Background -Hospitals with primary percutaneous coronary intervention(PPCI) capability may choose to predominately offer PPCI to their patients with ST-segment elevation myocardial infarction(STEMI), or they may selec...Background -Hospitals with primary percutaneous coronary intervention(PPCI) capability may choose to predominately offer PPCI to their patients with ST-segment elevation myocardial infarction(STEMI), or they may selectively offer PPCI or fibrinolytic therapy based on patient and hospital-level factors. Whether a greater level of hospital specialization with PPCI is associated with better quality of care is unknown. Methods and Results -We analyzed data from the National Registry of Myocardial Infarction-4 to compare in-hospital mortality and times to treatment in STEMI across different levels of hospital specialization with PPCI. We divided 463 hospitals into quartiles of PPCI specialization based on the relative proportion of reperfusion-treated patients who underwent PPCI(≤34.0%, >34.0 to 62.5%, >62.5 to 88.5%, >88.5%). Hierarchical multivariable regression assessed whether PPCI specialization was associated with better outcomes, after adjusting for patient and hospital characteristics, including PPCI volume. We found that greater PPCI specialization was associated with a lower relative risk of in-hospital mortality in patients treated with PPCI(adjusted relative risk comparing the highest and lowest quartiles, 0.64; P=0.006) but not in those treated with fibrinolytic therapy. Compared with patients at hospitals in the lowest quartile of PPCI specialization, adjusted door-to-balloon times in the highest quartile were significantly shorter(99.6 versus 118.3 minutes; P< 0.001), and the likelihood of door-to-balloon times exceeding 90 minutes was significantly lower(relative risk, 0.78; P< 0.001). Adjusting for PPCI specialization diminished the association between PPCI volume and clinical outcomes. Conclusions -Greater specialization with PPCI is associated with lower in-hospital mortality and shorter door-to-balloon times in STEMI patients treated with PPCI.展开更多
Objectives: We estimated the prevalence of renal impairment in heart failure(HF) patients and the magnitude of associated mortality risk using a systematic review of published studies. Background: Renal impairment in ...Objectives: We estimated the prevalence of renal impairment in heart failure(HF) patients and the magnitude of associated mortality risk using a systematic review of published studies. Background: Renal impairment in HF patients is associated with excess mortality, although precise risk estimates are unclear. Methods: A systematic search of MEDLINE(through May 2005) identified 16 studies characterizing the association between renal impairment and mortality in 80,098 hospitalized and non-hospitalized HF patients. All-cause mortality risks associated with any renal impairment(creatinine >1.0 mg/dl, creatinine clearance[CrCl] or estimated glomerular filtration rate[eGFR]< 90 ml/min, or cystatin-C >1.03 mg/dl) and moderate to severe impairment(creatinine ≥1.5, CrCl or eGFR< 53, or cystatin-C ≥1.56) were estimated using fixed-effects meta-analysis. Results: A total of 63%of patients had any renal impairment, and 29%had moderate to severe impairment. After follow-up ≥1 year, 38%of patients with any renal impairment and 51%with moderate to severe impairment died versus 24%without impairment. Adjusted all-cause mortality was increased for patients with any impairment(hazard ratio[HR]=1.56; 95%confidence interval[CI] 1.53 to 1.60, p< 0.001) and moderate to severe impairment(HR=2.31; 95%CI 2.18 to 2.44, p< 0.001). Mortality worsened incrementally across the range of renal function, with 15%(95%CI 14%to 17%) increased risk for every 0.5 mg/dl increase in creatinine and 7%(95%CI 4%to 10%) increased risk for every 10 ml/min decrease in eGFR. Conclusions: Renal impairment is common among HF patients and confers excess mortality. Renal function should be considered in risk stratification and evaluation of therapeutic strategies for HF patients.展开更多
Objectives We sought to determine whether changes in quality of life at 18 mon ths following aortic valve replacement differ depending on the use of tissue val ves or mechanical valves. Methods We prospectively studie...Objectives We sought to determine whether changes in quality of life at 18 mon ths following aortic valve replacement differ depending on the use of tissue val ves or mechanical valves. Methods We prospectively studied 73 patients with tiss ue valve replacements and 53 patients with mechanical valve replacements perform ed from April 1998 through March 1999 at Yale-New Haven Hospital. Quality of li fe was measured at baseline and at 18 months using the Medical Outcomes Trust Sh ort Form 36-Item Health Survey. Results Baseline unadjusted mean quality-of-l ife scores were lower in tissue valve recipients than in mechanical valve recipi ents and, for both groups, were generally lower than US population norms. At 18 months postoperatively, quality-of-life scores were greatly improved in both g roups and were comparable to population norms (ie, within one-half a standard d eviation). After adjusting for baseline quality of life, age, and other prognost ic factors in an analysis of covariance, improvements in quality-of-life score s for tissue valve recipients versus mechanical valve recipients were similar. O f 10(8 domains and 2 summary) scales examined, the only significant difference b etween the 2 groups was for the improvement in role limitations due to physical problems (Role Physical), which was more favorable in patients with mechanical v alve implants (P=.04). Conclusions The use of tissue valve implants versus mecha nical valve implants has little influence on improvement in quality of life at 1 8 months following aortic valve replacement. Thus, decisions about whether to ch oose a tissue valve or mechanical valve implant should depend upon other factors such as rates of complications and differences in the life span of the implants .展开更多
Background -Renal impairment is an emerging prognostic indicator in heart failure(HF) patients. Despite known racial differences in the progression of both HF and renal disease, it is unclear whether the prognosis for...Background -Renal impairment is an emerging prognostic indicator in heart failure(HF) patients. Despite known racial differences in the progression of both HF and renal disease, it is unclear whether the prognosis for renal impairment in HF patients differs by race. We sought to determine in HF patients the 1-year mortality risks associated with elevated creatinine and impaired estimated glomerular filtration rate(eGFR) and to quantify racial differences in mortality. Methods and Results -We retrospectively evaluated the National Heart Care Project nationally representative cohort of 53 640 Medicare patients hospitalized with HF. Among 5669 black patients, mean creatinine was 1.6±0.9mg/dL, and 54%had an eGFR ≤60, compared with creatinine 1.5±0.7 mg/dL and 68%eGFR ≤60 in 47 971 white patients. Higher creatinine predicted increased mortality risk, although the magnitude of risk differed by race(interaction P=0.0001). Every increase in creatinine of 0.5 mg/dL was associated with a >10%increased risk in adjusted mortality for blacks, compared with >15%increased risk in whites(interaction P=0.0001), with the most striking racial disparities at the highest levels of renal impairment. Depressed eGFR showed similar racial differences(interaction P=0.0001). Conclusions -Impaired renal function predicts increased mortality in elderly HF patients, although risks are more pronounced in whites. Distinct morbidity and mortality burdens in black versus white patients underscore the importance of improving patient risk-stratification, defining optimal therapies, and exploring physiological underpinnings of racial differences.展开更多
Context: The Centers for Medicare &Medicaid Services(CMS) and the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) measure and report quality process measures for acute myocardial infarction(AM...Context: The Centers for Medicare &Medicaid Services(CMS) and the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) measure and report quality process measures for acute myocardial infarction(AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital’s outcomes can be made from its performance on publicly reported processes. Objective: To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates. Design, Setting, and Participants: We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction(NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data. Main Outcome Measures: Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older. Results: We found moderately strong correlations(correlation coefficients ≥0.40; P values< .001) for all pairwise comparisons between β-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures(correlation coefficients< 0.40; P values< .001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates(P values< .001) but together explained only 6.0%of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI. Conclusions: The publicly reported AMI process measures capture a small proportion of the variation in hospitals’risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.展开更多
文摘Background -Hospitals with primary percutaneous coronary intervention(PPCI) capability may choose to predominately offer PPCI to their patients with ST-segment elevation myocardial infarction(STEMI), or they may selectively offer PPCI or fibrinolytic therapy based on patient and hospital-level factors. Whether a greater level of hospital specialization with PPCI is associated with better quality of care is unknown. Methods and Results -We analyzed data from the National Registry of Myocardial Infarction-4 to compare in-hospital mortality and times to treatment in STEMI across different levels of hospital specialization with PPCI. We divided 463 hospitals into quartiles of PPCI specialization based on the relative proportion of reperfusion-treated patients who underwent PPCI(≤34.0%, >34.0 to 62.5%, >62.5 to 88.5%, >88.5%). Hierarchical multivariable regression assessed whether PPCI specialization was associated with better outcomes, after adjusting for patient and hospital characteristics, including PPCI volume. We found that greater PPCI specialization was associated with a lower relative risk of in-hospital mortality in patients treated with PPCI(adjusted relative risk comparing the highest and lowest quartiles, 0.64; P=0.006) but not in those treated with fibrinolytic therapy. Compared with patients at hospitals in the lowest quartile of PPCI specialization, adjusted door-to-balloon times in the highest quartile were significantly shorter(99.6 versus 118.3 minutes; P< 0.001), and the likelihood of door-to-balloon times exceeding 90 minutes was significantly lower(relative risk, 0.78; P< 0.001). Adjusting for PPCI specialization diminished the association between PPCI volume and clinical outcomes. Conclusions -Greater specialization with PPCI is associated with lower in-hospital mortality and shorter door-to-balloon times in STEMI patients treated with PPCI.
文摘Objectives: We estimated the prevalence of renal impairment in heart failure(HF) patients and the magnitude of associated mortality risk using a systematic review of published studies. Background: Renal impairment in HF patients is associated with excess mortality, although precise risk estimates are unclear. Methods: A systematic search of MEDLINE(through May 2005) identified 16 studies characterizing the association between renal impairment and mortality in 80,098 hospitalized and non-hospitalized HF patients. All-cause mortality risks associated with any renal impairment(creatinine >1.0 mg/dl, creatinine clearance[CrCl] or estimated glomerular filtration rate[eGFR]< 90 ml/min, or cystatin-C >1.03 mg/dl) and moderate to severe impairment(creatinine ≥1.5, CrCl or eGFR< 53, or cystatin-C ≥1.56) were estimated using fixed-effects meta-analysis. Results: A total of 63%of patients had any renal impairment, and 29%had moderate to severe impairment. After follow-up ≥1 year, 38%of patients with any renal impairment and 51%with moderate to severe impairment died versus 24%without impairment. Adjusted all-cause mortality was increased for patients with any impairment(hazard ratio[HR]=1.56; 95%confidence interval[CI] 1.53 to 1.60, p< 0.001) and moderate to severe impairment(HR=2.31; 95%CI 2.18 to 2.44, p< 0.001). Mortality worsened incrementally across the range of renal function, with 15%(95%CI 14%to 17%) increased risk for every 0.5 mg/dl increase in creatinine and 7%(95%CI 4%to 10%) increased risk for every 10 ml/min decrease in eGFR. Conclusions: Renal impairment is common among HF patients and confers excess mortality. Renal function should be considered in risk stratification and evaluation of therapeutic strategies for HF patients.
文摘Objectives We sought to determine whether changes in quality of life at 18 mon ths following aortic valve replacement differ depending on the use of tissue val ves or mechanical valves. Methods We prospectively studied 73 patients with tiss ue valve replacements and 53 patients with mechanical valve replacements perform ed from April 1998 through March 1999 at Yale-New Haven Hospital. Quality of li fe was measured at baseline and at 18 months using the Medical Outcomes Trust Sh ort Form 36-Item Health Survey. Results Baseline unadjusted mean quality-of-l ife scores were lower in tissue valve recipients than in mechanical valve recipi ents and, for both groups, were generally lower than US population norms. At 18 months postoperatively, quality-of-life scores were greatly improved in both g roups and were comparable to population norms (ie, within one-half a standard d eviation). After adjusting for baseline quality of life, age, and other prognost ic factors in an analysis of covariance, improvements in quality-of-life score s for tissue valve recipients versus mechanical valve recipients were similar. O f 10(8 domains and 2 summary) scales examined, the only significant difference b etween the 2 groups was for the improvement in role limitations due to physical problems (Role Physical), which was more favorable in patients with mechanical v alve implants (P=.04). Conclusions The use of tissue valve implants versus mecha nical valve implants has little influence on improvement in quality of life at 1 8 months following aortic valve replacement. Thus, decisions about whether to ch oose a tissue valve or mechanical valve implant should depend upon other factors such as rates of complications and differences in the life span of the implants .
文摘Background -Renal impairment is an emerging prognostic indicator in heart failure(HF) patients. Despite known racial differences in the progression of both HF and renal disease, it is unclear whether the prognosis for renal impairment in HF patients differs by race. We sought to determine in HF patients the 1-year mortality risks associated with elevated creatinine and impaired estimated glomerular filtration rate(eGFR) and to quantify racial differences in mortality. Methods and Results -We retrospectively evaluated the National Heart Care Project nationally representative cohort of 53 640 Medicare patients hospitalized with HF. Among 5669 black patients, mean creatinine was 1.6±0.9mg/dL, and 54%had an eGFR ≤60, compared with creatinine 1.5±0.7 mg/dL and 68%eGFR ≤60 in 47 971 white patients. Higher creatinine predicted increased mortality risk, although the magnitude of risk differed by race(interaction P=0.0001). Every increase in creatinine of 0.5 mg/dL was associated with a >10%increased risk in adjusted mortality for blacks, compared with >15%increased risk in whites(interaction P=0.0001), with the most striking racial disparities at the highest levels of renal impairment. Depressed eGFR showed similar racial differences(interaction P=0.0001). Conclusions -Impaired renal function predicts increased mortality in elderly HF patients, although risks are more pronounced in whites. Distinct morbidity and mortality burdens in black versus white patients underscore the importance of improving patient risk-stratification, defining optimal therapies, and exploring physiological underpinnings of racial differences.
文摘Context: The Centers for Medicare &Medicaid Services(CMS) and the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) measure and report quality process measures for acute myocardial infarction(AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital’s outcomes can be made from its performance on publicly reported processes. Objective: To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates. Design, Setting, and Participants: We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction(NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data. Main Outcome Measures: Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older. Results: We found moderately strong correlations(correlation coefficients ≥0.40; P values< .001) for all pairwise comparisons between β-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures(correlation coefficients< 0.40; P values< .001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates(P values< .001) but together explained only 6.0%of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI. Conclusions: The publicly reported AMI process measures capture a small proportion of the variation in hospitals’risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.
