardiography and rest equilibrium radionuclide angiography--1 year after cardiac transplantation.

BACKGROUND

Coronary artery vasculopathy is the most important cause of late death after orthotopic cardiac transplantation. Several clinical variables have been identified as risk factors for development of coronary vasculopathy. Traditional noninvasive diagnostic testing has been shown to be relatively insensitive for identifying patients with angiographic vasculopathy.

METHODS

Results of prospectively acquired noninvasive testing in 47 consecutive transplant recipients alive 1 year after transplantation were related to subsequent survival. Other clinical variables previously shown to be associated with the development of coronary artery vasculopathy were also included in the analysis.

RESULTS

The 5-year survival rate after cardiac transplantation was 81%. By univariate analysis, echocardiography (chi-square 9.21) and stress thallium-201 myocardial perfusion imaging (chi-square 16.76) were predictive for survival, whereas rest equilibrium radionuclide angiography was not. Clinical contributors to survival were donor age (chi-square 4.56), number of human leukocyte antigen mismatches (chi-square 3.06) and cold ischemic time (chi-square 3.23). By multivariate analysis, stress myocardial imaging remained the only significant predictor of survival (risk ratio 0.27; 95% confidence interval 0.06 to 0.89).

CONCLUSIONS

Normal thallium-201 stress myocardial perfusion imaging 1 year after cardiac transplantation is an important predictor of 5-year survival.

Reproducibility of quantitative planar thallium-201 scintigraphy: quantitative criteria for reversibility of myocardial perfusion defects

Fifty-two paired stress/delayed planar 201TI studies (27 exercise studies, 25 dipyridamole studies) were processed twice by seven technologists to assess inter- and intraobserver variability. The reproducibility was inversely related to the size of 201TI perfusion abnormalities. Intraobserver variability was not different between exercise and dipyridamole studies for lesions of similar size. Based upon intraobserver variability, objective quantitative criteria for reversibility of perfusion abnormalities were defined. These objective criteria were tested prospectively in a separate group of 35 201TI studies and compared with the subjective interpretation of quantitative circumferential profiles. Overall, exact agreement existed in 78% of images (kappa statistic k = 0.66). We conclude that quantification of planar 201TI scans is highly reproducible, with acceptable inter- and intraobserver variability. Objective criteria for lesion reversibility correlated well with analysis by experienced observers.

Quantitative analysis of planar technetium-99m-sestamibi myocardial perfusion images using modified background subtraction

Standard interpolative background subtraction, as used for thallium-201 (201Tl), may create artifacts when applied to planar technetium-99m-Sestamibi (99mTc-Sestamibi) images, apparently because of the oversubtraction of relatively high extra-cardiac activity. A modified background subtraction algorithm was developed and compared to standard background subtraction in 16 patients who had both exercise-delayed 201Tl and exercise-rest 99mTc-Sestamibi imaging. Furthermore, a new normal data base was generated. Normal 99mTc-Sestamibi distribution was slightly different compared to 201Tl. Using standard background subtraction, mean defect reversibility was significantly underestimated by 99mTc-Sestamibi compared to 201Tl (2.8 +/- 4.9 versus -1.8 +/- 8.4, p less than 0.05). Using the modified background subtraction, mean defect reversibility on 201Tl and 99mTc-Sestamibi images was comparable (2.8 +/- 4.9 versus 1.7 +/- 5.2, p = NS). We conclude, that for quantification of 99mTc-Sestamibi images a new normal data base, as well as a modification of the interpolative background subtraction method should be employed to obtain quantitative results comparable to those with 201Tl.

Demonstration of reperfusion after thrombolysis with technetium-99m isonitrile myocardial imaging

Technetium-99m isonitrile myocardial perfusion imaging was employed in a patient undergoing thrombolytic therapy with recombinant tissue plasminogen activator for acute anteroseptal myocardial infarction. Technetium-99m isonitrile does not demonstrate significant myocardial redistribution after intravenous injection. The imaging agent was administered in the emergency room, prior to the initiation of thrombolytic therapy. The initial area at risk for infarction was visualized on images obtained after the patient had been effectively treated. Imaging performed 5 days later, after repeat injection of [99mTc]isonitrile, showed a smaller myocardial perfusion defect indicating salvage of myocardium. Thus, this technique offers promise as a noninvasive means of assessing the area at risk, the success of reperfusion, and the presence of salvaged myocardium, early in the course of acute myocardial infarction.

Quantitative planar thallium-201 stress scintigraphy: a critical evaluation of the method

The results of quantitative analysis of planar thallium-201 stress scintigraphy are superior to those of visual analysis. The increased sensitivity for detection of coronary artery disease is associated with maintenance of specificity. Consequently, we believe that quantitative analysis is the state-of-the-art for planar 201Tl stress scintigraphy. We emphasize that for reliable and reproducible results, rigorous quality control and strict adherence to a standardized imaging protocol are necessary. An important feature is clarity of display of computer data. In our experience, the most important feature for making quantitative analysis reliable and accessible for a broader user market is simultaneous display of the lower limits of normal with processed patient data. This provides a simple visual impression of the degree and extent of abnormal 201Tl distribution and kinetics relative to the lower limit of normal.