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The results of clinical investigations for identifying the relationship between hydroxymethylglutaryl-CoA reductate inhibitors (statins) and patient outcomes in elderly persons with acute myocardial infarction are discussed.

Studies documenting racial differences in health care use are common in the medical literature. However, observational studies of racial differences in health care use lack a framework for interpreting reports of variations in health care use, leading to various terms, ranging from 'variations' to 'bias,' that suggest different causes, consequences, and, ultimately, remedies for such variations in treatment. We propose criteria to assess racial differences in health care use by using a clinical equity (equal treatment based on equal clinical need) framework. This framework differentiates between initial reports of racial differences and subsequent classifications of their findings as racial disparities or racial bias in health care use. Racial variations in health care use may be considered disparities after demonstrating that racial differences are not attributable to treatment eligibility, clinical contraindications, patient preferences, or confounding by other clinical factors and are associated with adverse consequences. Racial bias with adverse consequences in health care may be inferred if a racial variation in treatment that has been characterized as a disparity persists after accounting for health care system factors (for example, type of hospital at which the patient was treated). We apply this framework to published reports of racial differences in treatment to determine which studies provide evidence of differences, disparities, and bias. We discuss the use of such a framework in directing policy interventions for alleviating inappropriate racial variations in health care use.

Objectives: To determine if there are sex differences in the use of coronary, revascularization in elderly patients after acute myocardial infarction (AMI), and if sex differences vary by type of [...]

Background: Type 2 diabetes mellitus is associated with a heavy burden of suffering. Screening for diabetes is controversial. Purpose: To examine the evidence that screening and earlier treatment are effective in reducing morbidity and mortality associated with diabetes. Data Sources: MEDLINE, the Cochrane Library, reviews, and experts, all of which addressed key questions about screening. Study Selection: Studies that provided information about the existence and length of an asymptomatic phase of diabetes; studies that addressed the accuracy and reliability of screening tests; and randomized, controlled trials with health outcomes for various treatment strategies were selected. Data Extraction: Two reviewers abstracted relevant information using standardized abstraction forms and graded articles according to U.S. Preventive Services Task Force criteria. Data Synthesis: No randomized, controlled trial of screening for diabetes has been performed. Type 2 diabetes mellitus includes an asymptomatic preclinical phase; the length of this phase is unknown. Screening tests can detect diabetes in its preclinical phase. Over the 10 to 15 years after clinical diagnosis, tight glycemic control probably reduces the risk for blindness and end-stage renal disease, and aggressive control of hypertension, lipid therapy, and aspirin use reduce cardiovascular events. The magnitude of the benefit is larger for cardiovascular risk reduction than for tight glycemic control. The additional benefit of starting these treatments in the preclinical phase, after detection by screening, is uncertain but is probably also greater for cardiovascular risk reduction. Conclusions: The interventions that are most closely beneficial during the preclinical phase are those that affect the risk for cardiovascular disease. The magnitude of additional benefit of initiating tight glycemic control during the preclinical phase is uncertain but probably small.

Background: Many studies have found that women are less likely than men to have cardiac catheterization after an acute myocardial infarction; however, it is unknown whether sex differences reflect inappropriate treatment. Objective: To ascertain whether cardiac catheterization use after acute myocardial infarction in men and women varied by sex and the appropriateness of the procedure, as determined by clinical guidelines. Design: Retrospective analysis of chart-abstracted data. Setting: U.S. acute-care hospitals. Patients: 143 444 Medicare patients who were hospitalized for acute myocardial infarction between 1994 and 1996. Measurements: Cardiac catheterization use within 60 days of hospitalization for acute myocardial infarction. Results: Women had lower crude rates of cardiac catheterization than men (35.7% for women vs. 46.5% for men [P0.2]; difference, 0.5 percentage point). Rates of cardiac catheterization use among patients with weak indications did not significantly differ between men and women (16.5% for women vs. 18.0% for men [P=0.096]; difference, 1.5 percentage points). Sex differences in cardiac catheterization use were largest for patients with equivocal indications (39.4% for women vs. 42.5% for men [P Conclusions: Among elderly persons, women have lower rates of cardiac catheterization use after an acute myocardial infarction than men. However, this difference was attenuated after multivariable adjustment, and it occurred primarily in patients with equivocal indications. We found no sex variations in procedure use among patients who had strong indications for cardiac catheterization.

OBJECTIVE--To evaluate the relationship between A1C and glucose therapy intensification (GTI) in patients with diabetes mellitus (DM) hospitalized for acute myocardial infarction (AMI). RESEARCH DESIGN AND METHODS--A1C was measured as [...]

The article targets the need for older patients to be included in heart attack medical care quality measurements, as they are currently an under-represented patient group.

Background: A paced rhythm can mask the electrocardiographic features of an acute myocardial infarction, complicating timely recognition and treatment. Objective: To evaluate characteristics, treatment, and outcomes among patients presenting with paced rhythms during myocardial infarction. Design: Retrospective cohort study. Setting: U.S. acute care hospitals. Patients: 102 249 Medicare beneficiaries at least 65 years of age who were treated for acute myocardial infarction between 1994 and 1996. Measurements: Provision of three treatments for acute myocardial infarction (emergent reperfusion, aspirin, and [Beta]-blockers), death at 30 days, and long-term follow-up. Results: 1954 patients (1.9%) presented with paced rhythms during myocardial infarction. These patients were older; were predominantly male; and had higher rates of congestive heart failure, diabetes, and previous infarction. They were significantly less likely to receive emergent reperfusion (relative risk [RR], 0.27 [95% CI, 0.22 to 0.33]), aspirin (RR at admission, 0.91 [CI, 0.88 to 0.94]; RR at discharge, 0.87 [CI, 0.83 to 0.92]), and [Beta]-blockers at admission (RR, 0.89 [CI, 0.82 to 0.96]). In addition, there was a trend toward decreased use of [Beta]-blockers at discharge (RR, 0.91 [CI, 0.76 to 1.06]). Crude mortality rates were higher among patients with paced rhythms than among those without at 30 days (25.8% vs. 21.3%; P = 0.001) and at 1 year (47.1% vs. 36.1%; P = 0.001). Among patients with paced rhythms, risk for death at 30 days decreased after adjustment for illness severity and decreased use of therapy (RR, 1.03 [CI, 0.93 to 1.14]). Patients with paced rhythms remained at additional risk for long-term mortality (hazard ratio, 1.12 [CI, 1.06 to 1.18]). Conclusions: Patients with paced rhythms were less likely than those without to receive treatment for acute myocardial infarction and had poorer short- and long-term outcomes. However, this mortality risk diminished after adjustment for treatment. This suggests that improved recognition and treatment of myocardial infarction may improve outcomes, particularly in the short term. Ann Intern Med. 2001;134:644-651. www.annals.org

Background: Some physicians may resort to deception to secure third-party payer approval for patient procedures. Related physician attitudes, including willingness to use deception, are not well understood. Objective: To determine physician willingness to deceive a third-party payer and physician attitudes toward deception of third-party payers. Methods: A cross-sectional mailed survey was used to evaluate physician willingness to use deception in 6 vignettes of varying clinical severity: coronary bypass surgery, arterial revascularization, intravenous pain medication and nutrition, screening mammography, emergent psychiatric referral, and cosmetic rhinoplasty. We evaluated 169 board-certified internists randomly selected from 4 high- and 4 low-managed care penetration metropolitan markets nationwide for willingness to use deception in each vignette. Results: Physicians were willing to use deception in the coronary bypass surgery (57.7%), arterial revascularization (56.2%), intravenous pain medication and nutrition (47.5%), screening mammography (34.8%), and emergent psychiatric referral (32.1%) vignettes. There was little willingness to use deception for cosmetic rhinoplasty (2.5%). Rates were highest for physicians practicing in predominantly managed care markets, for clinically severe vignettes, and for physicians spending less time in clinical practice. Physician ratings of the justifiability of deception varied by perspective and vignette. Conclusions: Many physicians sanction the use of deception to secure third-party payers' approval of medically indicated care. Such deception may reflect a tension between the traditional ethic of patient advocacy and the new ethic of cost control that restricts patient and physician choice in the use of limited resources. Arch Intern Med. 1999; 159:2263-22 70