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A study was conducted to evaluated the association between length of stay and short-term outcomes among Medicare older patients hospitalized for heart failure. Results indicated that with a reduced length of hospital stay 30-day mortality decreased; however, posthospital readmission and mortality risk increased.

Cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries hospitalized between 2004 and 2006 in acute care hospitals in US was conducted to determine the association between hospital volume threshold and the death rate for patients hospitalized for acute myocardial infarction, heart failure, or pneumonia. Admission to higher-volume hospitals was found to be associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, but volume threshold above which an increased condition-specific hospital was not significantly associated with reduced mortality.

A study was conducted to evaluate the low-dose ionizing radiation exposure that occurs after medical imaging procedures. Results indicate that such procedures lead to high cumulative effective doses of radiation.

The study attempts to evaluate the hospital 30-day risk-standardized mortality rates (RSMRs) for those patients that have been discharged with acute myocardial infarction (AMI). The results indicate that there was a significant decrease in hospital mortality rate for patients with AMI.

A study was conducted to evaluate whether patients receiving an implantable cardioverter-defibrillator (ICD) from nonelectrophysiologists had more negative outcomes as compared to implants done by electrophysiologists who were certified for the procedure. Results indicated that implants done by nonelectrophysiologists had a higher risk of procedural complications.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2005.03.009 Byline: Tobias T. Lee, Jersey Chen, David J. Cohen, Lana Tsao Abstract: The association between low blood pressure and prognosis in the general population has been controversial, with some reports suggesting an increased mortality for patients with the lowest blood pressures. Whereas many standard heart failure therapies decrease blood pressure, the relationship between mortality and blood pressure in patients with heart failure has not been previously evaluated. Author Affiliation: Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA Article History: Received 6 October 2004; Accepted 1 March 2005

Internet-based report cards may not be the best way to rate hospitals. In a study of 141,914 Medicare patients admitted to 3,363 hospitals for treatment of a heart attack, report cards on HealthGrades.com did not accurately discriminate between hospitals that provided the best care and hospitals that provided the worst care., Context: Health care "report cards" have attracted significant consumer interest, particularly publicly available internet health care quality rating systems. However, the ability of these ratings to discriminate between hospitals is not known. Objective: To determine whether hospital rating for acute myocardial infarction (AMI) mortality from a prominent Internet hospital ratir g system accurately discriminate between hospitals' performance based on process of care and outcomes. Design, Setting, and Patients: Data from the Cooperative Cardiovascular Project, a retrospective systematic medical record review of 141914 Medicare fee-for-service beneficiaries 65 years or older hospitalized with AMI at 3363 US acute care hospitals during a 4- to 8-month period between January 1994 and February 1996 were compared with ratings obtained from HealthGrades.com (1-star: worse outcomes than predicted, 5-star: better outcomes than predicted) based on 1994-1997 Medicare data. Main Outcome Measures: Quality indicators of AMI care, including use of acute reperfusion therapy, aspirin, [beta]-blockers, angiotensin-converting enzyme inhibitors; 30-day mortality. Results: Patients treated at higher-rated hospitals were significantly more likely to receive aspirin (admission: 75.4% 5-star vs 66.4% 1-star, P for trend = .001; discharge: 79.7% 5-star vs 68.0% 1-star, P = .001 and [beta]-blockers (admission: 54.8% 5-star vs 35.7% 1-star, P = .001; discharge: 63.3% 5-star vs 52.1% 1-star, P = .001), but not angiotensin-converting enzyme inhibitors (59.6% 5-star vs 57.4% 1-star, P = .40). Acute reperfusion therapy rates were highest for patients treated at 2-star hospitals (60.6%) and lowest for 5-star hospitals (53.6% 5-star, P =.008). Risk-standardized 30-day mortality rates were lower for patients treated at higher-rated than lower-rated hospitals (21.9% 1-star vs 15.9% 5-star, P = .001). However, there was marked heterogeneity within rating groups and substantial overlap of individual hospitals across rating strata for mortality and process of care; only 3.1% of comparisons between 1-star and 5-star hospitals had statistically lower risk-standardized 30-day mortality rat es in 5-star hospitals. Similar findings were observed in comparisons of 30-day mortality rates between individual hospitals in all other rating groups and when comparisons were restricted to hospitals with a minimum of 30 cases during the study period. Conclusion Hospital ratings published by a prominent Internet health care quality rating system identified groups of hospitals that, in the aggregate, differed in their quality of care and outcomes. However, the ratings poorly discriminated between any 2 individual hospitals' process of care or mortality rates during the study period. Limitations in discrimination may undermine the value of health care quality ratings for patients or payers and may lead to misperceptions of hospitals' performance.

Women who have had a heart attack are less likely than men to have cardiac catheterization even when the woman's doctor is also a woman. This means that bias on the part of male doctors is not responsible for the lower rate of cardiac catheterization in female cardiac patients., Context Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. Objective To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. Design, Setting, and Patients Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104231 Medicare fee-for-service beneficiaries who were hospitalized in US acute care hospitals for an AMI between January 1994 and February 1995. Main Outcome Measure Use of cardiac catheterization within 60 days of admission, compared between the 4 groups of patient sex-physician sex combinations. Results Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs 50.8%; P=.001) or female physicians (34.8% vs 45.8%; P=.001). Sex differences in procedure use were not greater when a patient and physician were of different sexes (P for interaction=.85). After potential confounders in multivariable analysis were accounted for, women were less likely to undergo cardiac catheterization (risk ratio, 0.90 [95% confidence interval {CI}, 0.880.92]), regardless of the treating physician's sex. Patients treated by male physicians were more likely to undergo cardiac catheterization (risk ratio, 1.06 [95% CI, 1.02-1.10]) than those treated by female physicians, regardless of patient sex. Conclusions Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician. These results suggest that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.

Black heart attack patients who are treated by a black doctor are no more likely to have cardiac catheterization then black patients treated by a white doctor. Black heart attack patients as a group are less likely to have cardiac catheterization than whites, but a study of 35,676 white patients and 4,039 black patients found this was not caused by the race of the doctor.

Heart attack patients admitted to hospitals ranked high on a U.S. News & World Report annual list have lower mortality rates because these hospitals are more likely to use aspirin and beta blockers. Researchers compared mortality rates among elderly heart attack patients at three different types of hospitals: those whose cardiology services ranked high on the America's Best Hospitals list, similarly-equipped hospitals not ranked as high, and all other hospitals. Although 30-day mortality rates were lowest at the high-ranking hospitals, these hospitals were also more likely to use aspirin and beta blockers. After adjusting for this factor, mortality rates were approximately the same.

Byline: Harlan M. Krumholz, Jersey Chen, Jaime E. Murillo, David J. Cohen, Martha J. Radford Abstract: Although cost estimates for acute myocardial infarction are necessary for decisions about allocating scarce resources, there is a relative paucity of studies that estimate these costs across the entire spectrum of hospitals in actual clinical practice. This study sought to determine the correlates of in-hospital costs for acute myocardial infarction in patients 65 years of age and older. In the Cooperative Cardiovascular Project pilot, medical records were abstracted for acute myocardial infarction hospitalizations in Connecticut from June 1, 1992, through May 20, 1993. In-hospital costs were calculated by multiplying charges from cost centers by the Medicare ratio of cost-to-charge. Among the 2628 patients in the study sample, the total mean in-hospital cost was $14,772, and the median in-hospital cost was $10,409 (twenty-fifth to seventy-fifth percentile, $6960 to $17,225). The largest proportion of the costs were concentrated in room costs (43% of the total). Although several demographic and clinical characteristics were significantly associated with cost, they accounted for only 7% of the variation. In-hospital procedures and adverse outcomes accounted for 53% of the variation. (Am Heart J 1998;135:523-31.) Author Affiliation: New Haven, Middletown, and Farmington, Conn., and Boston, Mass Article History: Received 27 February 1997; Accepted 18 August 1997 Article Note: (footnote) [star] From the aSection of Cardiovascular Medicine, bDepartment of Medicine, the Section of Chronic Disease Epidemiology, cDepartment of Epidemiology and Public Health, and the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, the dConnecticut Peer Review Organization, Middletown, eCardiology Division, Department of Medicine, University of Connecticut Medical School, Farmington, Conn., and the fDivision of Cardiovascular Medicine, Department of Medicine, Beth Israel Hospital, Boston, Mass., [star][star] Supported in part by the Patrick and Catherine Weldon Donaghue Medical Research Foundation., a Reprint requests: Harlan M. Krumholz, MD, Yale University School of Medicine, 333 Cedar St., P.O. Box 208025, New Haven, CT 06520-8025, E-mail: harlan.krumholz@yale.edu, aa The analyses upon which this publication is based were performed under Contract Number 500-96-P549, entitled 'Utilization and Quality Control Peer Review Organization for the State of Connecticut,' sponsored by the Health Care Financing Administration, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this Contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed., acents 0002-8703/98/$5.00 + 0 4/1/86011

Many elderly heart attack patients are not receiving thrombolytic therapy even though they might benefit from it. Thrombolytic drugs break up the blood clots that cause most heart attacks. Researchers analyzed Medicare data on 3,093 patients treated for a heart attack. Of the 753 patients who had no contraindications for thrombolytic therapy, over half did not receive it. Those who were older, had no chest pain and who were hospitalized more than 6 hours after their symptoms began were most likely not to receive thrombolytic therapy., Objective. -- To determine the correlates of thrombolytic therapy use in a population-based sample of elderly patients hospitalized with acute myocardial infarction who were eligible for the therapy on presentation. Design. -- Retrospective cohort study using data from medical charts and administrative files. Setting. -- All acute care, nongovernmental hospitals in Connecticut. Patients. -- A cohort of 3093 patients aged 65 years and older with a discharge diagnosis of acute myocardial infarction covered by Medicare from May 1992 to May 1993. Results. -- Among the 753 patients with ST-segment elevation of 1 mm or more in at least 2 contiguous leads, left bundle branch block not known to be old, and no absolute contraindications to thrombolytic therapy who were not referred for direct angioplasty or bypass surgery, 419 patients (56%) did not receive thrombolytic therapy. The strongest predictors of not receiving thrombolytic therapy included advanced age, absence of chest pain, presentation more than 6 hours after the onset of symptoms, left bundle branch block, total ST-segment elevation of 6 mm or less, presence of Q waves, ST-segment elevation in only 2 leads, and altered mental status. Physicians documented why they did not administer thrombolytic therapy in 19% of the charts. Delay in presentation and increased age were the most common reasons cited. Among the subset of 261 patients who presented with chest pain and within 6 hours of symptoms, 197 (75%) received thrombolytic therapy. Conclusions. -- Many eligible and ideal patients for thrombolytic therapy are not treated. Physicians are less likely to use thrombolytic therapy in eligible patients with characteristics associated with an increased risk of bleeding, lower-risk infarction, less certain diagnosis, less certain efficacy, or altered mental status. These findings suggest that the lack of treatment represents a clinical judgment rather than an inadvertent omission. In some cases, such as the lower use of thrombolytic therapy with older age, these judgments are not consistent with the published literature and may represent opportunities to improve care.

Many elderly persons who have a heart attack do not receive beta blockers. These drugs have been shown to reduce the risk of a second heart attack. Researchers analyzed beta blocker use in 115,015 elderly patients who had a heart attack in 1994 or 1995. Of the 45,308 who had no contraindication to beta blocker use, only half received a prescription for a beta blocker when they were discharged from the hospital. The rate of beta blocker use varied from 30.3% to 77.1% depending on the state. Rates were highest in New England. One year after discharge, those taking beta blockers had a 14% lower risk of mortality.

Many elderly persons who have a heart attack do not receive beta blockers. These drugs have been shown to reduce the risk of a second heart attack. Researchers analyzed beta blocker use in 115,015 elderly patients who had a heart attack in 1994 or 1995. Of the 45,308 who had no contraindication to beta blocker use, only half received a prescription for a beta blocker when they were discharged from the hospital. The rate of beta blocker use varied from 30.3% to 77.1% depending on the state. Rates were highest in New England. One year after discharge, those taking beta blockers had a 14% lower risk of mortality.

Many elderly persons who have a heart attack do not receive beta blockers. These drugs have been shown to reduce the risk of a second heart attack. Researchers analyzed beta blocker use in 115,015 elderly patients who had a heart attack in 1994 or 1995. Of the 45,308 who had no contraindication to beta blocker use, only half received a prescription for a beta blocker when they were discharged from the hospital. The rate of beta blocker use varied from 30.3% to 77.1% depending on the state. Rates were highest in New England. One year after discharge, those taking beta blockers had a 14% lower risk of mortality.

Many elderly persons who have a heart attack do not receive beta blockers. These drugs have been shown to reduce the risk of a second heart attack. Researchers analyzed beta blocker use in 115,015 elderly patients who had a heart attack in 1994 or 1995. Of the 45,308 who had no contraindication to beta blocker use, only half received a prescription for a beta blocker when they were discharged from the hospital. The rate of beta blocker use varied from 30.3% to 77.1% depending on the state. Rates were highest in New England. One year after discharge, those taking beta blockers had a 14% lower risk of mortality.