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Background: Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited.Objective: We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI).Research Design: This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999.Subjects: A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included.Measures: Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type.Results: The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4-89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17-3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64-37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97-5.30, P = 0.07).Conclusions: Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance. [ABSTRACT FROM AUTHOR]

Background: National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics.Methods and Results: We used data (n = 335,244 patients with AMI discharged from 682 hospitals) from the National Registry of Myocardial Infarction (NRMI) and from the American Hospital Association Annual Survey of Hospitals and hierarchical modeling to examine the associations between hospital characteristics and hospital-level rates of change in beta-blocker use during 1996-1999. On average, hospital rates of beta-blocker use for patients with AMI increased 5.9 percentage points (standard deviation, 9.7 percentage points) from the premidpoint time period (April 1996-February 1998) to the postmidpoint time period (March 1998-September 1999) of the study. The range in hospital-level changes in beta-blocker rates was substantial, from a decline of -50.0 percentage points to an increase of +35.7 percentage points. AMI volume and teaching status, geographic region, and initial beta-blocker use rates were associated with rate of improvement, but the magnitude of these effects was modest.Conclusions: The study reveals marked hospital-level variation in improvement in beta-blocker use after AMI. Several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of beta-blockers. [ABSTRACT FROM AUTHOR]

Context: Based on evidence that beta-blockers can reduce mortality in patients with acute myocardial infarction (AMI), many hospitals have initiated performance improvement efforts to increase prescription of beta-blockers at discharge. Determination of the factors associated with such improvements may provide guidance to hospitals that have been less successful in increasing beta-blocker use.Objectives: To identify factors that may influence the success of improvement efforts to increase beta-blocker use after AMI and to develop a taxonomy for classifying such efforts.Design, Setting, and Participants: Qualitative study in which data were gathered from in-depth interviews conducted in March-June 2000 with 45 key physician, nursing, quality management, and administrative participants at 8 US hospitals chosen to represent a range of hospital sizes, geographic regions, and changes in beta-blocker use rates between October 1996 and September 1999.Main Outcome Measures: Initiatives, strategies, and approaches to improve care for patients with AMI.Results: The interviews revealed 6 broad factors that characterized hospital-based improvement efforts: goals of the efforts, administrative support, support among clinicians, design and implementation of improvement initiatives, use of data, and modifying variables. Hospitals with greater improvements in beta-blocker use over time demonstrated 4 characteristics not found in hospitals with less or no improvement: shared goals for improvement, substantial administrative support, strong physician leadership advocating beta-blocker use, and use of credible data feedback.Conclusions: This study provides a context for understanding efforts to improve care in the hospital setting by describing a taxonomy for classifying and evaluating such efforts. In addition, the study suggests possible elements of successful efforts to increase beta-blocker use for patients with AMI. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally. BACKGROUND: Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA). METHODS: We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals. RESULTS: Top performers were those with median door-to-balloon times of < or =90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG. CONCLUSIONS: Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change. [ABSTRACT FROM AUTHOR]

Objectives: We sought to determine the association of age with the change in quality of life (QOL) after valve surgery.Background: Improvement in QOL is one of the principal goals of valve surgery. These procedures are being done with increasing frequency for older patients.Methods: We prospectively studied 148 patients with aortic valve procedures and 72 patients with mitral valve procedures. Patients' QOL was measured at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-Item (SF-36) Health Survey (response rate 90%). The association of age with change in QOL was measured by multiple regression analysis and based on two meta-scores of the SF-36: the Mental Component Summary (MCS) and the Physical Component Summary (PCS).Results: Overall improvement in most domains of the SF-36, including the MCS and the PCS scores, was substantial. Improvement in the MCS score was not influenced by age in either aortic (0.09 score point improvement per 10-year age increments; p = 0.9) or mitral (0.90 score point improvement per 10-year age increments; p = 0.3) patients. Similarly, improvement in the PCS score did not vary by age in aortic patients (-1.00 score points per 10-year age increments; p = 0.2) and only slightly varied by age in mitral patients (-1.90 score points per 10-year age increments, p = 0.02). In the latter, despite statistical significance, the association was not substantial or clinically important.Conclusions: Among patients referred for cardiac valve surgery, age does not appear to limit the QOL benefits of surgery. [ABSTRACT FROM AUTHOR]

Objectives: This study was designed to examine whether female gender is associated with poorer recovery after coronary artery bypass graft (CABG) surgery.Background: The risks and benefits associated with CABG surgery in women are not as well established as they are in men, and there are concerns that women may have worse outcomes. The recovery period after CABG (the first four to eight weeks after the surgery) is a vulnerable time, with higher risks of complications and hospital readmission. There is little information on patients' experiences during this phase, particularly among women.Methods: We prospectively followed 1,113 patients (804 men and 309 women) who underwent first CABG consecutively between February 1999 and February 2001. Patients were interviewed at baseline and between six and eight weeks after surgery. Clinical data were abstracted from medical records.Results: Compared with men, women were older and more often had unstable angina and congestive heart failure, lower physical function (PF), and more depressive symptoms in the month before surgery. At six to eight weeks after CABG surgery, after adjustment for baseline characteristics, the rate of hospital readmission was 20.5% in women and 11.0% in men (p = 0.005), and the mean number of physical symptoms and side effects was 2.5 in women and 2 in men (p = 0.0009). Whereas, on average, PF remained unchanged in men (an increase in score of 0.3 points, 95% confidence interval [CI], -1.1 to 1.8) and depressive symptoms improved (a decrease of 0.2 depressive symptoms, 95% CI, -0.4 to -0.04), women showed, on average, a 13-point decline in physical function (95% CI, -15.8 to -10.4) and an increase of 0.5 in depressive symptoms (95% CI, 0.1 to 0.9).Conclusions: After CABG surgery, women have a more difficult recovery compared with men, which is not explained by illness severity, presurgery health status, or other patient characteristics. [ABSTRACT FROM AUTHOR]

Objectives: We determined the effect of a targeted education and support intervention on the rate of readmission or death and hospital costs in patients with heart failure (HF).Background: Disease management programs for patients with HF including medical components may reduce readmissions by 40% or more, but the value of an intervention focused on education and support is not known.Methods: We conducted a prospective, randomized trial of a formal education and support intervention on one-year readmission or mortality and costs of care for patients hospitalized with HF.Results: Among the 88 patients (44 intervention and 44 control) in the study, 25 patients (56.8%) in the intervention group and 36 patients (81.8%) in the control group had at least one readmission or died during one-year follow-up (relative risk = 0.69, 95% confidence interval [CI]: 0.52, 0.92; p = 0.01). The intervention was associated with a 39% decrease in the total number of readmissions (intervention group: 49 readmissions; control group: 80 readmissions, p = 0.06). After adjusting for clinical and demographic characteristics, the intervention group had a significantly lower risk of readmission compared with the control group (hazard ratio = 0.56, 95% CI: 0.32, 0.96; p = 0.03) and hospital readmission costs of $7,515 less per patient.Conclusions: A formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with HF. [ABSTRACT FROM AUTHOR]

Background: Preterm birth (birth at <37 completed weeks gestation) is a significant public heatlh concern worldwide. Important health, and developmental consequences of preterm birth include altered temperament development, with greater dysregulation and distress proneness., Aims: The present study leveraged advanced quantitative techniques, namely machine learning approaches, to discern the contribution of narrowly defined and broadband temperament dimensions to birth status classification (full-term vs. preterm). Along with contributing to the literature addressing temperament of infants born preterm, the present study serves as a methodological demonstration of these innovative statistical techniques., Study Design: This study represents a metanalysis conducted with multiple samples ( N = 19) including preterm ( n = 201) children and ( n = 402) born at term, with data combined across investigations to perform classification analyses., Subjects: Participants included infants born preterm and term-born comparison children, either matched on chronological age or age adjusted for prematurity., Outcome Measures: Infant Behavior Questionnaire-Revised Very Short Form (IBQ-R VSF) was completed by mothers, with factor and item-level data considered herein., Results and Conclusions: Accuracy estimates were generally similar regardless of the comparison groups. Results indicated a slightly higher accuracy and efficiency for IBQR-VSF item-based models vs. factor-level models. Divergent patterns of feature importance (i.e., the extent to which a factor/item contributed to classification) were observed for the two comparison groups (chronological age vs. adjusted age) using factor-level scores; however, itemized models indicated that the two most critical items were associated with effortful control and negative emotionality regardless of comparison group., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

For pregnant women, the COVID-19 pandemic has resulted in unprecedented stressors, including uncertainty regarding prenatal care and the long-term consequences of perinatal infection. However, few studies have examined the role of this adverse event on maternal wellbeing and infant socioemotional development following the initial wave of the pandemic when less stringent public health restrictions were in place. The current study addressed these gaps in the literature by first comparing prenatal internalizing symptoms and infant temperament collected after the first wave of the pandemic to equivalent measures in a pre-pandemic sample. Second, associations between prenatal pandemic-related stress and infant temperament were examined. Women who were pregnant during the COVID-19 pandemic endorsed higher pregnancy-specific anxiety relative to the pre-pandemic sample. They also reported greater infant negative emotionality and lower positive affectivity and regulatory capacity at 2 months postpartum. Prenatal infection stress directly predicted infant negative affect. Both prenatal infection and preparedness stress were indirectly related to infant negative emotionality through depression symptoms during pregnancy and at 2 months postpartum. These results have implications for prenatal mental health screening procedures during the pandemic and the development of early intervention programs for infants born to mothers during this adverse event., (© 2024 The Authors. Infancy published by Wiley Periodicals LLC on behalf of International Congress of Infant Studies.)

Maternal well-being and stress during the perinatal period have been hypothesized to influence birth outcomes and the postnatal development of offspring. In the present study, we explored whether hair cortisol concentration (HCC) was related to symptoms of psychological distress during the perinatal period and with unpredicted birth complications (UBCs). Surveys measuring symptoms of perceived stress, state/trait anxiety, and depression were collected from 53 participants (mean age = 31.1, SD = 4.04; 83% Caucasian, 17% other races) during the third trimester and again at two and six months after birth, 24.5% of which reported UBCs. In a subset of participants, we measured HCC in hair samples collected during the third trimester (27-39 weeks) and six months after birth. Compared to participants reporting normal births, those reporting UBCs had significantly elevated composite stress, anxiety, and depression (SAD) scores two months after birth, but scores decreased by six months postpartum. During the third trimester, HCC was positively associated with reported SAD scores, and HCC was elevated in participants reporting birth complications. Logistic regression showed HCC, but not SAD scores, predicted UBCs (p = 0.023, pseudo R 2 = 19.7%). Repeated measures MANOVA showed HCC varied over the perinatal period depending on both SAD scores reported at two months postpartum and the experience of UBCs; but when SAD scores reported at six months postpartum were included in the model, the association between HCC and SAD scores and the influence of UBCs was diminished. Although generalizability is limited by our relatively small, homogeneous sample, findings support a positive association between reported psychological distress and HCC during pregnancy and at two months postpartum. We also report a novel finding that chronically elevated cortisol concentrations during pregnancy were related to the risk of UBCs and remain elevated through the early postpartum period, suggesting the importance of monitoring both psychological distress and HCC during the perinatal period., Competing Interests: Declaration of Competing Interest The authors report no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Developmental shifts in infant temperament predict distal outcomes including emerging symptoms of psychopathology in childhood. Thus, it is critical to gain insight into factors that shape these developmental shifts. Although parental depression and anxiety represent strong predictors of infant temperament in cross-sectional research, few studies have examined how these factors influence temperament trajectories across infancy., Methods: We used latent growth curve modeling to examine whether mothers' and fathers' anxiety and depression, measured in two ways - as diagnostic status and symptom severity - serve as unique predictors of developmental shifts in infant temperament from 3 to 12 months. Participants included mothers (N = 234) and a subset of fathers (N = 142). Prior to or during pregnancy, both parents were assessed for lifetime diagnoses of depression and anxiety as well as current severity levels. Mothers rated their infants' temperament at 3, 6, and 12 months of age., Results: Mothers' depression and anxiety primarily predicted initial levels of temperament at 3 months. Controlling for mothers' symptoms, fathers' depression and anxiety largely related to temperament trajectories across infancy. Lifetime diagnoses and symptom severities were associated with distinct patterns., Limitations: Infant temperament was assessed using a parent-report measure. Including an observational measure would provide a more comprehensive picture of the infants' functioning., Conclusions: These results indicate that mothers' and fathers' mental health are uniquely associated with infant temperament development when measured using diagnostic status and/or symptom severity. Future studies should examine whether these temperament trajectories mediate intergenerational transmission of risk for depression and anxiety., Competing Interests: Declaration of competing interest Ms. Knight's adult son works for Glaxo Smith Kline and has GSK stock options as part of his employment. Dr. Newport has received research support from Eli Lilly, Glaxo SmithKline (GSK), Janssen, the National Alliance for Research on Schizophrenia and Depression (NARSAD), the National Institutes of Health (NIH), Sage Therapeutics, Takeda Pharmaceuticals, the Texas Health & Human Services Commission, and Wyeth. He has served on speakers' bureaus and/or received honoraria from Astra-Zeneca, Eli Lilly, GSK, Pfizer and Wyeth. He has served on advisory boards for GSK, Janssen, and Sage Therapeutics. He has served as a consultant to Sage Therapeutics. Neither he nor family members have ever held equity positions in biomedical or pharmaceutical corporations., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Maternal adverse childhood experiences are known to significantly influence offspring development. However, mediators linking maternal early-life adversity with infant temperament remain largely unknown., Aims: The current study investigated whether prenatal internalizing symptoms mediate the association between maternal adverse childhood experiences and infant temperament at two months. Maternal sensitivity/responsiveness during the postpartum period was also examined as a moderator of these associations., Study Design: We used a repeated-measures design, with self-report measures administered during pregnancy. Self-report and observational data were also collected at 2 months postpartum., Subjects: The study included a community sample of 64 pregnant women and their infants., Outcome Measures: Participants completed measures assessing their early-life adversity and current depression/anxiety symptoms. At two months postpartum, mothers reported on their infant's temperament and participated in a parent-child interaction task designed to assess maternal sensitivity/responsiveness., Results and Conclusions: Maternal adverse childhood experiences indirectly predicted poor self-regulation during early infancy via prenatal internalizing symptoms. Maternal sensitivity/responsiveness was also found to moderate the association between maternal adverse childhood experiences and certain aspects of infant regulatory capacity and positive affectivity at two months. This research has implications for mental health screening procedures during pregnancy and the development of early intervention programs., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Age and gender differences are prominent in the temperament literature, with the former particularly salient in infancy and the latter noted as early as the first year of life. This study represents a meta-analysis utilizing Infant Behavior Questionnaire-Revised (IBQ-R) data collected across multiple laboratories (N = 4438) to overcome limitations of smaller samples in elucidating links among temperament, age, and gender in early childhood. Algorithmic modeling techniques were leveraged to discern the extent to which the 14 IBQ-R subscale scores accurately classified participating children as boys (n = 2,298) and girls (n = 2,093), and into three age groups: youngest (< 24 weeks; n = 1,102), mid-range (24 to 48 weeks; n = 2,557), and oldest (> 48 weeks; n = 779). Additionally, simultaneous classification into age and gender categories was performed, providing an opportunity to consider the extent to which gender differences in temperament are informed by infant age. Results indicated that overall age group classification was more accurate than child gender models, suggesting that age-related changes are more salient than gender differences in early childhood with respect to temperament attributes. However, gender-based classification was superior in the oldest age group, suggesting temperament differences between boys and girls are accentuated with development. Fear emerged as the subscale contributing to accurate classifications most notably overall. This study leads infancy research and meta-analytic investigations more broadly in a new direction as a methodological demonstration, and also provides most optimal comparative data for the IBQ-R based on the largest and most representative dataset to date., Competing Interests: The authors have declared that no competing interests exist.

This study examined the course of antidepressant use, sleep quality, and depression severity from pregnancy through 6-month postpartum in women with and without a depressive disorder during pregnancy. Women (N = 215) were interviewed during pregnancy, 1- and 6-month postpartum. Mixed linear models were used to examine the longitudinal course and inter-relationships for the time-varying variables of antidepressant use, subjective sleep quality, and depression severity. Pregnant women with a depressive disorder who did not use antidepressants had more variable depression severity over time with improvements in depression severity by 6-month postpartum. In contrast, the depression severity of their medicated counterparts remained stable and high throughout. Pregnant women without a depressive disorder had worse sleep quality when using antidepressants compared with when they were not. Antidepressant use significantly strengthened the magnitude of the effect of sleep quality on depression severity in women with a depressive disorder during pregnancy. When prenatally depressed women use antidepressants, their sleep disturbance is more highly linked to depression severity than when they do not. Furthermore, antidepressants are not adequately treating the sleep disturbance of these women or their remitted counterparts, leaving both groups vulnerable to significant negative mental and physical health outcomes.

Background: Since clinical management of heart failure relies on weights that are self-reported by the patient, errors in reporting will negatively impact the ability of health care professionals to offer timely and effective preventive care. Errors might often result from rounding, or more generally from individual preferences for numbers ending in certain digits, such as 0 or 5. We apply fraud detection methods to assess preferences for numbers ending in these digits in order to inform medical decision making., Methods: The Telemonitoring to Improve Heart Failure Outcomes trial tested an approach to telemonitoring that used existing technology; intervention patients (n = 826) were asked to measure their weight daily using a digital scale and to relay measurements using their telephone keypads. First, we estimated the number of weights subject to end-digit preference by dividing the weights by five and comparing the resultant distribution with the uniform distribution. Then, we assessed the characteristics of patients reporting an excess number of weights ending in 0 or 5, adjusting for chance reporting of these values., Results: Of the 114,867 weight readings reported during the trial, 18.6% were affected by end-digit preference, and the likelihood of these errors occurring increased with the number of days that had elapsed since trial enrolment (odds ratio per day: 1.002, p < 0.001). At least 105 patients demonstrated end-digit preference (14.9% of those who submitted data); although statistical significance was limited, a pattern emerged that, compared with other patients, they tended to be younger, male, high school graduates and on more medications. Patients with end-digit preference reported greater variability in weight, and they generated an average 2.9 alerts to the telemonitoring system over the six-month trial period (95% CI, 2.3 to 3.5), compared with 2.3 for other patients (95% CI, 2.2 to 2.5)., Conclusions: As well as overshadowing clinically meaningful changes in weight, end-digit preference can lead to false alerts to telemonitoring systems, which may be associated with unnecessary treatment and alert fatigue. In this trial, end-digit preference was common and became increasingly so over time. By applying fraud detection methods to electronic medical data, it is possible to produce clinically significant information that can inform the design of initiatives to improve the accuracy of reporting., Trial Registration: ClinicalTrials.gov registration number NCT00303212 March 2006.

Objectives: This study sought to determine whether a model that included self-reported socioeconomic, health status, and psychosocial characteristics obtained from patients recently discharged from hospitalizations for heart failure substantially improved 30-day readmission risk prediction compared with a model that incorporated only clinical and demographic factors., Background: Existing readmission risk models have poor discrimination and it is unknown whether they would be markedly improved by the inclusion of patient-reported information., Methods: As part of the Tele-HF (Telemonitoring to Improve Heart Failure Outcomes) trial, we conducted medical record abstraction and telephone interviews in a sample of 1,004 patients recently hospitalized for heart failure to obtain clinical, functional, and psychosocial information within 2 weeks of discharge. Candidate risk factors included 110 variables divided into 2 groups: demographic and clinical variables generally available from the medical record; and socioeconomic, health status, adherence, and psychosocial variables from patient interview., Results: The 30-day readmission rate was 17.1%. Using the 3-level risk score derived from the restricted medical record variables, patients with a score of 0 (no risk factors) had a readmission rate of 10.9% (95% confidence interval [CI]: 8.2% to 14.2%), and patients with a score of 2 (all risk factors) had a readmission rate of 32.1% (95% CI: 22.4% to 43.2%), a C-statistic of 0.62. Using the 5-level risk score derived from all variables, patients with a score of 0 (no risk factors) had a readmission rate of 9.6% (95% CI: 6.1% to 14.2%), and patients with a score of 4 (all risk factors) had a readmission rate of 55.0% (95% CI: 31.5% to 76.9%), a C-statistic of 0.65., Conclusions: Self-reported socioeconomic, health status, adherence, and psychosocial variables are not dominant factors in predicting readmission risk for patients with heart failure. Patient-reported information improved model discrimination and extended the predicted ranges of readmission rates, but the model performance remained poor. (Telemonitoring to Improve Heart Failure Outcomes [Tele-HF]; NCT00303212)., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: National attention has increasingly focused on readmission as a target for quality improvement. We present the development and validation of a model approved by the National Quality Forum and used by the Centers for Medicare & Medicaid Services for hospital-level public reporting of risk-standardized readmission rates for patients discharged from the hospital after an acute myocardial infarction., Methods and Results: We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with acute myocardial infarction. The model was derived using Medicare claims data for a 2006 cohort and validated using claims and medical record data. The unadjusted readmission rate was 18.9%. The final model included 31 variables and had discrimination ranging from 8% observed 30-day readmission rate in the lowest predictive decile to 32% in the highest decile and a C statistic of 0.63. The 25th and 75th percentiles of the risk-standardized readmission rates across 3890 hospitals were 18.6% and 19.1%, with fifth and 95th percentiles of 18.0% and 19.9%, respectively. The odds of all-cause readmission for a hospital 1 SD above average were 1.35 times that of a hospital 1 SD below average. Hospital-level adjusted readmission rates developed using the claims model were similar to rates produced for the same cohort using a medical record model (correlation, 0.98; median difference, 0.02 percentage points)., Conclusions: This claims-based model of hospital risk-standardized readmission rates for patients with acute myocardial infarction produces estimates that are excellent surrogates for those produced from a medical record model.

Background: Small studies suggest that telemonitoring may improve heart-failure outcomes, but its effect in a large trial has not been established., Methods: We randomly assigned 1653 patients who had recently been hospitalized for heart failure to undergo either telemonitoring (826 patients) or usual care (827 patients). Telemonitoring was accomplished by means of a telephone-based interactive voice-response system that collected daily information about symptoms and weight that was reviewed by the patients' clinicians. The primary end point was readmission for any reason or death from any cause within 180 days after enrollment. Secondary end points included hospitalization for heart failure, number of days in the hospital, and number of hospitalizations., Results: The median age of the patients was 61 years; 42.0% were female, and 39.0% were black. The telemonitoring group and the usual-care group did not differ significantly with respect to the primary end point, which occurred in 52.3% and 51.5% of patients, respectively (difference, 0.8 percentage points; 95% confidence interval [CI], -4.0 to 5.6; P=0.75 by the chi-square test). Readmission for any reason occurred in 49.3% of patients in the telemonitoring group and 47.4% of patients in the usual-care group (difference, 1.9 percentage points; 95% CI, -3.0 to 6.7; P=0.45 by the chi-square test). Death occurred in 11.1% of the telemonitoring group and 11.4% of the usual care group (difference, -0.2 percentage points; 95% CI, -3.3 to 2.8; P=0.88 by the chi-square test). There were no significant differences between the two groups with respect to the secondary end points or the time to the primary end point or its components. No adverse events were reported., Conclusions: Among patients recently hospitalized for heart failure, telemonitoring did not improve outcomes. The results indicate the importance of a thorough, independent evaluation of disease-management strategies before their adoption. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00303212.).

Background: Among individuals with ischemic heart disease, young women with an acute myocardial infarction (AMI) represent an extreme phenotype associated with an excess mortality risk. Although women younger than 55 years of age account for less than 5% of hospitalized AMI events, almost 16 000 deaths are reported annually in this group, making heart disease a leading killer of young women. Despite a higher risk of mortality compared with similarly aged men, young women have been the subject of few studies., Methods and Results: Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI. VIRGO will enroll 2000 women, 18 to 55 years of age, with AMI and a comparison cohort of 1000 men with AMI from more than 100 participating hospitals. The aims of the study are to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psychosocial risk factors; to determine whether there are sex differences in the quality of care received by young AMI patients; and to determine how these factors contribute to sex differences in outcomes (including mortality, hospitalization, and health status). Blood serum and DNA for consenting participants will be stored for future studies., Conclusions: VIRGO will seek to identify novel and prognostic factors that contribute to outcomes in this young AMI population. Results from the study will be used to develop clinically useful risk-stratification models for young AMI patients, explain sex differences in outcomes, and identify targets for intervention.

Background: Readmission soon after hospital discharge is an expensive and often preventable event for patients with heart failure. We present a model approved by the National Quality Forum for the purpose of public reporting of hospital-level readmission rates by the Centers for Medicare & Medicaid Services., Methods and Results: We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with heart failure. The model was derived with the use of Medicare claims data for a 2004 cohort and validated with the use of claims and medical record data. The unadjusted readmission rate was 23.6%. The final model included 37 variables, had discrimination ranging from 15% observed 30-day readmission rate in the lowest predictive decile to 37% in the upper decile, and had a c statistic of 0.60. The 25th and 75th percentiles of the risk-standardized readmission rates across 4669 hospitals were 23.1% and 24.0%, with 5th and 95th percentiles of 22.2% and 25.1%, respectively. The odds of all-cause readmission for a hospital 1 standard deviation above average was 1.30 times that of a hospital 1 standard deviation below average. State-level adjusted readmission rates developed with the use of the claims model are similar to rates produced for the same cohort with the use of a medical record model (correlation, 0.97; median difference, 0.06 percentage points)., Conclusions: This claims-based model of hospital risk-standardized readmission rates for heart failure patients produces estimates that may serve as surrogates for those derived from a medical record model.

Background: Telemonitoring, the use of communication technology to remotely monitor health status, is an appealing strategy for improving disease management., Methods and Results: We searched Medline databases, bibliographies, and spoke with experts to review the evidence on telemonitoring in heart failure patients. Interventions included: telephone-based symptom monitoring (n = 5), automated monitoring of signs and symptoms (n = 1), and automated physiologic monitoring (n = 1). Two studies directly compared effectiveness of 2 or more forms of telemonitoring. Study quality and intervention type varied considerably. Six studies suggested reduction in all-cause and heart failure hospitalizations (14% to 55% and 29% to 43%, respectively) or mortality (40% to 56%) with telemonitoring. Of the 3 negative studies, 2 enrolled low-risk patients and patients with access to high quality care, whereas 1 enrolled a very high-risk Hispanic population. Studies comparing forms of telemonitoring demonstrated similar effectiveness. However, intervention costs were higher with more complex programs (8383 dollars per patient per year) versus less complex programs (1695 dollars per patient per year)., Conclusion: The evidence base for telemonitoring in heart failure is currently quite limited. Based on the available data, telemonitoring may be an effective strategy for disease management in high-risk heart failure patients.

Background: The decision to replace or repair mitral valves is often a difficult decision, and outcomes from the patients' perspective should guide decision-making. We investigated whether the change in health related quality of life (HRQOL) after mitral valve surgery is different after valve repairs compared with replacements., Methods: We prospectively studied 25 patients with mitral valve replacement and 45 patients with valve repairs performed in 1998-99. We measured HRQOL at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-item Health Survey (SF-36) questionnaire. We compared mean HRQOL scores of the groups with age-adjusted U.S. population scores. We used analysis of covariance to determine a change in HRQOL within groups (repair or replacement) and if the change in HRQOL was different between the groups., Results: We found few differences between the groups, with more men and simultaneous coronary artery bypass graft surgery in the valve repair group and more prior operation in the valve replacement group. HRQOL improved after surgery in most domains, and was comparable to age-adjusted U.S. norms in the valve repair group. In the multivariable analysis, mitral valve repair recipients reported higher social functioning compared with patients who received valve replacement (p = 0.04). We did not find other statistically significant differences. However, the adjusted improvements in the component scales of physical functioning (PCS) and mental functioning (MCS) were substantial in the valve repair group (mean changes: PCS = 6.8, p = 0.003; MCS = 8.1, p = 0.014) and less pronounced in the replacement group (mean changes: PCS = 3.6, p = 0.09; MCS = 4.3, fsp = 0.16)., Conclusions: While many considerations influence the decision to repair or replace mitral valves, these findings suggest that repair may be better from the health status perspective. Further studies are necessary to validate this finding.

Little is known about the extent to which patients are aware of nationally-recommended cholesterol and lipid subfraction targets. The authors interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their low-density lipoprotein, high-density lipoprotein, and total cholesterol levels as well as corresponding national targets. Only 8%, 8%, and 43% of patients could recall their low-density lipoprotein, high-density lipoprotein, and total cholesterol values, respectively. Only 5%, 2%, and 50% could correctly name targets for these values. Knowledge of cholesterol targets was particularly poor among women, nonwhites, and patients without any college education. Patients with multiple cardiac risk factors and patients with a previous history of cardiovascular disease were no more knowledgeable about their cholesterol targets than those without these conditions. These findings suggest that current cholesterol education efforts appear inadequate, particularly for women, nonwhites, and patients without any college education.

Background: Decision-support information technology is often adopted to improve clinical decision making, but it is rarely rigorously evaluated. Congress mandated the evaluation of Problem-Knowledge Couplers (PKC Corp, Burlington, Vt), a decision-support tool proposed for the Department of Defense's new health information network., Methods: This was a patient-level randomized trial conducted at 2 military practices. A total of 936 patients were allocated to the intervention group and 966 to usual care. Couplers were applied before routine ambulatory clinic visits. The primary outcome was quality of care, which was assessed based on the total percentage of any of 24 health care quality process measures (opportunities to provide evidence-based care) that were fulfilled. Secondary outcomes included medical resources consumed within 60 days of enrollment and patient and provider satisfaction., Results: There were 4639 health care opportunities (2374 in the Coupler group and 2265 in the usual-care group), with no difference in the proportion of opportunities fulfilled (33.9% vs 30.7%; P = .12). Although there was a modest improvement in performance on screening/preventive measures, it was offset by poorer performance on some measures of acute care. Coupler patients used more laboratory and pharmacy resources than usual-care patients (logarithmic mean difference, 71 dollars). No difference in patient satisfaction was observed between groups, and provider satisfaction was mixed., Conclusion: This study provides no strong evidence to support the utility of this decision-support tool, but it demonstrates the value of rigorous evaluation of decision-support information technology.

Little is known about patient awareness of nationally recommended blood pressure targets, especially among patients with cardiac disease. To examine this issue, we interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their systolic and diastolic blood pressure levels as well as corresponding national targets. We used bivariate and multivariate analyses to determine if any patient demographic or clinical characteristics were associated with blood pressure knowledge. Only 66.1% of patients could recall their own systolic and diastolic blood pressure levels. Only 48.9% of all patients could correctly name targets for these values. Knowledge of target blood pressure levels was particularly poor among patients who were female (odds ratio (OR) 0.69; 95% confidence interval (CI) 0.49-0.98), aged > or =60 years (OR 0.70, CI 0.51-0.97), without any college education (OR 0.48, CI 0.35-0.65), without a documented history of hypertension (OR 0.57, CI 0.39-0.84), and with known diabetes (OR 0.46, CI 0.33-0.66). Patients in the highest risk group, according to Joint National Committee guidelines stratification, were no more knowledgeable about their blood pressure levels and targets than lower risk patients. A significant proportion of patients hospitalized with coronary artery disease do not know their own blood pressure levels or targets. Current blood pressure education efforts appear inadequate, particularly for certain patient subgroups in which hypertension is an important modifiable risk factor.

Background: Despite national efforts to improve cholesterol management for patients with coronary artery disease, many patients are not reaching recommended cholesterol target levels. We sought to determine whether a nurse-based educational intervention, designed to educate patients with confirmed coronary artery disease about personal low-density lipoprotein (LDL) cholesterol target levels and encourage partnership with physicians, could increase adherence with National Cholesterol Education Program target levels (LDL cholesterol level < or =100 mg/dL)., Methods: Patients hospitalized with confirmed coronary artery disease were randomized to undergo a nurse-based educational intervention (375 patients) or usual care (381 patients) for a 12-month period after hospitalization. The primary outcome was the proportion of patients at the LDL cholesterol target level 1 year after hospitalization. The secondary outcome was the proportion of patients with accurate knowledge of LDL cholesterol target levels., Results: The groups were similar at baseline in demographic and clinical characteristics, percent at LDL cholesterol target level (43.9% and 41.1%, respectively), and percent with knowledge of LDL cholesterol target levels (both 5%). The proportion of patients at LDL cholesterol target levels at 1 year did not differ between the intervention (70.2%) and usual care group (67.4%, P =.46). At the conclusion of the trial, patient knowledge about LDL cholesterol target level was higher for the intervention group than the usual care group (19.6% and 6.7%, respectively, P =.001), but this was not associated with improved cholesterol management., Conclusions: Our nurse-based educational intervention did not result in a significant increase in the proportion of patients who reached target LDL cholesterol levels 1 year after hospitalization. Although the intervention improved patient knowledge of LDL cholesterol target levels, overall rates of LDL cholesterol knowledge remained low, and it was not associated with improved cholesterol management.

Background: Despite the many proposed methods for improving quality, little is known about which methods are being applied in practice across the United States or their perceived effectiveness., Methods: A descriptive, cross-sectional analysis of data from a telephone survey of quality improvement staff in 234 randomly selected hospitals participating in the National Registry of Myocardial Infarction was conducted to examine the prevalence and perceived effectiveness of various quality improvement interventions directed at increasing beta-blocker use after acute myocardial infarction., Results: The mean and median number of quality improvement interventions directed at beta-blocker use in the past 4 years was 5.0 per hospital. The most commonly reported effort was performance reporting about beta-blocker use (87.9%), although only 26.7% used physician-specific performance reporting. More than half the hospitals implemented clinical pathways (58.1%), standing orders (56.8%), or care coordinators (50.4%). Care coordinators (63.4%) and computer support systems (61.6%) were most frequently rated as "very effective." Clinical pathways (24.2%), counseling physicians who had poor performance (26.9%), and reminder forms (23.0%) were most frequently rated as not effective., Conclusions: Substantial variation in the types of quality improvement efforts implemented to increase beta-blocker use and perceived effectiveness were evident.

Background: The influence of physician leaders on their colleagues in local medical communities has been recognized for several decades. However, the literature indicates that little is known about the specific characteristics of physician leaders involved in improving quality in today's hospital environment. A taxonomy of the characteristics of the physician quality leader from the perspective of physicians and nonphysicians was developed., Subjects and Methods: Information about physician leaders working to improve acute myocardial infarction (AMI) was gathered from in-depth interviews with 45 key physicians and nursing, quality management, and administrative staff at eight hospitals. Data were analyzed using the constant comparative method of qualitative data analysis., Results: The physician leader characteristics were described in four main categories: personal commitment, professional credibility, quality improvement behaviors and skills, and institutional linkages. Each physician leader possessed different combinations of the characteristics from the four categories, revealing the complexity of the physician leader role., Conclusion: Understanding the key characteristics of physician leaders is a critical step in helping hospitals choose and develop physician leaders who can effectively bring about meaningful quality improvement.

With increasing attention directed at quality problems and medical errors in healthcare organizations, the ability of senior management to promote and sustain effective quality improvement efforts is paramount to their organizational success. We sought to define key roles and activities that comprise senior managers' involvement in improvement efforts directed at physicians' prescription of beta-blockers after acute myocardial infarction (AMI). We also developed a taxonomy to organize the diverse roles and activities of managers in quality improvement efforts and proposed key elements that might be most central to successful improvement efforts. Results are based on a qualitative study of 8 hospitals across the country and included in-depth interviews with 45 clinical and administrative staff from these hospitals. The findings help identify a checklist that senior managers may use to assess their own and others' participation in quality improvement efforts in their institutions. By reinforcing their current involvement or by identifying potential gaps in their involvement in quality improvement efforts, practitioners may enhance their effectiveness in promoting and sustaining quality in clinical care.

Background: Patients' viewpoint of their health status is increasingly used as an important outcome measure of the success of treatments. Because clinicians rarely formally measure patients' health-related quality of life, the question arises whether noninvasive testing for ischemia can provide similar information regarding physical functioning and general health perception., Methods: We measured physical functioning and general health status with the Medical Outcomes Study Short Form (SF-36) survey in 195 consecutive patients (68% male, mean age 55.6 +/- 11.1 years) referred for exercise testing with myocardial perfusion imaging. The survey was completed immediately before the exercise test., Results: In the multivariate analysis, the strongest predictor of physical functioning and general health perception was metabolic equivalents. However, the best model, including demographic, clinical, and test variables, predicted only 14% of the variation in physical functioning and 10% of the variability in general health perception., Conclusions: The variation in physical functioning and general health perception, as measured by the SF-36, among patients referred for exercise testing is not predicted well by the results of the test. As expected, several test results are significantly associated with physical functioning and general health perception; however, there was substantial overlap among individual patients, suggesting that the parameters are poor surrogates for the actual assessment of the domains. If these domains are deemed important to tracking patient outcomes, then they should supplement the current assessments of these patients.

Background-Preoperative identification of viable myocardium in patients with ischemic cardiomyopathy is considered important because CABG can result in recovery of left ventricular (LV) function. However, the hypothesis that lack of improvement of LV function after CABG is associated with poorer patient outcome is untested. Methods and Results-Outcome was compared in patients with ischemic LV dysfunction (LVEF 0.05 increase in LVEF (group A) and 36 (35%) had no significant change, or

Objective: To evaluate recent trends in the cost of percutaneous transluminal coronary angioplasty (PTCA), particularly the impact of newer technology and changing patient profile., Study Design: Retrospective study with a 6-month follow up., Patients and Methods: We compared the data on two groups of 100 consecutive patients admitted for elective PTCA at Yale-New Haven Hospital in 1995 and 1996. Hospital records, cineangiograms, and hospital cost accounting system were reviewed, and 6-month clinical outcomes were obtained from telephone interviews and medical chart review., Results: Demographic and clinical characteristics did not differ between the 1995 and 1996 groups of patients, nor was a difference detected in in-hospital and 6-month clinical outcomes between 1995 and 1996. Angiographic features of treated lesions were different between the two groups, with a significantly higher frequency of type C and totally occluded lesions in 1996 (p = 0.002 and p = 0.04, respectively). The total hospital costs were higher in 1996 compared with 1995 ($11,799 +/- $6189 vs $10,087 +/- $5608; p = 0.04). This difference persisted after adjustment for changes in patient population. The major factor responsible for escalating costs was a 45% increase in catheterization laboratory costs ($8575 +/- $4524 in 1996 vs $5916 +/- $3030 in 1995; P < 0.0001). In contrast, the noncatheterization costs decreased substantially during this period, largely as a result of an approximately 33% decrease in length of stay (3.75 +/- 2.66 days in 1995 vs 2.57 +/- 1.99 days in 1996; P = 0.0005). In a multiple linear regression model, the most important determinants of cost were lesion characteristics, stent use, and radiographic contrast volume., Conclusions: Despite cost reduction efforts, the costs of PTCA are rising because of increased consumption of resources in the catheterization laboratory.

Background: It has been suggested that in patients with a normal resting electrocardiogram (ECG), exercise radionuclide myocardial perfusion imaging (MPI) does not add significant incremental diagnostic information to exercise ECG., Methods and Results: Of 840 consecutive patients referred for physical exercise MPI, 313 (37%) had normal resting ECGs. There were 189 men and 124 women with a mean age of 54+/-11.9 years. Exercise MPI was performed with either TI-201 or 99mTc-labeled sestamibi. Overall concordance between exercise ECG result and MPI result was 79% (kappa agreement = .54). One hundred eighty-four patients had normal exercise ECG; 181 (98.4%) of these also had normal exercise MPI. In 271 patients with low (< or =20%) to intermediate (21% to 70%) pre-exercise likelihood of coronary artery disease (CAD), concordance between normal exercise ECG and normal MPI was 100%. In the high likelihood (> or =71%) group 3 (15 %) patients with normal exercise ECG had abnormal exercise MPI. Of 129 patients with abnormal exercise ECG, 67 (52%) patients also had abnormal MPI, but 62 (48%) patients had normal MPI. Complete follow-up was obtained in 89% of patients at 9 months. Only 1 hard cardiac event occurred: nonfatal myocardial infarction. Twenty-one (8%) patients had subsequent coronary revascularization or admission with unstable angina. Although both abnormal stress ECG and abnormal exercise MPI were significantly (P < .0001) associated with hard and "soft" events, the association of abnormal exercise MPI was significantly stronger. Because all patients with a low and intermediate likelihood of CAD who had normal exercise ECG also had normal exercise MPI, we propose a stepwise diagnostic testing strategy whereby exercise MPI imaging is performed only in patients with a low to intermediate likelihood of CAD when the exercise ECG is abnormal. When the exercise ECG is performed first, and exercise MPI is performed only when the exercise ECG is abnormal, substantial (38%) cost savings can be achieved. In patients with a high likelihood of CAD, the exercise ECG may be falsely negative, and exercise MPI is preferred., Conclusion: In patients with normal resting ECGs a stepwise diagnostic strategy can reduce costs of exercise testing without compromising diagnostic yield when pretest likelihood of coronary artery disease is taken into consideration.

Objectives: We sought to evaluate the prognostic value of routine noninvasive testing--stress thallium-201 imaging, rest two-dimensional echocardiography and rest equilibrium radionuclide angiography--1 year after cardiac transplantation., Background: Coronary artery vasculopathy is the most important cause of late death after orthotopic cardiac transplantation. Several clinical variables have been identified as risk factors for development of coronary vasculopathy. Traditional noninvasive diagnostic testing has been shown to be relatively insensitive for identifying patients with angiographic vasculopathy., Methods: Results of prospectively acquired noninvasive testing in 47 consecutive transplant recipients alive 1 year after transplantation were related to subsequent survival. Other clinical variables previously shown to be associated with the development of coronary artery vasculopathy were also included in the analysis., Results: The 5-year survival rate after cardiac transplantation was 81%. By univariate analysis, echocardiography (chi-square 9.21) and stress thallium-201 myocardial perfusion imaging (chi-square 16.76) were predictive for survival, whereas rest equilibrium radionuclide angiography was not. Clinical contributors to survival were donor age (chi-square 4.56), number of human leukocyte antigen mismatches (chi-square 3.06) and cold ischemic time (chi-square 3.23). By multivariate analysis, stress myocardial imaging remained the only significant predictor of survival (risk ratio 0.27; 95% confidence interval 0.06 to 0.89)., Conclusions: Normal thallium-201 stress myocardial perfusion imaging 1 year after cardiac transplantation is an important predictor of 5-year survival.

Fifty-two paired stress/delayed planar 201TI studies (27 exercise studies, 25 dipyridamole studies) were processed twice by seven technologists to assess inter- and intraobserver variability. The reproducibility was inversely related to the size of 201TI perfusion abnormalities. Intraobserver variability was not different between exercise and dipyridamole studies for lesions of similar size. Based upon intraobserver variability, objective quantitative criteria for reversibility of perfusion abnormalities were defined. These objective criteria were tested prospectively in a separate group of 35 201TI studies and compared with the subjective interpretation of quantitative circumferential profiles. Overall, exact agreement existed in 78% of images (kappa statistic k = 0.66). We conclude that quantification of planar 201TI scans is highly reproducible, with acceptable inter- and intraobserver variability. Objective criteria for lesion reversibility correlated well with analysis by experienced observers.

Standard interpolative background subtraction, as used for thallium-201 (201Tl), may create artifacts when applied to planar technetium-99m-Sestamibi (99mTc-Sestamibi) images, apparently because of the oversubtraction of relatively high extra-cardiac activity. A modified background subtraction algorithm was developed and compared to standard background subtraction in 16 patients who had both exercise-delayed 201Tl and exercise-rest 99mTc-Sestamibi imaging. Furthermore, a new normal data base was generated. Normal 99mTc-Sestamibi distribution was slightly different compared to 201Tl. Using standard background subtraction, mean defect reversibility was significantly underestimated by 99mTc-Sestamibi compared to 201Tl (2.8 +/- 4.9 versus -1.8 +/- 8.4, p less than 0.05). Using the modified background subtraction, mean defect reversibility on 201Tl and 99mTc-Sestamibi images was comparable (2.8 +/- 4.9 versus 1.7 +/- 5.2, p = NS). We conclude, that for quantification of 99mTc-Sestamibi images a new normal data base, as well as a modification of the interpolative background subtraction method should be employed to obtain quantitative results comparable to those with 201Tl.

The results of quantitative analysis of planar thallium-201 stress scintigraphy are superior to those of visual analysis. The increased sensitivity for detection of coronary artery disease is associated with maintenance of specificity. Consequently, we believe that quantitative analysis is the state-of-the-art for planar 201Tl stress scintigraphy. We emphasize that for reliable and reproducible results, rigorous quality control and strict adherence to a standardized imaging protocol are necessary. An important feature is clarity of display of computer data. In our experience, the most important feature for making quantitative analysis reliable and accessible for a broader user market is simultaneous display of the lower limits of normal with processed patient data. This provides a simple visual impression of the degree and extent of abnormal 201Tl distribution and kinetics relative to the lower limit of normal.

Technetium-99m isonitrile myocardial perfusion imaging was employed in a patient undergoing thrombolytic therapy with recombinant tissue plasminogen activator for acute anteroseptal myocardial infarction. Technetium-99m isonitrile does not demonstrate significant myocardial redistribution after intravenous injection. The imaging agent was administered in the emergency room, prior to the initiation of thrombolytic therapy. The initial area at risk for infarction was visualized on images obtained after the patient had been effectively treated. Imaging performed 5 days later, after repeat injection of [99mTc]isonitrile, showed a smaller myocardial perfusion defect indicating salvage of myocardium. Thus, this technique offers promise as a noninvasive means of assessing the area at risk, the success of reperfusion, and the presence of salvaged myocardium, early in the course of acute myocardial infarction.