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Objective: To demonstrate that it is possible to identify the cohort of students in their first year of medical school from which future psychiatrists will be recruited.Method: During a 3-year period, all first-year medical students at the University of Maryland completed a form indicating their specialty preference. Of those students, 403 pursued the regular psychiatry curriculum, and 34 participated in an enriched behavioural science and psychiatry program. Specialty was chosen after graduation.Results: The higher the first-year student ranked psychiatry as a preferred specialty, the more likely the student was to choose psychiatry as a career after graduation. This was true both for students in the regular psychiatry program and for those in the enriched program. Students in the enriched program were significantly more likely to choose psychiatry as a career than were "regular" psychiatry students who gave psychiatry the same ranking in their first year. Freshman students who ranked psychiatry 4th or lower were not likely to choose psychiatry, no matter how much encouragement they received from their psychiatry departments.Conclusions: 1) Specialty preferences in the freshman year are predictive of future career choices. 2) An enriched medical school program in psychiatry can increase the number of graduates choosing careers in psychiatry. To help resource-poor medical schools increase the number of American medical graduates choosing psychiatry, the authors propose 2 inexpensive enriched programs. [ABSTRACT FROM AUTHOR]

Background: Diagnostic errors are an underappreciated cause of preventable mortality in hospitals and pose a risk for severe patient harm and increase hospital length of stay., Objective: This study aims to explore the potential of machine learning and natural language processing techniques in improving diagnostic safety surveillance. We conducted a rigorous evaluation of the feasibility and potential to use electronic health records clinical notes and existing case review data., Methods: Safety Learning System case review data from 1 large health system composed of 10 hospitals in the mid-Atlantic region of the United States from February 2016 to September 2021 were analyzed. The case review outcome included opportunities for improvement including diagnostic opportunities for improvement. To supplement case review data, electronic health record clinical notes were extracted and analyzed. A simple logistic regression model along with 3 forms of logistic regression models (ie, Least Absolute Shrinkage and Selection Operator, Ridge, and Elastic Net) with regularization functions was trained on this data to compare classification performances in classifying patients who experienced diagnostic errors during hospitalization. Further, statistical tests were conducted to find significant differences between female and male patients who experienced diagnostic errors., Results: In total, 126 (7.4%) patients (of 1704) had been identified by case reviewers as having experienced at least 1 diagnostic error. Patients who had experienced diagnostic error were grouped by sex: 59 (7.1%) of the 830 women and 67 (7.7%) of the 874 men. Among the patients who experienced a diagnostic error, female patients were older (median 72, IQR 66-80 vs median 67, IQR 57-76; P=.02), had higher rates of being admitted through general or internal medicine (69.5% vs 47.8%; P=.01), lower rates of cardiovascular-related admitted diagnosis (11.9% vs 28.4%; P=.02), and lower rates of being admitted through neurology department (2.3% vs 13.4%; P=.04). The Ridge model achieved the highest area under the receiver operating characteristic curve (0.885), specificity (0.797), positive predictive value (PPV; 0.24), and F 1 -score (0.369) in classifying patients who were at higher risk of diagnostic errors among hospitalized patients., Conclusions: Our findings demonstrate that natural language processing can be a potential solution to more effectively identifying and selecting potential diagnostic error cases for review and therefore reducing the case review burden., (©Azade Tabaie, Alberta Tran, Tony Calabria, Sonita S Bennett, Arianna Milicia, William Weintraub, William James Gallagher, John Yosaitis, Laura C Schubel, Mary A Hill, Kelly Michelle Smith, Kristen Miller. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.08.2024.)

Background: Approximately half of all women with anginal symptoms and/or signs of ischemia and no obstructive coronary artery disease (INOCA) referred for coronary angiography have elevated risk for major adverse cardiac events (MACE), poor quality of life and resource consumption. Yet, guidelines focus on symptom management while clinical practice typically advocates only reassurance. Pilot studies of INOCA subjects suggest benefit with intensive medical therapy (IMT) that includes high-intensity statins and angiotensin converting enzyme inhibitors (ACE-I) or receptor blockers (ARB) to provide the rationale for a randomized pragmatic trial to limit MACE., Methods: The Women's IschemiA TRial to Reduce Events In Non-ObstRuctive CAD is a multicenter, prospective, randomized, blinded outcome evaluation (PROBE design) of a pragmatic strategy of IMT vs usual care (UC) in 4,422 symptomatic women with INOCA (NCT03417388) in approximately 70 United States sites. The hypothesis is that IMT will reduce the primary outcome of first occurrence of MACE by 20% vs. UC at ∼2.5 year followup. Secondary outcomes include quality of life, time to return to "duty"/work, healthcare utilization, angina, cardiovascular death and individual primary outcome components over 3 years follow-up. The study utilizes web-based data capture, e-consents, single IRB and centralized pharmacy distribution of strategy medications directly to patients' homes to reduce site and patient burden. A biorepository will collect blood samples to assess potential mechanisms., Conclusions: The results of this trial will provide important data necessary to inform guidelines regarding how best to manage this growing and challenging population of women with INOCA., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Prasugrel is a potent thienopyridine that may be preferentially used in younger patients with lower bleeding risk., Objective: We compared prasugrel use and outcomes by age from the PROMETHEUS study. We also assessed age-related trends in treatment effects with prasugrel versus clopidogrel., Methods: PROMETHEUS was a multicenter acute coronary syndrome (ACS) percutaneous coronary intervention (PCI) registry. We compared patients in age tertiles (T1 < 60 years, T2 60-70 years, T3 > 70 years). Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke or unplanned revascularization. Data were adjusted using multivariable Cox regression for age-related risks and propensity score stratification for thienopyridine effects., Results: The study included 19,914 patients: 7045 (35.0%) in T1, 6489 (33.0%) in T2 and 6380 (32.0%) in T3. Prasugrel use decreased from T1 to T3 (29.2% vs. 23.5% vs. 7.5%, p < 0.001). Crude 1-year MACE rates were highest in T3 (17.4% vs. 16.8% vs. 22.7%, p < 0.001), but adjusted risk was similar between the groups (p-trend 0.52). Conversely, crude incidence (2.8% vs. 3.8% vs. 6.9%, p < 0.001) and adjusted bleeding risk were highest in T3 (HR 1.24, 95% CI 0.99-1.55 in T2; HR 1.83, 95% CI 1.46-2.30 in T3; p-trend < 0.001; reference = T1). Treatment effects with prasugrel versus clopidogrel did not demonstrate age-related trends for MACE (p-trend = 0.91) or bleeding (p-trend = 0.28)., Conclusions: Age is a strong determinant of clinical risk as well as prasugrel prescription in ACS PCI with much lower use among older patients. Prasugrel did not have a differential treatment effect by age for MACE or bleeding. Frequency of prasugrel use and age-related temporal risks of all-cause death and bleeding after ACS PCI.

Background: Stroke represents a potentially calamitous complication among patients with acute coronary syndrome (ACS) undergoing percutaneous intervention (PCI). Data on the distribution of stroke occurrence post-PCI and its impact on mortality are scarce., Objectives: We sought to determine the incidence, predictors and impact of stroke on mortality in ACS patients undergoing PCI., Methods: A total of 19,914 ACS patients underwent PCI in the PROMETHEUS multicenter observational study. We calculated the cumulative stroke incidence at 30 days and 1 year using the Kaplan Meier method. We also compared the distribution of stroke, myocardial infarction (MI), and bleeding across time and evaluated their overlap. Predictors of stroke were identified through multivariable Cox-regression. Stroke, MI, and bleeding were assessed as time-updated covariates to estimate how each impacts subsequent mortality., Results: We found that 244 patients had a stroke within 1 year, a cumulative incidence of 1.5%. Previous cerebrovascular disease was the strongest predictor for post-PCI stroke, followed by ST-elevation MI presentation, hypertension, non-ST-elevation MI presentation, smoking, female sex, and age. Mortality risk was significantly higher among those who had a stroke versus those who did not (adjusted HR 4.84, p < .0001). However, the association attenuated over time with a much larger effect in the first 30 days of its occurrence (adjusted HR 17.7; 95% CI: 12.3-25.4, p < .0001) versus beyond 30 days (adjusted HR 1.22; 95% CI: 0.6-2.46, p = .58)., Conclusions: Stroke occurrence within 1 year was not uncommon for ACS patients undergoing PCI. When compared with MI and bleeding, stroke had a substantial impact on mortality that attenuated rapidly over time., (© 2019 Wiley Periodicals, Inc.)

Objective: To investigate the use of prasugrel after percutaneous coronary intervention (PCI) in African American (AA) patients presenting with acute coronary syndrome (ACS)., Background: AA patients are at higher risk for adverse cardiovascular outcomes after PCI and may derive greater benefit from the use of potent antiplatelet therapy., Methods: Using the multicenter PROMETHEUS observational registry of ACS patients treated with PCI, we grouped patients by self-reported AA or other races. Clinical outcomes at 90-day and 1-year included non-fatal myocardial infarction (MI), major adverse cardiac events (composite of death, MI, stroke, or unplanned revascularization) and major bleeding., Results: The study population included 2,125 (11%) AA and 17,707 (89%) non-AA patients. AA patients were younger, more often female (46% vs. 30%) with a higher prevalence of diabetes mellitus, chronic kidney disease, and prior coronary intervention than non-AA patients. Although AA patients more often presented with troponin (+) ACS, prasugrel use was much less common in AA vs. non-AA (11.9% vs. 21.4%, respectively, P = 0.001). In addition, the use of prasugrel increased with the severity of presentation in non-AA but not in AA patients. Multivariable logistic regression showed AA race was an independent predictor of reduced use of prasugrel (0.42 [0.37-0.49], P < 0.0001). AA race was independently associated with a significantly higher risk of MI at 90-days and 1 year after PCI., Conclusions: Despite higher risk clinical presentation and worse 1-year ischemic outcomes, AA race was an independent predictor of lower prasugrel prescription in a contemporary population of ACS patients undergoing PCI., (© 2019 Wiley Periodicals, Inc.)

Background: Clinical trial data studies suggest superiority of prasugrel over clopidogrel in patients with diabetes. However, the use, safety and efficacy profile of prasugrel in unselected diabetic patients presenting with acute coronary syndromes (ACS) remain unclear., Methods: PROMETHEUS was a prospective multicenter observational study of 19,919 ACS PCI patients enrolled between 2010 and 2013. The primary endpoint was 90-day major adverse cardiovascular events (MACE), comprising all-cause death, myocardial infarction, stroke or unplanned revascularization. The safety endpoint was bleeding requiring hospitalization., Results: We identified 7580 (38%) subjects with and 12,329 (62%) without diabetes. Diabetic patients were older and had significantly higher rates of cardiovascular risk factors. However, they were less likely to receive prasugrel (18.2% vs. 21.7%). Use of prasugrel did not increase with the severity of clinical presentation in diabetics, whereas, among non-diabetics, prescription of prasugrel was higher in NSTEMI and STEMI compared to unstable angina. The 90-day and 1-year adjusted risk of MACE was greater in diabetics (at 1 year: 22.7% vs. 16.5%; HR 1.22 [1.14-1.33], p < 0.001). At 1 year, the risk of bleeding was also higher in diabetics (4.9% vs. 4.1%, HR 1.19 [1.01-1.39], p = 0.035). After multivariable adjustment, use of prasugrel was associated with a lower risk of death in diabetic patients both at 90 days and 1 year., Conclusions: Use of prasugrel in diabetic patients with PCI-treated ACS was lower than in non-diabetics despite their high-risk profile and the severity of their clinical presentation. In diabetics, prasugrel was associated with a lower adjusted risk of 90-day death compared with clopidogrel., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: We sought to evaluate the results of percutaneous coronary intervention (PCI) in elderly patients in contemporary practice., Background: Prior studies of PCI in the elderly population demonstrate increased in-hospital mortality, but these studies are limited by small population size., Methods: Using the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) of 100,253 patients, the in-hospital outcomes in all 8,828 PCI procedures performed on octogenarians were evaluated. Patients underwent PCI between 1998 and 2000 at over 145 participating centers., Results: The mean age was 83.72 +/- 3.02 years, with female preponderance (53%). The PCI was considered angiographically successful in 93%, stents were placed in 75%, and the post-PCI length of stay was 3.3 +/- 5.1 days. Overall in-hospital mortality was 3.77% but was only 1.35% in PCI without recent myocardial infarction (MI) within one week (p < 0.0001). Patients having PCI within 6 h of the onset of their MI had an increase in mortality tenfold (13.79%) compared with patients without a recent MI (p < 0.0001). All groups that were defined based on time of PCI after MI onset up to seven days had increased mortality (all p < 0.0001). Older age (odds ratio [OR] of 1.03 per incremental year), depressed ejection fraction (EF) (OR 0.69 per 10 points for EF <60%), and time of PCI after MI onset (<6 h, OR 6.87; 6 to 24 h, OR 5.66; 24 h to one week, OR 2.93) were most strongly predictive of outcome by multivariate analysis. The predicted mortality from the multivariate model correlated well with the observed in-hospital mortality up to 20% mortality. A 254-point nomogram was constructed employing the logistic model using a weighted point system., Conclusions: In patients > or = 80 years old, PCI has good success and acceptable mortality. The presence of an acute or recent MI substantially increases the risk of in-hospital death.

Background: The Simple and Effective Arterial Closure (SEAL) trial examined the safety and effectiveness of the Duett vascular sealing device (Vascular Solutions, Minneapolis, Minn) versus manual compression after diagnostic and interventional coronary procedures. We compared quality of life and initial hospitalization costs among patients treated with the Duett device versus manual compression., Methods: Functional status was assessed with the Duke Activity Status Index (DASI) at 7 and 30 days after intervention. General health status was assessed with the Short Form (SF-36) at 30 days after intervention. Hospitalization costs were derived from the UB92 formulation of the hospital bill., Results: There was a strong trend toward higher functional status in patients receiving treatment with the Duett device at 7 days both before (P =.04) and after (P =.08) adjustment for significant covariates. This difference was significant in the diagnostic group but not in the interventional group. No significant differences in quality of life between the Duett device and manual compression at 30 days were found. There was no significant difference in total hospitalization costs between treatment arms (P =.91). For interventional patients, mean total in-hospital costs were $10,167 in the Duett group and $10,225 in the manual compression group (P =.82). For diagnostic patients, mean hospitalization costs were $7784 and $7996 for the Duett device and manual compression groups, respectively (P =.72). Trends toward reduced recovery/observation room costs with the Duett device (P =.06) were found; this difference was significant in the diagnostic group ($198 vs $279, P =.02)., Conclusions: The Duett sealing device was associated with significantly higher functional status at 7 days after the procedure in addition to shortened time to hemostasis and ambulation, with no associated increase in cost.

Transitions from one health care system to another are common, but they can affect coordination of care and measurement of patient outcomes. In this project, a community hospital and a tertiary center collaborated to obtain follow-up information on patients 30 days after they underwent cardiac catheterization and revascularization. Results show that patients experienced similar physical and emotional concerns regardless of diagnosis or procedure. Although the intent was to gather information, nurses also provided education and arranged services for patients. This project has implications for the development of collaborative interventions to improve care for patients after undergoing coronary procedures.

The resource-based relative value scale developed for use in the Medicare fee schedule can also be very useful in profiling and comparing physicians' cardiovascular utilization across different medical activities. This article applies relative value units (RVUs) to data from the Emory Angioplasty versus Surgery Trial. The Emory Angioplasty versus Surgery Trial was a randomized clinical trial to determine the efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass surgery (CABG). All physician services in the clinical trial provided to 2 groups of patients--those undergoing CABG and those receiving PTCA-over the course of 4 years were assigned physician work RVUs (representing the intensity of physician work required) and total RVUs (representing both the intensity and practice costs). Physician charges were also compiled. These data were used to profile and compare physician services to the 2 groups of patients by type of service, distribution over time, and clinical department. Comparisons based on RVUs contrast sharply with differences based on charges. Mean physician charges, in 1996 dollars, were $27,158 for CABG patients and $21,491 for PTCA patients, a 26% difference (p <0.001). Physician work RVUs generated an 18.3% difference (p = <0.001). Using total RVUs, the difference between the 2 groups was 3.3% (p = 0.249). Resource-based relative value weights are a valuable tool for analyzing and comparing physicians' use of cardiovascular resource. The results suggest that conclusions about physician resource utilization based on physician charges should be carefully evaluated. When possible, physician work RVUs should be compiled and evaluated along with physician charges.

Objective: To estimate the cost of lost work days due to ischaemic heart disease (IHD), and the cost of this reduced productivity using reduction in household income., Design and Setting: Using 2 years of nationally representative observational data, this study examined the effect on household income of IHD. This effect was estimated after accounting for unemployment, days lost to illness and other effects of illness on the income of workers aged 18 to 64 years., Main Outcome Measures and Results: Previous measures of indirect costs of disease have typically not included the loss in productivity due to suboptimal work performance. Among workers in this age group, IHD was associated with a reduction of $US3013 in annual household income; this reduction was independent of occupational class, age, size of household and educational level. Such a reduction may be because of reduced on-the-job performance, employer perception of this, or unrelated lifestyle choices. It represents an estimated $US6.05 billion annual loss in productivity in 1992 dollars (or $US6.45 billion in 1996 dollars)., Conclusions: Estimates of the indirect costs of chronic disease that do not account fully for the lost income of employees may significantly underestimate the benefits to employers and society of treatment and prevention.

This paper, the second in a series of 2, reviews major developments and trends in the current healthcare arena that will affect cardiovascular disease (CVD) treatment over the next 10 years. The paper also discusses the implications and future outlook for cardiovascular services in a managed care environment.

An effective therapy for a costly illness has economic consequences. There may also be differences between provider costs and payer costs and initial versus long-term costs; costs may also vary with the reimbursement scheme. Consider the case of an effective therapy to prevent restenosis after coronary angioplasty. Assume that the initial provider cost of angioplasty is $12,000 and that restenosis within 6 months results in repeat angioplasty in 20% of cases, with a follow-up cost of $2,400, or $14,400 total. Assume that a therapy costs $1,000 per angioplasty and decreases restenosis by 50%, resulting in repeat angioplasty in 10% of cases. This will result in an initial cost of $13,000 and a follow-up cost of $1,300, or $14,300 total. The total societal costs will be -$100, a slight savings. Thus, the $1,100 cost of therapy is offset by reduced costs associated with restenosis, and the societal costs are almost neutral. Assume that under fee for service providers charge costs plus 10% and that without the new therapy either a package price or a capitated system is revenue neutral. Changes in costs resulting from therapy to prevent restenosis are as follows (plus sign indicates cost or loss; minus sign indicates savings or profit): [table: see text] Under fee for service, the payer takes the risks, and the economic consequences to providers are minimal. The situation is reversed under capitation. For whoever takes the risk, there is an initial loss to pay for the therapy, but a long-term gain due to less restenosis. Under package pricing, the providers lose because of the cost of therapy and fewer procedures, while the payers gain. A new therapy, even if it is revenue neutral to society overall, may have considerable economic consequences, which vary with time and with the different perspectives of providers and payers.

Costs have become increasingly important in medicine in recent years as demand for services has outstripped readily available resources. Clinical microeconomics offers an approach to understanding cost and outcomes in an environment of economic scarcity. In this article the types of costs and methods for determining cost are presented. In addition, methods for assessing outcome and outcome in relation to cost are developed. Restenosis after coronary angioplasty is a prime example of a clinical problem requiring economic evaluation. This is because it results in little serious morbidity except for recurrent chest pain, but it has serious economic consequences which occur some time after the original angioplasty. This makes the economic assessment of restenosis complicated. The application of health care microeconomic principles to brachytherapy for restenosis in the coronary arteries is presented.

Objective: To predict hospital resource utilization for coronary surgery (CABG) from preoperative characteristics and to determine the influence of previous CABG on the results., Design: Two analyses of the data were used to predict hospital costs: 1) a univariate analysis of each preoperative variable; and 2) a multivariate analysis of preoperative variables, and interaction terms with previous CABG., Patients: A sample of 418 patients who received CABG at Emory University during 1990., Results: From the multivariate analysis, the determinants of costs were previous CABG (P = 0.0653), female sex (P = 0.1005), diabetes (P = 0.0805), older age (P = 0.0062), and a combination of previous CABG with female sex (P = 0.0017), previous myocardial infarction (P = 0.0636), low ejection fraction (P = 0.0001), and younger age (P = 0.0363). For the univariate analysis, the determinants of increased costs were similar to those from the multivariate analysis., Conclusion: The correlation between patients with potential medical difficulties or previous cardiovascular surgery show a positive impact on higher hospital costs.