Rapid brain natriuretic peptide test and Doppler echocardiography for early diagnosis of mild heart failure.
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BACKGROUND: The early identification of patients at risk for the development of clinical heart failure (HF) is a new challenge in an effort to improve outcomes. METHODS: We prospectively evaluated whether the combination of brain natriuretic peptide (BNP) measurements (Triage BNP test, Biosite Diagnostics) and echocardiography would effectively stratify patients with new symptoms in a cost-effective HF program aimed at early diagnosis of mild HF. A total of 252 patients were referred by 100 general practitioners. RESULTS: Among the study population, the median BNP value was 78 ng/L (range, 5-1491 ng/L). BNP concentrations were lower among patients without heart disease [median 15 ng/L (range, 5-167 ng/L); n = 96] than among patients with confirmed HF [median, 165 ng/L (22-1491 ng/L); n = 157; Mann-Whitney U-test, 12.3; P <0.001]. Patients were grouped into diastolic dysfunction [BNP, 195 (223) ng/L], systolic dysfunction [BNP, 290 (394) ng/L], and both systolic and diastolic dysfunction [BNP, 776 (506) ng/L]. In this model, a cutoff value of 50 ng/L BNP increases the diagnostic accuracy in predicting mild HF, avoiding 41 echocardiograms per 100 patients studied, with a net saving of 14% of total costs. CONCLUSIONS: Blood BNP concentrations, in a cost effective targeted screening, can play an important role in diagnosing mild HF and stratifying patients into risk groups of cardiac dysfunction. (+info)
Impact of on-site cardiac catheterization on resource utilization and fatal and non-fatal outcomes after acute myocardial infarction.
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BACKGROUND: Patterns of care for acute myocardial infarction (AMI) strongly depend on the availability of on-site cardiac catheterization facilities. Although the management found at hospitals without on-site catheterization does not lead to increased mortality, little it known about its impact on resource utilization and non-fatal outcomes. METHODS: We identified all patients (n = 35,289) admitted with a first AMI in the province of Quebec between January 1, 1996 and March 31, 1999 using population-based administrative databases. Medical resource utilization and non-fatal and fatal outcomes were compared among patients admitted to hospitals with and without on-site cardiac catheterization facilities. RESULTS: Cardiac catheterization and PCI were more frequently performed among patients admitted to hospitals with catheterization facilities. However, non-invasive procedures were not used more frequently at hospitals without catheterization facilities. To the contrary, echocardiography [odds ratio (OR), 2.04; 95% confidence interval (CI), 1.93-2.16] and multi-gated acquisition imaging (OR, 1.24; 95% CI, 1.17-1.32) were used more frequently at hospitals with catheterization, and exercise treadmill testing (OR, 1.02; 95% CI, 0.91-1.15) and Sestamibi/Thallium imaging (OR, 0.93; 95% CI, 0.88-0.98) were used similarly at hospitals with and without catheterization. Use of anti-ischemic medications and frequency of emergency room and physician visits, were similar at both types of institutions. Readmission rates for AMI-related cardiac complications and mortality were also similar [adjusted hazard ratio, recurrent AMI: 1.02, 95% CI, 0.89-1.16; congestive heart failure: 1.02; 95% CI, 0.90-1.15; unstable angina: 0.93; 95% CI, 0.85-1.02; mortality: 0.99; 95% CI, 0.93-1.05)]. CONCLUSION: Although on-site availability of cardiac catheterization facilities is associated with greater use of invasive cardiac procedures, non-availability of catheterization did not translate into a higher use of non-invasive tests or have an impact on the fatal and non-fatal outcomes available for study in our administrative database. (+info)
Second reading of coronary angiograms by radiologists.
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BACKGROUND: In many hospitals in the provinces of Quebec and Nova Scotia, as well as in some hospitals in the rest of Canada, coronary angiograms are performed and interpreted by invasive cardiologists, and are later reinterpreted and reported by radiologists. OBJECTIVE: To evaluate the value of second readings of coronary angiograms by radiologists. METHODS: Cardiology and radiology reports of a total of 160 consecutive coronary angiograms were compared from patients at three hospitals. Ten segments of the coronary tree were considered and 1582 segments were included. Agreement between cardiology and radiology interpretations was evaluated using per cent agreement, Pearson correlation and Bland-Altman limits of agreement. Agreement was calculated for each arterial segment and for each hospital. RESULTS: Excellent agreement was found between cardiology and radiology interpretations of coronary angiograms. Per cent agreement ranged from 94.9% to 100%, Pearson correlation ranged from 0.83 to 0.97 and Bland-Altman limits of agreement ranged from -18.1 to 19.4. Agreement was similar for each segment and for each hospital. Agreement remained excellent after exclusion of normal angiograms (n=348 segments), with a per cent agreement of 96.3%. Secondary analyses demonstrated a mean time delay of 13 days between angiograms and the subsequent radiology reports. CONCLUSIONS: There are minimal differences between the cardiology and radiology interpretations of coronary angiograms. Routine second reading by a radiologist may be redundant. (+info)
Measuring performance for treating heart attacks and heart failure: the case for outcomes measurement.
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To complement the current process measures for treating patients with heart attacks and with heart failure, which target gaps in quality but do not capture patient outcomes, the Centers for Medicare and Medicaid Services (CMS) has proposed the public reporting of hospital-level thirty-day mortality for these conditions in 2007. We present the case for including measurements of outcomes in the assessment of hospital performance, focusing on the care of patients with heart attacks and with heart failure. Recent developments in the methodology and standards for outcomes measurement have laid the groundwork for incorporating outcomes into performance monitoring efforts for these conditions. (+info)
U.S. trends in CABG hospital volume: the effect of adding cardiac surgery programs.
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Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality. (+info)
Randomized clinical trial of a postdischarge pharmaceutical care program vs regular follow-up in patients with heart failure.
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OBJECTIVE: To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF). METHOD: A randomized, prospective, open clinical trial in patients admitted for HF. The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up. Visits were completed at 2, 6, and 12 months. Hospital re-admissions, days of hospital stay, treatment compliance, satisfaction with the care received, and quality of life (EuroQol) were evaluated; a financial study was conducted in order to assess the possible impact of the program. The intervention was performed by the pharmacy department in coordination with the cardiology unit. RESULTS: 134 patients were included, with a mean age of 75 years and a low educational level. The patients of the intervention group had a higher level of treatment compliance than the patients in the control group. At 12 months of follow-up, 32.9% fewer patients in the intervention group were admitted again vs. the control group. The mean days of hospital stay per patient in the control group were 9.6 (SD=18.5) vs. 5.9 (SD=14.1) in the intervention group. No differences were recorded in quality of life, but the intervention group had a higher score in the satisfaction scale at two months [9.0 (SD=1.3) versus 8.2 (SD=1.8) p=0.026]. Upon adjusting a Cox survival model with the ejection fraction, the patients in the intervention group had a lower risk of re-admission (Hazard ratio 0.56; 95% CI: 0.32-0.97). The financial analysis evidenced savings in hospital costs of euro 578 per patient that were favorable to the intervention group. CONCLUSIONS: Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure, the total days of hospital stay, and improves treatment compliance without increasing the costs of care. (+info)
Coronary artery bypass grafting: how much does it cost?
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OBJECTIVE: To calculate the cost of coronary artery bypass grafting (CABG) and to compare it with the costs determined in two previous Canadian studies. DESIGN: Retrospective cost-analysis study. SETTING: A tertiary care referral hospital. PATIENTS: Fifty patients who had undergone successful triple and quadruple CABG between Jan. 3 and 30, 1989. MAIN RESULTS: The cost of CABG per patient varied from $10,982 to $33,676 (mean $14,328) (in 1988 Canadian dollars). The cost tended to increase with age and number of vessels grafted. Compared with the patients in the two previous Canadian studies our patients were older, had more vessels grafted and cost more to treat, even after the total hospital costs were adjusted for inflation. CONCLUSIONS: The population undergoing CABG is changing: it is older and has more diseased vessels. These changes have had a significant impact on the cost of CABG. Further study is required to determine the outcome and benefit of CABG in this group of patients. (+info)
Comparison of clinical and administrative data sources for hospital coronary artery bypass graft surgery report cards.
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BACKGROUND: Regardless of statistical methodology, public performance report cards must use the highest-quality validated data, preferably from a prospectively maintained clinical database. Using logistic regression and hierarchical models, we compared hospital cardiac surgery profiling results based on clinical data with those derived from contemporaneous administrative data. METHODS AND RESULTS: Fiscal year 2003 isolated coronary artery bypass grafting surgery results based on an audited and validated Massachusetts clinical registry were compared with those derived from a contemporaneous state administrative database, the latter using the inclusion/exclusion criteria and risk model of the Agency for Healthcare Research and Quality. There was a 27.4% disparity in isolated coronary artery bypass grafting surgery volume (4440 clinical, 5657 administrative), a 0.83% difference in observed in-hospital mortality (2.05% versus 2.88%), corresponding differences in risk-adjusted mortality calculated by various statistical methodologies, and 1 hospital classified as an outlier only with the administrative data-based approach. The discrepancies in volumes and risk-adjusted mortality were most notable for higher-volume programs that presumably perform a higher proportion of combined procedures that were misclassified as isolated coronary artery bypass grafting surgery in the administrative cohort. Subsequent analyses of a patient cohort common to both databases revealed the smoothing effect of hierarchical models, a 9% relative difference in mortality (2.21% versus 2.03%) resulting from nonstandardized mortality end points, and 1 hospital classified as an outlier using logistic regression but not using hierarchical regression. CONCLUSIONS: Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and nonstandardized end points. (+info)