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1.  Survival by the Fittest: Hospital‐Level Variation in Quality of Resuscitation Care 
PMCID: PMC3959720  PMID: 24584744
Editorials; cardiac arrest; resuscitation; survival; systems of care
2.  Comparison of Clinical Interpretation with Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice: The Assessing Angiography (A2) Project 
Circulation  2013;127(17):1793-1800.
Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently made.
Methods & Results
We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention (PCI) at 7 U.S. hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen’s weighted kappa statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (Q1 and Q3, 80.0 and 90.0%) with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was +8.2 ± 8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted kappa of 0.27 (95% CI, 0.18 to 0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA though none was <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50 to <70%) with variation existing across sites.
Physicians tended to assess coronary lesions treated with PCI as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, while approximately a quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.
PMCID: PMC3908681  PMID: 23470859
Health policy and outcomes research; Quality improvement; Coronary angiography; Percutaneous coronary intervention; Quantitative coronary angiography
3.  Protocol for a prospective, controlled study of assertive and timely reperfusion for patients with ST-segment elevation myocardial infarction in Tamil Nadu: the TN-STEMI programme 
BMJ Open  2013;3(12):e003850.
Over the past two decades, India has witnessed a staggering increase in the incidence and mortality of ST-elevation myocardial infarction (STEMI). Indians have higher rates of STEMI and younger populations that suffer from it when compared with developed countries. Yet, the recommended reperfusion therapy with fibrinolysis and percutaneous coronary intervention is available only to a minority of patients. This gap in care is a result of financial barriers, limited healthcare infrastructure and poor knowledge and accessibility of acute medical services for a majority of its population.
Methods and analysis
This is a prospective, multicentre, ‘pretest/post-test’ quasi-experimental, community-based study. This programme will use a ‘hub-and-spoke’ model of an integrated healthcare network based on clusters of primary-care health clinics, small hospitals and large tertiary-care facilities. It is an ‘all-comers’ study which will enrol consecutive patients presenting with STEMI to the participating hospitals. The primary objectives of the study is to improve the use of reperfusion therapy and reduce the time from first medical contact to device or drug in STEMI patients; and to increase the rates of early invasive risk stratification with coronary angiography within 3–24 h of fibrinolytic therapy in eligible patients through changes in process of care. Outcomes will be measured with statistical comparison made before and after implementing the TN-STEMI programme. The estimated sample size is based on the Kovai Erode Pilot study, which provided an initial work on establishing this type of programme in South India. It will be adequately powered at 80% with a superiority margin of 10% if 36 patients are enrolled per cluster or 108 patients in three clusters. Thus, the enrolment period of 9 months will result in a sample size of 1500 patients.
This study will be conducted in accordance with the ethical principles that have their origin in the current Declaration of Helsinki and ‘ethical guidelines for biomedical research on human participants’ as laid down by the Indian Council for Medical Research. All participating hospitals will still obtain local ethics committee approval of the study protocol and written informed consent will be obtained from all participants.
Dissemination and results
Our findings will be reported through scientific publications, research conferences and public policy venues aimed at state and local governments in India. If successful, this model can be extended to other areas of India as well as serve as a model of STEMI systems of care for low-income and middle-income countries across the world.
Trial is registered with Clinical trial registry of India, No: CTRI/2012/09/003002.
PMCID: PMC3855601  PMID: 24302505
4.  Use and Effectiveness of Intra-Aortic Balloon Pumps Among Patients Undergoing High Risk Percutaneous Coronary Intervention: Insights from the NCDR® 
IABPs are frequently used to provide hemodynamic support during high risk percutaneous coronary intervention (PCI), but clinical evidence to support their use is mixed. We examined hospital variation in IABP use among high risk PCI patients, and determined the association of IABP use on mortality in this population.
Methods and Results
We analyzed data submitted to the CathPCI Registry® between January 2005 and December 2007. High risk PCI was defined as having at least one of the following features: unprotected left main artery as the target vessel, cardiogenic shock, severely depressed left ventricular function, or ST segment elevation myocardial infarction. Hospitals were categorized into quartiles by their proportional use of IABP. We examined differences in in-hospital mortality across hospital quartiles using a hierarchical logistic regression model to adjust for differences in patient and hospital characteristics across hospital quartiles of IABP use. IABPs were used in 18,990 (10.5%) of 181,599 high risk PCIs. Proportional use of IABP varied significantly across hospital quartiles: Q1: 0.0%–6.5%; Q2: 6.6% to 9.2%; Q3: 9.3% to 14.1%; and Q4: 14.2% to 40.0%. In multivariable analysis, after adjustment for differences in patient and hospital characteristics, in-hospital mortality was comparable across quartiles of hospital IABP usage (Q1: Ref; Q2: Odds Ratio (OR) 1.11, 95% CI 0.99–1.24; Q3: OR 1.03, 95% CI 0.92–1.15; Q4: OR 1.06, 95% CI 0.94–1.18).
IABP use varied significantly across hospitals for high risk PCI. However, this variation in IABP use was not associated with differences in in-hospital mortality.
PMCID: PMC3801197  PMID: 22147887
Angioplasty; Atherosclerosis; Heart assist device
5.  Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest 
The New England journal of medicine  2013;368(11):1019-1026.
Little is known about the long-term outcomes in elderly survivors of in-hospital cardiac arrest. We determined rates of long-term survival and readmission among survivors of in-hospital cardiac arrest and examined whether these outcomes differed according to demographic characteristics and neurologic status at discharge.
We linked data from a national registry of inpatient cardiac arrests with Medicare files and identified 6972 adults, 65 years of age or older, who were discharged from the hospital after surviving an in-hospital cardiac arrest between 2000 and 2008. Predictors of 1-year survival and of readmission to the hospital were examined.
One year after hospital discharge, 58.5% of the patients were alive, and 34.4% had not been readmitted to the hospital. The risk-adjusted rate of 1-year survival was lower among older patients than among younger patients (63.7%, 58.6%, and 49.7% among patients 65 to 74, 75 to 84, and ≥85 years of age, respectively; P<0.001), among men than among women (58.6% vs. 60.9%, P = 0.03), and among black patients than among white patients (52.5% vs. 60.4%, P = 0.001). The risk-adjusted rate of 1-year survival was 72.8% among patients with mild or no neurologic disability at discharge, as compared with 61.1% among patients with moderate neurologic disability, 42.2% among those with severe neurologic disability, and 10.2% among those in a coma or vegetative state (P<0.001 for all comparisons). Moreover, 1-year readmission rates were higher among patients who were black, those who were women, and those who had substantial neurologic disability (P<0.05 for all comparisons). These differences in survival and readmission rates persisted at 2 years. At 3 years, the rate of survival among survivors of in-hospital cardiac arrest was similar to that of patients who had been hospitalized with heart failure and were discharged alive (43.5% and 44.9%, respectively; risk ratio, 0.98; 95% confidence interval, 0.95 to 1.02; P = 0.35).
Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year, and the rate of 3-year survival was similar to that among patients with heart failure. Survival and readmission rates differed according to the demographic characteristics of the patients and neurologic status at discharge. (Funded by the American Heart Association and the National Heart, Lung, and Blood Institute.)
PMCID: PMC3652256  PMID: 23484828
7.  Exposure to Low-Dose Ionizing Radiation from Medical Imaging Procedures in the United States 
The New England journal of medicine  2009;361(9):849-857.
Growing use of imaging procedures in the United States has raised concerns about exposure to low-dose ionizing radiation in the general population.
We identified 952,420 non-elderly adults in 5 healthcare markets across the United States between July 1, 2005 and December 31, 2007. Utilization data were used to determine cumulative effective doses of radiation from imaging procedures in millisieverts (mSv) and to calculate population-based rates of “moderate” (>3 to 20 mSv per year), “high” (>20 to 50 mSv per year) and “very-high” (>50 mSv per year) doses.
During the study period, 655,613 (68.8%) individuals underwent at least 1 imaging procedure associated with radiation exposure. The mean effective dose from imaging procedures was 2.4 mSv per person per year (std dev, 6.0 mSv); however, a wide distribution was noted with a median effective dose of 0.1 mSv per person per year (interquartile range, 0.0 to 1.7). Overall, the annual rate for moderate effective doses in the study population was 193.8 per 1000 enrollees, while high and very-high doses occurred at annual rates of 18.6 per 1000 enrollees and 1.9 per 1000 enrollees, respectively. In general, effective doses of radiation from imaging procedures increased with advancing age and were higher in women. Computed tomography and nuclear medicine scans accounted for 75.4% of the total effective dose and 81.8% occurred in non-hospitalized settings.
Imaging procedures are an important source of ionizing radiation in the United States and can lead to high radiation doses in patients.
PMCID: PMC3707303  PMID: 19710483
8.  Use of Medical Imaging Procedures With Ionizing Radiation in Children: A Population-Based Study 
To determine population-based rates of use of diagnostic imaging procedures with ionizing radiation in children, stratified by age and gender.
Retrospective cohort analysis.
All settings utilizing imaging procedures with ionizing radiation.
Individuals less than 18 years old, alive and continuously enrolled in Unitedhealthcare between January 1, 2005 and December 31, 2007 in 5 large U.S. healthcare markets.
Main Outcome Measure
Number and type of diagnostic imaging procedures utilizing ionizing radiation in children.
355,088 children were identified. A total of 436,711 imaging procedures using ionizing radiation were performed in 150,930 (42.5%) patients. The highest rates of use were in children greater than 10 years old, with frequent use in infants under 2 years old as well. Plain radiography accounted for nearly 85% of imaging procedures performed. Computed tomography (CT) scans – associated with substantially higher doses of radiation – were commonly used, accounting for 12% of all procedures during the study period. Overall, 7.9% of children received at least one CT and 3.5% received 2 or more, with CT of the head most frequent.
Exposure to ionizing radiation from medical diagnostic imaging procedures may occur frequently among children. Efforts to optimize and ensure appropriate use of these procedures in the pediatric population should be encouraged.
PMCID: PMC3686496  PMID: 21199972
9.  Trends in Survival After In-Hospital Cardiac Arrest 
The New England journal of medicine  2012;367(20):1912-1920.
Despite numerous advances in resuscitation care in recent years, it remains unknown whether survival and neurological function after in-hospital cardiac arrest has improved over time.
We identified all adults with an index in-hospital cardiac arrest at 374 hospitals in the Get With The Guidelines-Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends: (1) were due to improved survival during the acute resuscitation or post-resuscitation care and (2) occurred at the expense of greater neurological disability among survivors.
Among 84,625 hospitalized patients with cardiac arrest, 67,135 (79.3%) had an initial rhythm of asystole or pulseless electrical activity while 17,490 (20.7%) had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P for trend <0.001). Risk-adjusted rates of survival to discharge in the overall cohort increased from 13.7% in 2000 to 22.4% in 2009 (adjusted rate-ratio per 1-year: 1.04, 95% CI [1.02–1.05]; P for trend <0.001). Survival improvement was similar in both rhythm groups and largely due to improved survival from the acute resuscitation (risk-adjusted rates: 42.7% in 2000, 54.1% in 2009; adjusted rate-ratio per 1-year: 1.03, 95% CI [1.02–1.04]; P for trend <0.001). Importantly, rates of neurological disability among survivors decreased over time (risk-adjusted rates: 32.9% in 2000, 28.1% in 2009; P for trend=0.02).
Both survival and neurological outcomes after in-hospital cardiac arrest have improved over the past decade.
PMCID: PMC3517894  PMID: 23150959
10.  Duration of resuscitation efforts and subsequent survival after in-hospital cardiac arrest 
Lancet  2012;380(9852):1473-1481.
During in-hospital cardiac arrests, it is uncertain how long resuscitation should continue prior to termination of efforts. We hypothesized that the duration of resuscitation varies across hospitals, and that patients at hospitals with longer attempts have higher survival rates.
Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 hospitals within a large national registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts among its non-survivors as a measure of the hospital’s overall tendency for longer attempts. We then determined the association between a hospital’s tendency for longer attempts and risk-adjusted survival using multilevel regression models.
The overall proportion of patients achieving immediate survival with return of spontaneous circulation (ROSC) was 48·5% while 15·4% survived to discharge. For patients achieving ROSC, the median resuscitation time was 12 minutes (IQR: 6–21) while it was 20 minutes (IQR: 14–30) for those not achieving ROSC (i.e., non-survivors). Compared with patients at hospitals with the shortest attempts (median duration, 16 minutes), patients at hospitals with the longest attempts (median duration, 25 minutes) had a higher likelihood of ROSC (adjusted risk-ratio 1·12, [95% CI: 1·06–1·18]; p <0·001) and survival to discharge (adjusted risk-ratio 1·12, [95% CI: 1·02–1·23]; p=0·021). These findings were more prominent in cardiac arrests due to asystole and pulseless electrical activity (p for interaction<0.01 for both ROSC and survival to discharge).
The duration of resuscitation attempts varies across hospitals. Patients at hospitals with longer attempts have a higher likelihood of ROSC and survival to discharge, particularly when the arrest is due to asystole and pulseless electrical activity.
The American Heart Association, the Robert Wood Johnson Foundation Clinical Scholars Program, the National Institutes of Health.
PMCID: PMC3535188  PMID: 22958912
11.  Improvements in Door-to-Balloon Time in the United States: 2005-2010 Krumholz: Trends in D2B Time: 2005-2010 
Circulation  2011;124(9):1038-1045.
Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know if improvements in door-to-balloon times were shared equally among patient and hospital groups.
Methods and Results
This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention acute myocardial infarction-8 (AMI-8) inpatient measure from January 1, 2005 through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure including the number and percentage in each group as well as the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005 to a median of 64 minutes in the three quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes (27.3% to 70.4%). The declines in median times were greatest among groups that had the highest median times during the first period: Patients >75 years of age (median decline 38 minutes); women (35 minutes); and African Americans (42 minutes).
National progress has been achieved in the treatment of patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention.
PMCID: PMC3598634  PMID: 21859971
percutaneous coronary intervention; myocardial infarction; balloon; reperfusion
12.  Automated External Defibrillators and Survival After In-Hospital Cardiac Arrest 
Automated external defibrillators (AEDs) improve survival from out-of-hospital cardiac arrests, but data on their effectiveness in hospitalized patients are limited.
To evaluate the association of AED use and survival for in-hospital cardiac arrest.
Design, Setting, Patients
Cohort study of 11,695 hospitalized patients with cardiac arrests between January 1, 2000 and August 26, 2008 at 204 hospitals following the introduction of AEDs on general hospital wards.
Main Outcome Measure
Survival to hospital discharge by AED use, using multivariable hierarchical regression analyses to adjust for patient factors and hospital site.
Of 11,695 patients, 9616 (82.2%) had non-shockable rhythms (asystole and pulseless electrical activity) and 2079 (17.8%) had shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia). AEDs were used in 4515 (38.6%) patients. Overall, 2117 (18.1%) patients survived to hospital discharge. Within the entire study population, AED use was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16.3% vs. 19.3%; adjusted rate ratio (RR), 0.85; 95% confidence interval (CI), 0.78–0.92; P<0.001). Among cardiac arrests due to non-shockable rhythms, AED use was associated with lower survival (10.4% vs. 15.4%; adjusted RR, 0.74; 95% CI, 0.65–0.83; P<.001). In contrast, for cardiac arrests due to shockable rhythms, AED use was not associated with survival (38.4% vs. 39.8%; adjusted RR, 1.00; 95% CI, 0.88–1.13; P=0.99). These patterns were consistently observed in both monitored and non-monitored hospital units where AEDs were used, after matching patients to the individual units in each hospital where the cardiac arrest occurred, and with a propensity score analysis.
Use of AEDs in hospitalized patients with cardiac arrest is not associated with improved survival.
PMCID: PMC3587791  PMID: 21078809
13.  Variation in the Use of Lower Extremity Vascular Procedures for Critical Limb Ischemia 
Many believe that variation in vascular practice may affect limb salvage rates in patients with severe PAD. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown.
Methods and Results
Using Medicare 2003–2006, we identified all patients with CLI who underwent major lower extremity amputation in the 306 hospital referral regions (HRRs) described in the Dartmouth Atlas of Healthcare. For each patient, we studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year prior to amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the HRR undergoing vascular procedure in the year before amputation. Overall, 20,464 patients with CLI underwent major lower extremity amputations during the study period, and collectively underwent 25,800 vascular procedures in the year prior to undergoing amputation. However, these procedures were not distributed evenly − 54% of patients had no vascular procedures performed in the year prior to amputation, 14% underwent 1 vascular procedure, and 21% underwent more than one vascular procedure. In the regions in the lowest quintile of vascular intensity, vascular procedures were performed in 32% of patients. Conversely, in the regions in the highest quintile of vascular intensity, revascularization was performed in 58% of patients in the year prior to amputation (p<0.0001). In analyses accounting for differences in age, sex, race, and comorbidities, patients in high intensity regions were 2.4 times as likely to undergo revascularization in the year prior to amputation than patients in low intensity regions (adjusted OR=2.4, 95% CI 2.1–2.6, p<0.001).
Significant variation exists in the intensity of vascular care provided to patients in the year prior to major amputation. In some regions, patients receive intensive care, while in other regions, far less vascular care is provided. Future work is needed to determine the association between intensity of vascular care and limb salvage.
PMCID: PMC3281555  PMID: 22147886
epidemiology; outcomes research; peripheral vascular disease; treatment disparities; vascular disease
14.  A Validated Prediction Tool for Initial Survivors of In-Hospital Cardiac Arrest 
Archives of internal medicine  2012;172(12):947-953.
Accurate estimation of favorable neurological survival after in-hospital cardiac arrest could provide critical information for physicians, patients, and families.
Within the Get With The Guidelines-Resuscitation registry, we identified 42,957 patients from 551 hospitals admitted between January 2000 and October 2009 who were successfully resuscitated from an in-hospital cardiac arrest. A simple prediction tool for favorable neurological survival in patients successfully resuscitated from an in-hospital cardiac arrest was developed using multivariable logistic regression, with two-thirds of the sample randomly selected as the derivation cohort and one-third as the validation cohort. Favorable neurological status was defined as the absence of severe neurological deficits (Cerebral Performance Category score of ≤2).
Rates of favorable neurological survival were similar in the derivation (n=7052; 24.6%) and validation cohorts (n=3510; 24.5%). Eleven variables were associated with favorable neurological survival: younger age, initial cardiac arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia with a defibrillation time of ≤2 minutes, baseline neurological status without disability, arrest location in a monitored unit, shorter duration of resuscitation, and absence of mechanical ventilation, renal insufficiency, hepatic insufficiency, sepsis, malignancy, and hypotension prior to the arrest. The model had excellent discrimination (C statistic of 0.80 for both the derivation and validation cohorts) and calibration. The prediction tool demonstrated the ability to identify patients across a wide range of rates of favorable neurological survival: patients in the top decile had a 70.7% probability of this outcome while patients in the bottom decile had a 2.8% probability.
Among successfully resuscitated patients with an in-hospital cardiac arrest, a simple, bedside prediction tool provides robust estimates of the probability of favorable neurological survival. This tool permits accurate prognostication after cardiac arrest for physicians, patients, and families.
PMCID: PMC3517176  PMID: 22641228
Prediction; Risk Score; Cardiac Arrest; Survival; Neurological Disability
15.  Hospital PCI Appropriateness and In-Hospital Procedural Outcomes: Insights from the NCDR® 
Measurement of hospital quality has traditionally focused on processes of care and post-procedure outcomes. Appropriateness measures for percutaneous coronary intervention (PCI) assess quality as it relates to patient selection in the context of anticipated benefits relative to potential harm. The association, if any, between patient selection for PCI and processes of care and post-procedural outcomes is unknown. Defining whether these measures are redundant or complementary can inform the optimal range of metrics for monitoring quality.
We included patients undergoing non-acute (elective) PCI within the NCDR CathPCI Registry® between July 2009 and April 2011. We examined the association between a hospital’s proportion of non-acute PCIs categorized as inappropriate by the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization and in-hospital mortality, bleeding complications, and use of optimal guideline-directed medical therapy at discharge (i.e. aspirin, thienopyridines, and statins).
A total of 203,531 non-acute PCIs from 779 hospitals were classified by the AUC. Of these, 101,779 (50.0%) were classified as appropriate, 77,220 (35.5%) as uncertain, and 24,532 (12.1%) as inappropriate. When categorized as hospital tertiles, the range of inappropriate PCI was 0.0 to 8.1% in the lowest-tertile, 8.1 to 15.2% in the middle-tertile, and 15.2 to 58.6% in the highest-tertile. Compared with lowest-tertile hospitals, mortality was not significantly different at middle-tertile (adjusted odds ratio [OR] 0.93; 95% confidence interval [CI] 0.73 to 1.19) or highest-tertile hospitals (OR 1.12; 95% CI 0.88 to 1.43; p=0.35 for differences between any tertile). Similarly, risk-adjusted bleeding did not vary significantly (middle-tertile OR 1.13; 95% CI 1.02 to 1.16; highest-tertile OR 1.02; 95% CI 0.91 to 1.16; p=0.07 for differences between any tertile) nor did use of optimal therapy at discharge after PCI (85.3% vs. 85.7% vs. 85.2%; P=0.58).
In a national cohort of non-acute PCIs, a hospital’s proportion of inappropriate PCIs was not associated with in-hospital mortality, bleeding, or medical therapy at discharge. These findings suggest that PCI appropriateness measures aspects of hospital PCI quality that are independent of, and complementary to, traditional quality metrics.
PMCID: PMC3520092  PMID: 22576845
Appropriateness criteria; Coronary artery disease; Percutaneous coronary intervention; Utilization; Hospital; Quality of care; Health services research
17.  What Is the Experience of National Quality Campaigns? Views from the Field 
Health Services Research  2010;45(6 Pt 1):1651-1669.
To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements.
Data Sources
In-depth interviews, hospital surveys, and Health Quality Alliance data.
Study Design
We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N=99) at hospitals reporting strong influence (n=6) as well as hospitals reporting limited influence (n=6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data.
Data Collection Methods
In-depth, open-ended interviews; hospital survey.
Principal Findings
Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes.
The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals.
PMCID: PMC3026952  PMID: 20698898
Quality improvement; campaigns; hospitals; acute myocardial infarction
18.  Physician Specialty and Carotid Stenting Among Elderly Medicare Beneficiaries in the United States 
Archives of internal medicine  2011;171(20):1804-1810.
The use of carotid stenting is rising across the United States. How physician specialty relates to its utilization or outcomes is uncertain.
We performed an observational analysis of fee-for-service Medicare beneficiaries 65 years or older undergoing carotid stenting between 2005 and 2007 in 306 hospital referral regions (HRRs). We first determined how frequently carotid stenting was performed by different specialists within each HRR, and then used multivariable regression models to compare population-based utilization rates and 30-day outcomes for it across HRRs based on the proportion performed by cardiologists, surgeons, radiologists or a mix of specialists.
In 272 HRRs where at least 15 cases were performed during the study period, we identified 28,700 carotid stenting procedures performed by 2588 operators. While cardiologists made up approximately one-third of these operators, they were responsible for 14,919 (52.0%) procedures. Significant differences were noted in the characteristics of patients treated by cardiologists as compared with other specialties, including higher rates of invasive cardiac procedures and lower rates of acute stroke or transient ischemic attacks in the 180 days prior to carotid stenting. Population-based utilization rates were significantly higher in HRRs where cardiologists performed most procedures relative to HRRs where most were done by other specialists or a mix of specialists (P<0.001). In contrast, risk-standardized outcomes did not appear to differ across HRRs based on physician specialty.
Carotid stenting is being performed by operators from diverse specialties. HRRs where cardiologists perform most procedures have higher population-based utilization rates with similar outcomes.
PMCID: PMC3213299  PMID: 21824938
19.  Operator Experience and Outcomes with Carotid Stenting in Medicare Beneficiaries 
Although the efficacy of carotid stenting has been established in clinical trials, operator experience and outcomes with the procedure in routine clinical practice are less certain.
To correlate outcomes with 2 measures of operator experience: (1) annual volume; and (2) experience at the time of the procedure among new operators who first performed carotid stenting after a national coverage decision by the Centers for Medicare & Medicaid Services (CMS).
Design, Setting, & Patients
Observational study using administrative data on fee-for-service Medicare beneficiaries 65 years or older undergoing carotid stenting between 2005 and 2007.
Main Outcome Measure
30-day mortality stratified by very-low, low, medium, and high annual operator volumes (<6, 6 to 11, 12 to 23, and ≥24 procedures per year) and treatment early versus late during a new operator’s experience (1st to 11th procedure and 12th procedure or higher).
24,701 procedures were performed by 2339 operators. Of these, 11,846 were performed by 1792 new operators who first performed carotid stenting after its national coverage decision. Overall, 30-day mortality was 1.9% and rate of failure to use an embolic protection device was 4.8%. The median annual operator volume in Medicare beneficiaries was 3.0 per year (IQR, 1.4 to 6.5) and 11.6% of operators performed ≥12 procedures per year during the study period. Observed 30-day mortality was higher among patients treated by operators with lower annual volumes (2.5% [95% CI, 2.1%-2.9%], 1.9% [95% CI, 1.6%-2.3%], 1.6% [95% CI, 1.3%-1.9%], and 1.4% [95% CI, 1.1%-1.7%] across the 4 categories; P<0.001) and among patients treated early versus late during a new operator’s experience (2.3% [95% CI, 2.0%-2.7%] and 1.4% [95% CI, 1.1%-1.9%]; P=0.001). After multivariable adjustment, patients treated by very-low volume operators had a higher risk of 30-day mortality when compared with patients treated by high volume operators (adjusted OR, 1.9; 95% CI, 1.4 to 2.7; P<0.001). Similarly, we found a higher risk of 30-day mortality in patients treated early versus late during a new operator’s experience (adjusted OR, 1.7; 95% CI, 1.2 to 2.4; P=0.001).
Among older patients undergoing carotid stenting, lower annual operator volume and early experience were associated with increased 30-day mortality.
PMCID: PMC3208144  PMID: 21954477
20.  Do imaging studies performed in physician offices increase downstream utilization? An empiric analysis of cardiac stress testing with imaging 
Jacc. Cardiovascular Imaging  2011;4(6):630-637.
To compare patterns of downstream testing and procedures after stress testing with imaging performed at physician offices versus at hospital-outpatient facilities.
Stress testing with imaging has grown dramatically in recent years, but whether the location of where the test is performed correlates with different patterns for subsequent cardiac testing and procedures is unknown.
We identified 82,178 adults with private health insurance from 2005–2007 who underwent ambulatory myocardial perfusion imaging (MPI) or stress echocardiography (SE). Subsequent MPI, SE, cardiac catheterization or revascularization within 6 months were compared between physician office and hospital-outpatient settings.
Overall, 84.5% of MPI and 84.9% of SE were performed in physician offices. The proportion of patients who underwent subsequent MPI, SE or cardiac catheterization was not statistically different between physician office and hospital-outpatient settings for MPI (14.2% v 14.1%, p=0.80) or SE (7.9% v 8.6%, p=0.21). However, patients with physician-office imaging had slightly higher rates of repeat MPI within 6 months compared with hospital-outpatient imaging for both index MPI (3.5% v 2.0%, p<0.001) and SE (3.4% v 2.1%, p<0.001), and slightly lower rates of cardiac catheterization after index MPI (11.5% v 12.3, p=0.01) and SE (4.5% v 7.0%, p<0.001). Differences in 6-month utilization were observed across the 5 healthcare markets after index MPI but not after index SE.
Physician office imaging is associated with slightly higher repeat MPI and fewer cardiac catheterizations than hospital outpatient imaging, but no overall difference in the proportion of patients undergoing additional further testing or procedures. While regional variation exists, especially for MPI, the relationship between physician-office location of stress testing with imaging and greater downstream resource utilization appears modest.
PMCID: PMC3319749  PMID: 21679898
myocardial perfusion imaging; stress echocardiography; health services research; physician office imaging; health policy
21.  Reduction in Acute Myocardial Infarction Mortality in the United States 
Jama  2009;302(7):767-773.
During the last 2 decades, health care professional, consumer, and payer organizations have sought to improve outcomes for patients hospitalized with acute myocardial infarction (AMI). However, little has been reported about improvements in hospital short-term mortality rates or reductions in between-hospital variation in short-term mortality rates.
To estimate hospital-level 30-day risk-standardized mortality rates (RSMRs) for patients discharged with AMI.
Design, Setting, and Patients
Observational study using administrative data and a validated risk model to evaluate 3 195 672 discharges in 2 755 370 patients discharged from nonfederal acute care hospitals in the United States between January 1, 1995, and December 31, 2006. Patients were 65 years or older (mean, 78 years) and had at least a 12-month history of fee-for-service enrollment prior to the index hospitalization. Patients discharged alive within 1 day of an admission not against medical advice were excluded, because it is unlikely that these patients had sustained an AMI.
Main Outcome Measure
Hospital-specific 30-day all-cause RSMR.
At the patient level, the odds of dying within 30 days of admission if treated at a hospital 1 SD above the national average relative to that if treated at a hospital 1 SD below the national average were 1.63 (95% CI, 1.60-1.65) in 1995 and 1.56 (95% CI, 1.53-1.60) in 2006. In terms of hospital-specific RSMRs, a decrease from 18.8% in 1995 to 15.8% in 2006 was observed (odds ratio, 0.76; 95% CI, 0.75-0.77). A reduction in between-hospital heterogeneity in the RSMRs was also observed: the coefficient of variation decreased from 11.2% in 1995 to 10.8%, the interquartile range from 2.8% to 2.1%, and the between-hospital variance from 4.4% to 2.9%.
Between 1995 and 2006, the risk-standardized hospital mortality rate for Medicare patients discharged with AMI showed a significant decrease, as did between-hospital variation.
PMCID: PMC3349070  PMID: 19690309
22.  Appropriateness of Percutaneous Coronary Intervention 
Jama  2011;306(1):53-61.
Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown.
To assess the appropriateness of PCI in the United States.
Design, Setting, and Patients
Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication.
Main Outcome Measures
Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures.
Of 500 154 PCIs, 355 417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103 245 [20.6%]; non–ST-segment elevation myocardial infarction, 105 708 [21.1%]; high-risk unstable angina, 146 464 [29.3%]), and 144 737 (28.9%) for nonacute indications. For acute indications, 350 469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72 911 PCIs (50.4%) were classified as appropriate, 54 988 (38.0%) as uncertain, and 16 838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%–16.7%).
In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals.
PMCID: PMC3293218  PMID: 21730241
23.  The Door-to-Balloon Alliance for Quality: Who Joins National Collaborative Efforts and Why? 
The Door-to-Balloon (D2B) Alliance is a collaborative effort of more than 900 hospitals aimed at improving D2B times for ST–segment elevation myocardial infarction. Although such collaborative efforts are increasingly used to promote improvement, little is known about the types of health care organizations that enroll and their motivations to participate.
To examine the types of hospitals enrolled and reasons for enrollment, a cross-sectional study was conducted of 915 D2B Alliance hospitals and 654 hospitals that did not join the D2B Alliance. Data were obtained from the American Hospital Association’s Annual Survey of Hospitals and a Web-based survey completed by 797 enrolled hospitals (response rate, 87%). Chi-square statistics were used to examine statistical associations, and qualitative data analysis was used to characterize reported reasons for enrolling.
Hospitals that enrolled in the D2B Alliance were significantly (p values < .05) more likely to be larger, nonprofit (versus for-profit), and teaching (versus nonteaching) hospitals. Earlier- versus later-enrolling hospitals were more likely to have key recommended strategies already in place at the time of enrollment. Improving quality and “doing the right thing” were commonly reported reasons for enrolling; however, hospitals also reported improving market share, meeting regulatory and accreditation requirements, and enhancing reputation as primary reasons for joining.
The findings highlight the underlying goals of organizations to improve their position in the external environment—including economic, regulatory, accreditation, and professional environments. Designing quality improvement collaborative efforts to appeal to these goals may be an important strategy for enhancing participation and, in turn, increasing the uptake of evidence-based innovations.
PMCID: PMC3203951  PMID: 19241729
24.  Interhospital Transfers among Medicare Beneficiaries Admitted for Acute Myocardial Infarction at Non-Revascularization Hospitals 
Patients with acute myocardial infarctions (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability, yet we know little about the basis for how such revascularization hospitals are selected.
Methods and Results
We examined interhospital transfer patterns in 71,336 AMI patients admitted to hospitals without revascularization capabilities in the 2006 Medicare claims using network analysis and regression models. A total of 31,607 (44.3%) AMI patients were transferred from 1,684 non-revascularization hospitals to 1,104 revascularization hospitals. Median time to transfer was 2 days. Median transfer distance was 26.7 miles, with 96.1% within 100 miles. In 45.8% of cases, patients bypassed a closer hospital to go to farther hospital that had a better 30-day risk standardized mortality rates. However, in 36.8% of cases, another revascularization hospital with lower 30-day risk-standardized mortality was actually closer to the original admitting non-revascularization hospital than the observed transfer destination. Adjusted regression models demonstrated that shorter transfer distances were more common than transfers to the hospitals with lowest 30-day mortality rates. Simulations suggest that an optimized system that prioritized the transfer of AMI patients to a nearby hospital with the lowest 30-day mortality rate might produce clinically meaningful reduction in mortality.
Over 40% of AMI patients admitted to non-revascularization hospitals are transferred to revascularization hospitals. Many patients are not directed to nearby hospitals with the lowest 30-day risk-standardized mortality, and this may represent an opportunity for improvement.
PMCID: PMC3103265  PMID: 20682917
patient transfers; revascularization; networks; Medicare; mortality
25.  Cumulative Exposure to Ionizing Radiation from Diagnostic and Therapeutic Cardiac Imaging Procedures: A Population-Based Analysis 
To describe radiation exposure from cardiac imaging procedures over time in a general population.
Cardiac imaging procedures frequently expose patients to ionizing radiation, but their contribution to effective doses of radiation in the general population is unknown.
We used administrative claims to identify cardiac imaging procedures performed from 2005-2007 in 952,420 non-elderly insured adults in 5 U.S. healthcare markets. We estimated 3-year cumulative effective doses of radiation in millisieverts (mSv) from these procedures We then calculated population-based annual rates of radiation exposure to effective doses ≤3 mSv/year (background level of radiation from natural sources), >3-20 mSv/year, or >20 mSv/year (upper annual limit for occupational exposure averaged over 5 years).
90,121 (9.5%) individuals underwent at least one cardiac imaging procedure using radiation. Among patients who underwent ≥1 cardiac imaging procedure, the mean cumulative effective dose over 3 years was 16.4 mSv (range 1.5-189.5 mSv). Myocardial perfusion imaging accounted for 74% of the cumulative effective dose. Overall, 47.8% of cardiac imaging procedures were performed in physician offices; this proportion was higher for myocardial perfusion imaging (74.8%) and cardiac CT studies (76.5%). The annual population-based rate of receiving an effective dose of >3-20 mSv/year was 89.0 per 1000; and 3.3 per 1000 for cumulative doses >20 mSv/year. Annual effective doses increased with age and were generally higher among men.
Cardiac imaging procedures lead to substantial radiation exposure and effective doses for many patients in the United States.
PMCID: PMC2952402  PMID: 20619569
radiation; imaging; epidemiology

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