Metal Oxides in Surface Sediment Control Nickel Bioavailability to Benthic Macroinvertebrates.

In aquatic ecosystems, the cycling and toxicity of nickel (Ni) are coupled to other elemental cycles that can limit its bioavailability. Current sediment risk assessment approaches consider acid-volatile sulfide (AVS) as the major binding phase for Ni, but have not yet incorporated ligands that are present in oxic sediments. Our study aimed to assess how metal oxides play a role in Ni bioavailability in surficial sediments exposed to effluent from two mine sites. We coupled spatially explicit sediment geochemistry (i.e., separate oxic and suboxic) to the indigenous macroinvertebrate community structure. Effluent-exposed sites contained high concentrations of sediment Ni and AVS, though roughly 80% less AVS was observed in surface sediments. Iron (Fe) oxide mineral concentrations were elevated in surface sediments and bound a substantial proportion of Ni. Redundancy analysis of the invertebrate community showed surface sediment geochemistry significantly explained shifts in community abundances. Relative abundance of the dominant mayfly (Ephemeridae) was reduced in sites with greater bioavailable Ni, but accounting for Fe oxide-bound Ni greatly decreased variation in effect thresholds between the two mine sites. Our results provide field-based evidence that solid-phase ligands in oxic sediment, most notably Fe oxides, may have a critical role in controlling nickel bioavailability.

Bioamplification as a bioaccumulation mechanism for persistent organic pollutants (POPs) in wildlife.

Persistent organic pollutant bioaccumulation models have generally been formulated to predict bioconcentration and biomagnification. A third bioaccumulation process that can mediate chemical fugacity in an organism is bioamplification.Bioamplification occurs when an organism loses body weight and the chemical partitioning capacity occurs at a rate that is faster than the chemical can be eliminated.Although bioamplification has not been widely recognized as a bioaccumulation process, the potential consequences of this process are significant. Bioamplification causes an increase in chemical fugacity in the animal's tissues and results in there distribution of contaminants from inert storage sites to more toxicologically sensitive tissues. By reviewing laboratory and field studies, we have shown in this paper that bioamplification occurs across taxonomic groups that include, invertebrates,amphibians, fishes, birds, and mammals. Two case studies are presented, and constitute multi-life stage non-steady state bioaccumulation models calibrated for yellow perch and herring gulls. These case studies were used to demonstrate that bioamplification is predicted to occur under realistic scenarios of animal growth and seasonal weight loss. Bioamplification greatly enhances POP concentrations and chemical fugacities during critical physiological and behavioral events in an animal's life history, e.g., embryo development, juvenile stages, metamorphosis, reproduction, migration, overwintering, hibernation, and disease. Consequently,understanding the dynamics of bioamplification, and how different life history scenario scan alter tissue residues, may be helpful and important in assessing wildlife hazards and risks.

Tissue distribution kinetics of 2,2',4,4',5,5'-hexachlorobiphenyl in ringdoves after oral dosing.

Ring doves were provided contaminated food spiked with [(13)C]-2,2',4,4',5,5'-hexachlorobiphenyl (PCB 153) over a period of 63 days. Animals were sacrificed after 0.33, 0.5, 1, 2, 4, 8, 18, 36 and 63 days following access to contaminated food. At each time point, chemical concentrations in blood, liver, brain, gonad, adipose and remaining whole carcass was determined. Whole body concentrations of PCB 153 increased linearly with time over the experiment indicating that the birds did not reach steady state with their food after 63 days. Tissue/plasma concentration ratios were plotted as a function of time to determine time to inter-tissue steady state for fast and slowly perfused tissues. Liver, brain and gonad achieved steady state concentrations with plasma in less than 3 days, whereas fat and carcass tissues required 9.7 and 11.5 days, respectively. The results indicate that inter-tissue distribution kinetics for PCBs in birds is relatively rapid and completed within a little over a week following exposure to a contaminated diet.

Bioamplification and the selective depletion of persistent organic pollutants in Chinook salmon larvae.

The maternal provisioning of yolk to eggs transfers significant quantities of persistent organic pollutants (POPs). As yolk utilization progresses via metabolic activity, there is a potential to realize further increases in POP concentrations if yolk lipids are depleted at a faster rate than POPs, a condition referred to as bioamplification. This study investigated the bioamplification of POPs in Chinook salmon ( Oncorhynchus tshawytscha ) eggs and larvae. Chinook eggs were sampled from the Credit River, ON, Canada, and brought to an aquaculture facility where they were fertilized, incubated, and maintained posthatch until maternally derived lipid reserves became depleted (approximately 168 days). The loss of chemicals having an octanol-water partition coefficient (log K(OW)) greater than 5.8 was slow to negligible from days 0-135. However, during the increase in water temperatures in early spring, K(OW)-dependent elimination of POPs was observed. Bioamplification was maximized for the highest log K(OW) POPs, with an approximate 5-fold increase in lipid equivalents concentrations in 168 day old larvae as compared to newly fertilized eggs. This study demonstrates that later yolk-sac Chinook larvae (before exogenous feeding) are exposed to higher lipid equivalents POP concentrations than predicted by maternal deposition, which could lead to underestimates in the toxicity of critical life stages.

Derivation and validation of a clinical prediction rule for nosocomial pneumonia after coronary artery bypass graft surgery.

BACKGROUND: Nosocomial pneumonia is an important cause of morbidity and mortality among surgical patients in the United States. The emergence of effective but potentially costly or risky preventive interventions makes perioperative risk stratification desirable. We sought to develop a prediction rule for pneumonia after coronary artery bypass grafting (CABG), a common surgical procedure. METHODS: Data on individuals undergoing CABG at 32 hospitals in 6 states were extracted from Tenet Healthcare's Quality and Resource Management System. A logistic regression-based prediction rule was developed in half of the study sample and validated in the remaining patients. RESULTS: Of 17,143 individuals undergoing CABG from January 1999 through February 2004, 361 (2%) developed pneumonia without a known aspiration etiology. Thirteen independent predictors of pneumonia were identified in the derivation subset of the sample: body mass index <18.5 (defined as the weight in kilograms divided by the square of the height in meters), smoking history, admission from a nonresidential setting, cancer history, chronic obstructive pulmonary disease, Canadian Cardiovascular Society score 3, prior internal mammary artery CABG, emergency status, serum creatinine level >1.2 mg/dL, percutaneous transluminal coronary angioplasty, blood transfusion, preoperative vancomycin administration, and receipt of mechanical ventilation for >1 day. The model-based rule was well calibrated (Hosmer-Lemeshow X(2)=5.51; P=.70) and demonstrated good discrimination (area under the receiver-operating characteristic curve [ROC AUC], 0.78) in the derivation group. Discriminatory ability was also reasonable in the validation cohort (ROC AUC, 0.75; P=.18, for difference in ROC AUC between groups). CONCLUSIONS: Using a large cohort of patients treated at community and teaching hospitals, we derived and validated a prediction rule for pneumonia after CABG. This index may prove to be useful in prioritizing receipt of preventive interventions.

A Novel In Situ Toxicity Identification Evaluation (iTIE) System for Determining which Chemicals Drive Impairments at Contaminated Sites.

Human-dominated waterways contain thousands of chemicals. Determining which chemical is the most important stressor is important, yet very challenging. The Toxicity Identification Evaluation (TIE) procedure from the US Environmental Protection Agency uses a series of chemical and physical manipulations to fractionate compounds within a matrix and systematically identify potential toxicants through laboratory bioassay testing. Although this may provide useful information, it lacks ecological realism because it is subject to laboratory-related artifacts and is resource intensive. The in situ Toxicity Identification Evaluation (iTIE) technology was developed to improve this approach and has undergone a number of modifications over the past several years. The novel prototype 3 consists of an array of iTIE ambient water fractionation units. Each unit is connected to a peristaltic pumping system with an organism exposure chamber that receives water from a resin chamber to chemically fractionate test site water. Test organisms included freshwater and marine standard toxicity test species. Postfractionation waters are collected for subsequent chemical analyses. Currently, the resins allow for separation of ammonia, metals, and nonpolar organics; the subsequent toxicity responses are compared between treatments and unfractionated, ambient exposures. The iTIE system was deployed to a depth of 3 m and evaluated in streams and marine harbors. Chemical analyses of water and iTIE chemical sorptive resins confirmed chemical groups causing lethal to sublethal responses. The system proved to be as sensitive or more so than the traditional phase 1 TIE test and required almost half of the resources to complete. This iTIE prototype provides a robust technology that improves stressor-causality linkages and thereby supports strong evidence for ecological risk weight-of-evidence assessments. Environ Toxicol Chem 2020;39:1746-1754. © 2020 SETAC.

Dimethyldimethyl Hydantoin: An Alternative Fluid for Morphological and Genetic Preservation.

Modern taxonomy requires the preservation of biospecimens for both morphological and molecular applications. The utility of a previously identified preservative, dimethyldimethylhydantoin hydantoin (Dekafald®), to retain both physical diagnostic traits and the DNA integrity of biological specimens remains unknown. Using 439 eggs and 414 larvae from two North American fish species, we compared three hydantoin solutions at different concentrations (5%, 10%, and 20%) with gold standard preservatives (10% buffered formalin, 95% ethanol) to evaluate morphological trait retention up to 90 days, and DNA barcoding success up to 56 days. While the 5% hydantoin solution had the most sequencing success by 56 days, the 10% hydantoin solution was the best multipurpose preservative. Future work should assess the performance of ∼10% hydantoin solution over longer time periods, and its applicability to other taxa such as Arthropoda.

Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.

BACKGROUND: The Veterans Affairs' (VA) National Surgical Quality Improvement Program (NSQIP) has been associated with significant reductions in postoperative morbidity and mortality. We sought to determine if NSQIP methods and risk models were applicable to private sector (PS) hospitals and if implementation of the NSQIP in the PS would be associated with reductions in adverse postoperative outcomes. METHODS: Data from patients (n = 184,843) undergoing major general or vascular surgery between October 1, 2001, and September 30, 2004, in 128 VA hospitals and 14 academic PS hospitals were used to develop prediction models based on VA patients only, PS patients only, and VA plus PS patients using logistic regression modeling, with measures of patient-related risk as the independent variables and 30-day postoperative morbidity or mortality as the dependent variable. RESULTS: Nine of the top 10 predictors of postoperative mortality and 7 of the top 10 for postoperative morbidity were the same in the VA and PS models. The ratios of observed to expected mortality and morbidity in the PS hospitals based on a model using PS data only versus VA + PS data were nearly identical (correlation coefficient = 0.98). Outlier status of PS hospitals was concordant in 26 of 28 comparisons. Implementation of the NSQIP in PS hospitals was associated with statistically significant reductions in overall postoperative morbidity (8.7%, P = 0.002), surgical site infections (9.1%, P = 0.02), and renal complications (23.7%, P = 0.004). CONCLUSIONS: The VA NSQIP methods and risk models in general and vascular surgery were fully applicable to PS hospitals. Thirty-day postoperative morbidity in PS hospitals was reduced with the implementation of the NSQIP.

Effects of military trauma exposure on women veterans' use and perceptions of Veterans Health Administration care.

BACKGROUND: Few studies have addressed how military trauma exposure, particularly sexual assault and combat exposure, affects women veterans' use and perceptions of Veterans Health Administration (VHA) care. OBJECTIVE: The aim of the present study was to evaluate the effects of military sexual assault and combat exposure on women veterans' use and perceptions of different aspects of VHA care. DESIGN: Cross-sectional telephone survey of a national sample of women veterans. PARTICIPANTS: Women from the VA's National Registry of Women Veterans. MEASUREMENTS: Sociodemographic characteristics, VHA care utilization, perceptions of care. RESULTS: Women veterans with histories of military sexual assault reported more use of VHA services, but less satisfaction, poorer perceptions of VHA facilities and staff, and more problems with VHA services compared to women veterans without histories of sexual assault. Combat exposure was related to more problems with VHA staff, although few other differences were observed for women with and without histories of combat exposure. CONCLUSIONS: Findings provide information on areas that can be targeted with respect to caring for women veterans exposed to military sexual trauma and combat exposure, including improving interactions with VHA staff and the ease of using VHA services.

Influenza vaccination and risk of mortality among adults hospitalized with community-acquired pneumonia.

BACKGROUND: Influenza vaccination has been shown to reduce illness and all-cause mortality in vulnerable populations through the prevention of influenza infection. Attenuation of the severity of illness by vaccination has been reported for respiratory tract infections due to bacterial pathogens and would represent an important additional health benefit of influenza vaccination. We evaluated the impact of prior influenza vaccination on in-hospital mortality and other health outcomes among hospitalized adults with community-acquired pneumonia (CAP). METHODS: Consecutive individuals hospitalized with CAP during "influenza season" (November to April, 1999-2003) at hospitals operated by Tenet HealthCare were identified using a database constructed to improve quality of patient care. Associations between vaccination status and all-cause in-hospital mortality were evaluated using logistic regression models. RESULTS: Among 17 393 adults hospitalized with CAP during the study period, 1590 (19% of those with recorded vaccine status) had a history of influenza vaccination in the current or most recent influenza season. Vaccine recipients were less likely to die in hospital of any cause than individuals without vaccination (odds ratio, 0.30; 95% confidence interval, 0.22-0.41). These effects remained significant after adjustment for the presence of comorbid illnesses and pneumococcal vaccination (adjusted odds ratio for death, 0.61; 95% confidence interval, 0.43-0.87) and under widely varying assumptions about individuals with missing vaccination status. CONCLUSIONS: Prior influenza vaccination was associated with improved survival in hospitalized patients with CAP during influenza season. This observation, if confirmed by other studies, would represent an important additional benefit of enhanced influenza vaccine coverage.

Use of multiple lines of evidence to provide a realistic toxic substances control act ecological risk evaluation based on monitoring data: D4 case study.

D4 (octamethylcyclotetrasiloxane) is a high-production-volume cyclic volatile methyl siloxane with a wide range of industrial and consumer applications. This study conducted a robust ecological risk evaluation for D4 using exposure data collected under a nation-wide environmental monitoring program facilitated under the Toxic Substances Control Act (TSCA). This ecological risk evaluation was conducted consistent with the principles outlined in the U.S. Environmental Protection Agency's (EPA's) Guidance to Assist Interested Persons in Developing and Submitting Draft Risk Evaluations under TSCA (U.S. EPA 2017a). The evaluation examined multiple lines of evidence (LoEs) to determine the potential risks from D4 to aquatic receptors in rivers and streams in the United States from municipal wastewater treatment plant (WWTP) discharges and discharges from manufacturing, processing, and/or formulating (MPF) facilities after onsite wastewater treatment. The LoEs consisted of comparing D4 concentrations measured in water and sediment to toxicity thresholds derived from laboratory studies; comparing D4 concentrations measured in biota tissue to critical target lipid body burdens (CTLBBs); comparing fugacity-based chemical activities between toxicity thresholds and measured environmental concentrations; and assessing benthic macroinvertebrate community structure and habitat suitability. The approach taken moves beyond a standard deterministic hazard quotient approach to incorporate more advanced methods for risk prediction, using distributions rather than conservative point estimates of exposure to obtain a realistic view of the probability of harm, consistent with EPA's stated intent to "strive to utilize probabilistic approaches for exposure assessments included in a risk evaluation" (U.S. EPA 2017b). The risk evaluation concluded there is negligible risk to water column and sediment receptors from D4 discharged from MPF facilities after onsite wastewater treatment or from municipal WWTPs that may treat a mix of industrial and consumer wastewater.

The patient safety in surgery study: background, study design, and patient populations.

BACKGROUND: The purpose of this article is to describe the background, design, and patient populations of the Patient Safety in Surgery Study, as a preliminary to the articles in this journal that will report the results of the Study. STUDY DESIGN: The Patient Safety in Surgery Study was a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in patients undergoing major general and vascular operations at 128 Veterans Affairs (VA) medical centers and 14 selected university medical centers between October 1, 2001 and September 30, 2004. An Internet-based data collection system was used to input data from the different private medical centers. Semiannual feedback of observed to expected mortality and morbidity ratios was provided to the participating medical centers. RESULTS: During the 3-year study, total accrual in general surgery was 145,618 patients, including 68.5% from the VA and 31.5% from the private sector. Accrual in vascular surgery totaled 39,225 patients, including 77.8% from the VA and 22.2% from the private sector. VA patients were older and included a larger proportion of male patients and African Americans and Hispanics. The VA population included more inguinal, umbilical, and ventral hernia repairs, although the private-sector population included more thyroid and parathyroid, appendectomy, and operations for breast cancer. Preoperative comorbidities were similar in the two populations, but the rates of comorbidities were higher in the VA. American Society of Anesthesiologists classification tended to be higher in the VA. CONCLUSIONS: The National Surgical Quality Improvement Program methodology was successfully implemented in the 14 university medical centers. The data from the study provided the basis for the articles in this issue of the Journal of the American College of Surgeons.

The "new economics" of clinical quality improvement: the case of community-acquired pneumonia.

Hospitals and health systems have developed substantial infrastructure, at significant expense, to improve care quality and support the collection and distribution of quality metrics. Yet providers often have little understanding of what return, if any, they have earned on the investment because they typically view quality improvement efforts simply as a cost of doing business. After analyzing data from 10,512 patients with community-acquired pneumonia, we found that better performance on two quality measures was associated with shorter length of stay and improved financial performance. For example, a one-day decrease in the time until patients were shifted from intravenous to oral antibiotics was associated with a 0.8-day reduction in length of stay and a nearly 60 percent increase in margins. Providers can adapt the methods we used to derive these findings to identify other quality metrics that simultaneously increase care quality and generate economic value. To derive maximum clinical and financial benefit, however, providers must ensure that clinical quality staff members are adequately supported and skilled to set priorities and to implement effective initiatives.

An in situ toxicity identification and evaluation water analysis system: Laboratory validation.

It is difficult to assess the toxicity of a single stressor and establish a strong stressor-causality link when multiple stressors coexist. Toxicity identification evaluation (TIE) methodology uses a series of chemical and physical manipulations to fractionate compounds within a matrix and systematically identify potential toxicants. The current US Environmental Protection Agency application of TIE can provide valuable information but often lacks ecological realism and is subject to laboratory-related artifacts. An in situ TIE device (iTIED) was designed to assess the sources of toxicity in aquatic ecosystems. For this laboratory validation, each unit was equipped with a sorbent resin chamber, an organism exposure chamber, a water collection container, and a peristaltic pump. Chemical analyses of water processed by each iTIED unit were compared with both lethal and sublethal molecular responses of the organisms. The compound removal effectiveness of different sorbent resins was also compared. In addition to successfully fractionating diverse chemical mixtures, the iTIED demonstrated a potential for early detection of molecular biomarkers, which could identify chronic toxicity that may go unnoticed in traditional TIE assays. Utilizing this novel in situ system will reduce the uncertainty associated with laboratory-based simulations and aid management efforts in targeting compounds that pose the greatest threat. Environ Toxicol Chem 2017;36:1636-1643. © 2016 SETAC.

Prior pneumococcal vaccination is associated with reduced death, complications, and length of stay among hospitalized adults with community-acquired pneumonia.

BACKGROUND: Vaccination with pneumococcal polysaccharide reduces the incidence of bacteremic pneumococcal disease in adults. We investigated the impact of prior pneumococcal vaccination on in-hospital mortality and the probability of respiratory failure among hospitalized adults with community-acquired pneumonia. METHODS: Consecutive individuals hospitalized with community-acquired pneumonia (diagnosed by International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0-487.0) at 109 community and teaching hospitals in the United States were identified using the Quality and Resource Management System, a database constructed by Tenet HealthCare to improve the quality of patient care. Vaccination status, comorbidities, and outcomes were abstracted by case managers concurrently with patient care. Associations between vaccination, survival, and respiratory failure were defined using multivariable logistic regression models. RESULTS: Of 62,918 adults hospitalized with community-acquired pneumonia between 1999 and 2003, 7390 (12%) had a record of prior pneumococcal vaccination. Vaccine recipients were less likely to die of any cause during hospitalization than were individuals with no record of vaccination (adjusted odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.59), even after adjustment for the presence of comorbid illnesses, age, smoking, and influenza vaccination and under varying assumptions about missing vaccination data. Vaccination also lowered the risk of respiratory failure (adjusted OR, 0.67; 95% CI, 0.59-0.76) and other complications and reduced median length of stay by 2 days, compared with nonvaccination (P<.001). CONCLUSIONS: Prior vaccination against pneumococcus is associated with improved survival, decreased chance of respiratory failure or other complications, and decreased length of stay among hospitalized patients with community-acquired pneumonia. These observations reinforce current efforts to improve compliance with existing pneumococcal vaccination recommendations for adults.

Barriers to Veterans Health Administration care in a nationally representative sample of women veterans.

BACKGROUND: Women veterans are generally less healthy than their nonveteran female counterparts or male veterans. Accumulating evidence suggests there may be barriers to women veterans' access to and use of Veterans Health Administration (VHA) care. OBJECTIVE: To document perceived and/or actual barriers to care in a nationally representative sample of women veterans and examine associations with VHA use. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Women who are current and former users of VHA from VA's National Registry of Women Veterans. MEASUREMENTS: Assessments of perceptions of VHA care, background characteristics, and health service use. RESULTS: Perceptions of VHA care were most positive regarding facility/physical environment characteristics and physician skill and sensitivity and least positive regarding the availability of needed services and logistics of receiving VHA care (M=0.05 and M=-0.10; M=-0.23 and M=-0.25, respectively). The most salient barrier to the use of VHA care was problems related to ease of use. Moreover, each of the barriers constructs contributed unique variance in VHA health care use above and beyond background characteristics known to differentiate current users from former VHA users (Odds ratio [OR]=4.03 for availability of services; OR=2.63 for physician sensitivity and skill: OR=2.70 for logistics of care; OR=2.30 for facility/physical environment). Few differences in barriers to care and their association with VHA health care use emerged for women with and without service-connected disabilities. CONCLUSIONS: Findings highlight several domains in which VHA decisionmakers can intervene to enhance the care available to women veterans and point to a number of areas for further investigation.

Risk factors for serious complication after uvulopalatopharyngoplasty.

OBJECTIVE: To test the hypothesis that comorbidity, performance of concurrent sleep apnea procedures in addition to uvulopalatopharyngoplasty, body mass index, apnea-hypopnea index, and lowest oxygen saturation are risk factors for serious perioperative complications after uvulopalatopharyngoplasty. DESIGN: Prospective cohort and nested case-control studies. SETTING: United States Veterans Affairs medical centers. PATIENTS: A prospective cohort of 3130 consecutive adult inpatients who underwent uvulopalatopharyngoplasty from 1991 to 2001 was retrospectively analyzed from the Veterans Affairs National Surgical Quality Improvement Program database to determine the relationship between perioperative complications and both concurrent procedures and medical comorbidity. A nested case-control analysis was conducted on 43 cases with complications and 212 controls without complications from the cohort. Controls were matched on age, sex, year of operation, and concurrent surgery; this case-control analysis enabled the study of body mass index, apnea-hypopnea index, and lowest oxygen saturation, which were not available in the cohort database. Multivariate logistic regression measured associations between risk factors and complications, adjusting or controlling for age, sex, race, smoking status, year of uvulopalatopharyngoplasty, and presence of any concurrent procedure. MAIN OUTCOME MEASURE: Sixteen specific serious perioperative complications, including 30-day mortality. RESULTS: The cohort included 3130 veterans (97% were men aged 50+/-11 [mean+/-SD] years). In the cohort study, comorbidity was associated with serious complication: the adjusted risk ratio was 1.96 (95% confidence interval, 1.16-3.18) for each increase in American Society of Anesthesiologists class. Concurrent nonnasal procedures increased the risk of complication compared with no concurrent procedures (adjusted risk ratio, 4.94; 95% confidence interval, 2.34-10.4). In the case-control analyses, the apnea-hypopnea index, body mass index, and medical comorbidity were each associated with serious complication after adjustment for confounding variables, but this study had insufficient power to determine if these risk factors were independent of each other. Concurrent retrolingual procedures demonstrated an independent association with complication after adjustment for confounders. The lowest oxygen saturation was not associated with serious complication. CONCLUSIONS: Apnea-hypopnea index, body mass index, and medical comorbidity were each associated with serious complication; however, the low complication rate precluded demonstration of associations independent of each other. Concurrent retrolingual procedures were also associated with serious complication, but the cumulative risk of separate retrolingual procedures is unknown.

Data feedback and clinical process improvement in acute myocardial infarction.

BACKGROUND: Numerous reports have shown substantial undertreatment of acute myocardial infarction (AMI). The goal of this intervention study was to improve both the acute and discharge care of patients with AMI. Thirty-eight Tenet hospitals participated in a cardiac improvement collaborative called the Partnership for Change. Interventions included the implementation of a computerized concurrent data feedback system and the organization, staffing, and deployment of performance improvement teams at each hospital. METHODS: Data were collected on 11 394 patients with AMI between January 1, 2001, and June 30, 2002. We calculated rates of treatments including aspirin (first 24 hours and at discharge), beta-blocking agent (first 24 hours and at discharge), reperfusion using thrombolysis (first 30 minutes) or percutaneous intervention (first 2 hours), angiotensin-converting enzyme inhibitor (at discharge), smoking cessation counseling (during hospital stay), and referral to a cardiac rehabilitation program (at discharge). RESULTS: Statistically significant increases were seen for all indicators. Aspirin use during the first 24 hours increased from 86.4% to 96.5% and use at discharge increased from 70.0% to 87.4%. The use of beta-blocking agents during the first 24 hours increased from 51.4% to 88.4% and use at discharge increased from 62.4% to 83.5%. Reperfusion during the first 2 hours increased from 25.9% to 35.3%. Discharge use of angiotensin-converting enzyme inhibitors increased from 29.3% to 43.3%. Smoking cessation counseling increased from 35.1% to 80.6%. Referral to a cardiac rehabilitation program increased from 16.9% to 41.7%. All P values were <.001. CONCLUSIONS: The implementation of a rapid-cycle computerized concurrent data feedback system along with on-site process improvement teams was associated with a substantial increase in the use of both acute and discharge treatments for AMI.