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The article offers information on a study which determined the link between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation during acute myocardial infarction (AMI). Data analyzed by researchers were from a registry of AMI patients enrolled between April 11, 2005 and December 31, 2008 at 24 U.S. hospitals. Medical records were utilized to determine insurance information, while information on financial concerns was taken from structured interviews. A detailed discussion on the research findings is presented.

The article presents a study that evaluates the effect of a mental illness diagnosis on quality of care and outcomes among patients with heart failure. Participants include 53,314 Medicare beneficiaries, with 17% having a mental illness diagnosis. Results showed that eligible patients with mental illness diagnoses had lower rates of left ventricular ejection fraction (LVEF) evaluation when compared with patients without mental illness diagnoses. LVEF is a measure of the quality of care. It concludes that elderly patients diagnosed with mental illness receive poorer care during hospitalization and has a greater risk of readmission to the hospital and death.

Background Health care expenditure per person is significantly higher in the United States compared with Canada, but whether there are differences in quality of care of many conditions is unknown. We compared the process of care and outcomes of patients with heart failure, the most common cause of hospitalization for individuals 65 years and older in both countries. Methods We compared processes of care and 30-day and 1-year risk-standardized mortality rates among 28 521 US Medicare beneficiaries and 8180 similarly aged patients in Ontario, Canada, hospitalized with heart failure from 1998 to 2001. Results More US patients underwent left ventricular ejection fraction assessment during hospitalization compared with Canadian patients (61.2% vs 41.7%, P<.001). At discharge, patients in the United States were prescribed β-blockers more frequently (28.7% vs 25.4%, P<.001) but angiotensin-converting enzyme inhibitors less frequently (54.3% vs 63.4%, P<.001). Among ideal candidates, prescription of β-blockers (32.5% vs 29.7%, P = .08) or angiotensin-converting enzyme inhibitors (78.3% vs 77.6%, P = .68) was not significantly different between the 2 countries. The US patients had lower risk characteristics on admission and lower crude mortality rates at 30 days and 1 year. Thirty-day risk-standardized mortality was significantly lower for the US patients (8.9% vs 10.7%, P<.001), but 1-year risk-standardized mortality was no longer significantly different (32.2% vs 32.3%, P = .98). Conclusion Patients with heart failure who are hospitalized in the United States had lower short-term mortality at 30 days, but 1-year mortality rates were not significantly different between the United States and Canada. [ABSTRACT FROM AUTHOR]

Comments on the push for regional treatment centers for patients with acute coronary syndromes. Planning for regionalized care begun by the State of Maryland; Presentation of concerns for this approach to patient care and possible unintended consequences; Arguments for the benefits of the ACS centers, which are based on studies with notable limitations; Lack of clear consensus on the specific nature of ACS regionalization; Risks to patients; Concerns about how the direct admission of ACS patients will be handled; Economic implications; Concern that regionalization may be the end of quality care at non-ACS facilities; Conclusion and belief there is not enough data to support the value of these centers at this time.

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. [ABSTRACT FROM AUTHOR]

Background Rates of guideline-based care for elderly patients with heart failure vary by state, and overall are not optimal. Identifying factors associated with the lack of uniformly high-quality health care might aid efforts to improve care. We therefore sought to determine the extent to which provider and hospital characteristics contribute to small-area geographic variation in heart failure care after controlling for patient factors. Methods We studied 30 228 Medicare patients who were older than 65 years and hospitalized with heart failure. We mapped rates for 2 quality measures—documentation of left ventricular ejection fraction and appropriate prescription of angiotensin-converting enzyme inhibitors—across the United States, using a Bayesian technique that smooths rates and enhances assessment for significant patterns of small-area variation. We used nonlinear hierarchical models to assess for associations between the the quality indicators and provider and hospital characteristics independent of patient characteristics. Results Smoothed, unadjusted rates of left ventricular ejection fraction documentation ranged from 30.1% to 67.2% and of angiotensin-converting enzyme inhibitor prescription from 55.8% to 87.1% among hospital referral regions; regional patterns were apparent. After patient factors were controlled for, care at hospitals without a medical school affiliation, without invasive cardiac capabilities, or in a rural location, as well as not having a cardiologist as an attending physician, was significantly associated with lower rates of left ventricular ejection fraction documentation. Hospitalization at a nonteaching facility was significantly associated with failure to prescribe angiotensin-converting enzyme inhibitors. Conclusion Characteristics of providers and hospitals explain in part the geographic variation in guideline-based care for elderly patients with heart failure. [ABSTRACT FROM AUTHOR]

Examines the association between U.S. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation of hospitals, quality of care and survival among Medicare patients hospitalized for acute myocardial infarction (AMI). Requirements under the JCAHO accreditation program; Quality of AMI care and outcomes; Mortality rates of hospitals accredited with commendation.

: PurposeOlder patients are less likely to receive guideline-recommended medical therapies during acute myocardial infarction. However, it is unclear whether the lower rates of treatment reflect elderly patients’ increased number of comorbid conditions, physician or hospital effects, or true age-associated variation. Furthermore, it is unclear whether age-associated variations in care are similar or vary among treatments.: MethodsWe evaluated 146,718 Medicare patients from the Cooperative Cardiovascular Project aged ≥65 years who were hospitalized between 1994 and 1996 with a confirmed myocardial infarction, to ascertain whether rates of acute reperfusion therapy and use of aspirin (admission, discharge), beta-blockers (admission, discharge), and angiotensin-converting enzyme (ACE) inhibitors varied among patients aged 65 to 69 years, 70 to 74 years, 75 to 79 years, 80 to 84 years, and ≥85 years. We identified patients who were considered eligible for each therapy and who had no treatment contraindications. Associations between age and use of therapy were assessed, adjusting for patient, physician, hospital, and geographic factors.: ResultsAdjusted treatment rates were higher for patients aged 65 to 69 years than for patients aged ≥85 years for acute reperfusion therapy (54.4% vs. 31.2%, P <0.0001 for trend), beta-blockers (admission: 52.2% vs. 43.8%, P <0.0001 for trend; discharge: 61.8% vs. 55.3%, P <0.0001 for trend), aspirin at admission (73.8% vs. 71.0%, P <0.0001 for trend), and ACE inhibitors (61.6% vs. 57.1%, P = 0.02 for trend); there were no differences in the prescription of aspirin at discharge (76.0% vs. 73.6%, P = 0.05).: ConclusionElderly patients are less likely to receive guideline-indicated therapies when hospitalized with myocardial infarction. The effects of age were largest for acute reperfusion and smallest for aspirin. [Copyright &y& Elsevier]

Reports on a study to investigate the relationship between patient sex, physician sex, and the use of cardiac procedures, specifically whether sex differences in cardiac catheterization after acute myocardial infarcation (AMI) were greater when patients were treated by male attending physicians compared with female physicians. Methods; Results; Conclusion suggesting that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.

Presents a reply to a letter to the editor of "The Journal of the American Medical Association" regarding acute coronary syndromes and regionalization of care. Discussion of an article by Rathore and colleagues found in a previous issue of the journal.

Presents a reply from the authors of an article about racial disparities in the care of heart failure which appeared in a previous issue of the 'Journal of the American Medical Association.'