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The number of uninsured Americans increased by more than 6 million adults, primarily due to a decline in employer-sponsored coverage without a compensatory increase in federal- and state-sponsored coverage such as the authorization of health savings accounts through 2003 Medicare Modernization Act. Efforts to improve the use of recommended health care services among the uninsured should focus on patient education and expanding insurance eligibility for both lower-income and higher-income adults.

An attempt is made to determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. The findings reveal that door-to-balloon times were longer during off-hours than regular hours while door-to-drug times did not differ appreciably by time of day or day of week.

Race and ethnicity differences in door-to-drug and door-to-balloon times for patients receiving primary reperfusion for ST-segment elevation myocardial infarction are estimated. The results revealed that a substantial portion of the racial and ethnic disparity in time to treatment was accounted for by the specific hospital to which patients were admitted, in contrast to differential treatment by race and ethnicity inside the hospital.

There are several factors that make some hospitals more likely to treat heart attack patients with beta blockers. They include having doctors on staff who advocate beta blocker use, and strong support for this position among other staff doctors and hospital administrators. Beta blockers can lower mortality rates from a heart attack.

The article examines the association between hospital readmission and mortality rates for cardiac patients who were presented with clinical case of acute myocardial infarction, heart failure and pneumonia. It highlights the impact of quality of medical care provided by health care centers in resolving the risk associated with cardiac patients. The Centers for Medicare & Medicaid Services in the U.S. on the basis of a cohort analysis revealed that differences in performance of hospitals and diagnostic parameters implied by hospital were of immense use in determination of readmission rate and mortality rate of cardiac patients.

The article discusses the results of a study which used a system developed by the U.S. Centers for Medicare & Medicaid Services to examine the national performance in door-in to door-out (DIDO) time. The study examined the association of the national median DIDO time with patient and hospital characteristics. The study concluded that rarely does the DIDO time met the recommended 30 minutes among patients requiring transfer to another facility for percutaneous coronary intervention.

The article discusses a study of health care quality at hospitals in U.S. states and in the U.S. territories. The hospitals involved discharged at least one Medicare fee-for-service (FFS) adult diagnosed with acute myocardial infarction (AMI), heart failure (HF) or pneumonia (PNE) from July 2005 to June 2008. Hospitals in the U.S. territories differ from stateside ones in terms of for-profit ownership. Mortality rates are said to be higher in hospitals in the U.S. territories.

The article presents a study examining quality process measures for acute myocardial infarction and the measures' association with 30-day mortality rates. The study concludes that multiple measures are needed to better evaluate hospital performance. The article discusses variations in risk-standardized short-term mortality rates, the Centers for Medicare & Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations, the use of β-blocker, aspirin, and angiotensin-converting enzyme inhibitors, reperfusion therapy, and smoking cessation counseling.

Background: Treatment outcomes are an important determinant of patients' treatment preferences. Although studies have examined how well surrogates agree with patients' preferences for specific treatment interventions, agreement regarding the valuation of health states as treatment outcomes is unknown. Methods: Cross-sectional cohort study consisting of in-home interviews with 193 persons 60 years or older and seriously ill with cancer, congestive heart failure, or chronic obstructive pulmonary disease and their caregivers. Patients were asked whether, facing an exacerbation of illness, they would find a series of health states acceptable as a result of treatment (a rating of "unacceptable" meant they would prefer to die than to receive treatment). Caregivers were asked whether they would find these states acceptable for the patient. Results: There was 80% or greater agreement for health states that were overall rated either acceptable (current health, mild memory impairment, mild pain, or other symptoms) or unacceptable (coma). There was 58% to 62% agreement (κ = 0.10-0.25) about states with more severe physical or cognitive impairment. When disagreement occurred, caregivers were more likely to rate the state as acceptable. There was 61% to 65% agreement (κ = 0.20-0.28) about states with severe pain or other symptoms. When disagreement occurred, caregivers and patients were equally likely to rate the state as acceptable. Conclusions: Patient-caregiver agreement about the acceptability of health states with functional or cognitive impairment, severe pain, or other symptoms was poor. Caregivers making surrogate decisions based on considerations of treatment outcomes may not effectively represent patients' preferences. [ABSTRACT FROM AUTHOR]

The authors' reply to a letter to the editor in response to the article "Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality," by E. H. Bradley and colleagues is presented.

A letter to the editor is presented in response to the article by Dr. Butler and colleagues on the 10 promoted strategies for reducing readmission for patients with heart failure in issue 310(19):2035-2036.

A letter to the editor is presented in response to the article "Refusal of care: patients' well being and physicians' ethical obligations: 'but doctor, I want to go home'," by Joseph A. Carrese, published in the August 9, 2006 issue (Volume 296, Number 6).

The letter agrees with readers' comments on the effectiveness of percutaneous coronary intervention in myocardial infarction patients.

Background: Critical pathways have been purported to decrease resource utilization in the management of head and neck cancer. Prior reports have documented shorter lengths of stay (LOS) for pathway patients than for historical cohorts., Objective: To critically evaluate the impact of critical pathways on LOS after laryngectomy., Design: Length-of-stay trends of 2 concurrent observational cohorts of laryngectomy patients (September 1992 to February 1999) were compared, 1 at each of 2 medical centers. One center instituted a critical pathway for laryngectomy patients in February 1997; the other never used such pathways. In addition, we examined the independent impact of the critical pathway at the pathway institution after controlling for date of laryngectomy (which reflected temporal trends) and other confounding variables., Results: Both centers experienced reductions in LOS after February 1997, but there was no statistically significant difference between the reductions (1.9 days at the pathway center vs 1.5 days at the nonpathway center; P>.05). Multivariable linear and linear spline regression models demonstrated that the use of critical pathways at the pathway institution had no statistically significant impact on LOS after controlling for the date of laryngectomy., Conclusions: Pathway implementation has a limited direct impact on LOS in relatively low-volume procedures such as laryngectomy. Although pathways may influence utilization trends, their impact is likely mediated by the development and educational process that accompanies pathway adoption rather than implementation of the pathway itself. The inclusion of temporal trends and contemporary cohorts provides substantial insight into the effectiveness of critical pathways.