Harnessing Data to Assess Equity of Care by Race, Ethnicity and Language.

OBJECTIVE: Determine any disparities in care based on race, ethnicity and language (REaL) by utilizing inpatient (IP) core measures at Texas Health Resources, a large, faith-based, non-profit health care delivery system located in a large, ethnically diverse metropolitan area in Texas. These measures, which were established by the U.S. Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC), help to ensure better accountability for patient outcomes throughout the U.S. health care system. METHODS: Sample analysis to understand the architecture of race, ethnicity and language (REaL) variables within the Texas Health clinical database, followed by development of the logic, method and framework for isolating populations and evaluating disparities by race (non-Hispanic White, non-Hispanic Black, Native American/Native Hawaiian/Pacific Islander, Asian and Other); ethnicity (Hispanic and non-Hispanic); and preferred language (English and Spanish). The study is based on use of existing clinical data for four inpatient (IP) core measures: Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), Pneumonia (PN) and Surgical Care (SCIP), representing 100% of the sample population. These comprise a high number of cases presenting in our acute care facilities. Findings are based on a sample of clinical data (N = 19,873 cases) for the four inpatient (IP) core measures derived from 13 of Texas Health's wholly-owned facilities, formulating a set of baseline data. RESULTS: Based on applied method, Texas Health facilities consistently scored high with no discernable race, ethnicity and language (REaL) disparities as evidenced by a low percentage difference to the reference point (non-Hispanic White) on IP core measures, including: AMI (0.3%-1.2%), CHF (0.7%-3.0%), PN (0.5%-3.7%), and SCIP (0-0.7%).

Safety and efficacy of minimally invasive atrial septal defect closure.

BACKGROUND: Atrial septal defects (ASDs) have been surgically closed with low mortality utilizing the conventional sternotomy approach (CSA). The technical ease of ASD closure has triggered interest in minimally invasive closure (MIC) to obviate the morbidity associated with sternotomy. Our study assesses the safety and efficacy of minimally invasive ASD closure. METHODS: Preoperative, intraoperative, and postoperative data were collected on 68 patients (39 CSA, 29 MIC) who underwent ASD closure from January 1997 to August 2002. Using univariate analysis of 17 preoperative risk factors there was no statistically significant difference between the two groups. RESULTS: MIC resulted in equivalent success rates in ASD closures, with similar morbidity, no mortality, and a significant difference in postoperative length of stay (3.93 +/- 1.6 days versus 5.36 +/- 2.51 days, p = 0.006). CONCLUSIONS: In experienced hands, MIC is an excellent alternative to CSA in ASD closure.

Long-Term Value of Stress Echocardiography in the Triage of Patients with Atypical Chest Pain Presenting to the Emergency Department.

The purpose of this study was to assess the use of stress echocardiography in the triage of patients presenting to the emergency department with atypical chest pain. We hypothesized that a negative stress echocardiogram would identify patients with a very low risk for future cardiac events, thus reducing the requirement for unnecessary hospitalizations. Stress testing was performed in 105 patients presenting with atypical chest pain, no prior history of coronary artery disease, a nondiagnostic electrocardiogram (ECG), negative serial creatine phosphokinase level at 0 and 4 hours, and baseline normal echocardiograms. Cardiac stress was invoked using an exercise protocol in 75 (71%) patients and intravenous dobutamine in 30 (29%) patients, with ECG and echocardiography results analyzed separately. Cardiac events (myocardial infarction, coronary revascularization, and cardiac death) were noted in 7 (7%) patients with a mean follow-up of 2.8 +/- 1.3 years. Univariate analysis identified five predictors of future cardiac events, but only stress-induced wall motion abnormalities were found to be predictive with multivariate analysis. Kaplan-Meier estimate of cumulative event-free survival for cardiac events at 3 years was 99% for a negative stress echocardiogram (no stress-induced wall motion abnormalities) compared with 95% for stress ECG (< 1-mm ST segment depression). The event-free rate of a positive stress echocardiogram and stress ECG was 25% and 63%, respectively. We conclude that stress echocardiography can be performed safely in patients presenting with atypical chest pain. A negative stress echocardiogram carries an excellent 3-year prognosis and thus identifies patients who may forgo hospital admission and further cardiovascular workup.

Failure of Serial Electrocardiograms to Exclude a Large Anterior Myocardial Infarction and the Role of Transesophageal Echocardiogram in Acute Myocardial Infarction.

When patients present with acute onset of chest pain suggestive of myocardial ischemia, immediate clinical decisions regarding thrombolysis, percutaneous transluminal coronary angioplasty, or both are usually based on the history and abnormal electrocardiograms and confirmed by the presence of abnormally elevated cardiac enzymes. However, there are potential limitations of the electrocardiograms and initial cardiac enzymes in the diagnosis and confirmation of acute myocardial infarction. We describe the case of a patient who presented with an acute onset of chest pain and had a normal electrocardiogram and initial cardiac enzymes yet was found by transesophageal echocardiography to have a large myocardial infarction.

Ventricular Septal Defect Masquerading as Severe Tricuspid Regurgitation: A Case Report and Literature Review.

Two-dimensional echocardiography (2-D) is a useful technique for noninvasive evaluation cardiac structure, function, and hemodynamics; however, multiple factors may limit the technical adequacy of the 2-D examination. In this article, we present the case of a ventricular septal defect to right atrial shunt, which was misinterpreted as severe tricuspid regurgitation secondary to severe pulmonary hypertension, despite the absence of right ventricular enlargement or hypertrophy. A transesophageal echocardiography (TEE) examination was performed to explain the discrepancy between the 2-D and Doppler findings, the results of which are discussed, along with a review of the literature.

Is a Full Digital Echocardiography Laboratory Feasible for Routine Daily Use?

To determine the feasibility and accuracy of digital echocardiography for routine interpretation of two-dimensional and Doppler echocardiography, we studied 93 consecutive patients chosen at random from our daily workload. The parameters studied included cavity sizes, biventricular regional and global systolic and diastolic function, valvular structure and function, and presence or absence of pericardial disease. The results were first interpreted using quad screen, digital format cine loops. These results were then compared with the results obtained from reviewing the video-tape images. Seventy-nine patients (87%) showed complete concordance between the digital system and video tape. Among the 1156 echocardiographic parameters/measurements examined in all patients, a 99% concordance rate (normal vs abnormal) was found. Disagreements between the digital system and video tape in the patients undergoing two-dimensional/Doppler exams included mitral valve prolapse in 3, mild valvular insufficiency in 5, a small pleural effusion in 2, and a wall-motion abnormality in 3 patients. In conclusion, the use of digital technology for evaluation of routine echocardiograms appears to compare favorably with the interpretation of images using the conventional video tape. (ECHOCARDIOGRAPHY, Volume 13, September 1996)

Assessment of Renal Perfusion in a Canine Model Using FS069, A New Transpulmonary Echocontrast Agent.

We have previously demonstrated the safety and efficacy of FS069, a new transpulmonary echocontrast agent, for myocardial opacification. To our knowledge, no information exists regarding the use of this agent for transcutaneous assessment of renal perfusion. We studied 14 mongrel dogs using intravenously administered FS069. Renal ultrasound imaging was performed with a Hewlett-Packard Sonos 1500 using a 3.5-MHz transducer. Renal blood flow (ReBF) was altered using renal artery occlusion in four dogs and dipyridamole (0.56 mg/kg IV) in ten dogs. Renal perfusion was quantitatively assessed before and after each intervention using background subtracted peak intensity. ReBF was assessed with radiolabeled microspheres in ten dogs. Renal opacification was observed in all 14 dogs at baseline. The intravenous contrast dose required to produce optimal renal opacification ranged from 0.3-0.7 cc. After renal artery occlusion, peak intensity was reduced from 5.4 +/- 5.8 to 0.93 +/- 1.1 units (r = 0.99, P < 0.008). As expected, blood pressure and ReBF dropped in all ten dogs after dipyridamole administration. Interestingly, peak intensity increased in all but one dog. An inverse correlation (r = -0.75, P = 0.02) was observed between ReBF and peak intensity (percent change from baseline). The inverse relation between ReBF and peak intensity observed suggests vasoconstriction of the afferent arterioles in response to dipyridamole and a reduced clearance of the contrast. These findings are in agreement with previous data demonstrating decreased renal thallium clearance postdipyridamole administration. Our data document the feasibility to assess renal perfusion under various flow states after intravenous injection of FS069.

On-Line Myocardial Tissue Characterization with a New Commercially Produced Software.

Myocardial tissue characterization has been performed using various ultrasonic techniques, one of which is the cyclic variation of integrated backscatter, a method that analyzes the acoustic properties of the myocardium using backscattered radiofrequency signals to provide information about myocardial structure and function. Previous studies using prototype equipment have demonstrated a reduction in the cardiac cycle variation of integrated backscatter in various pathologic states. Recently, a commercially produced software package that allows online analysis of cyclic variation of integrated backscatter has been made available for testing by various investigators. To evaluate this new commercially produced software, we compared integrated backscatter results in three groups of patients: a control group; an end-stage cardiomyopathy group; and a heart transplant recipient group. Integrated backscatter of the septum and posterior walls in the parasternal long axis and 12, 3, 6, and 9 o'clock regions in the short axis was performed using a commercially produced program (Hewlett-Packard Sonos 1500). In the control group, the mean cyclic variation of integrated backscatter was 5.04 +/- 1.60 dB in the septum and did not significantly vary from the rest of the regions studied. In comparison, cyclic variation of integrated backscatter in every region studied was reduced in the cardiomyopathy and heart transplant groups. Intraobserver variability, interobserver variability, and reproducibility over a 3-month interval was found to be 6.5%, 5.7%, and 7.5%, respectively. These results indicate that: (1) online analysis of cardiac cyclic variation of integrated backscatter is possible utilizing commercially produced software; (2) results obtained are consistent with a low intraobserver and interobserver variability and are reproducible over time; and (3) as observed in the comparison between the transplant and control groups, this information may detect changes in cardiac structure even in the absence of changes in function. (ECHOCARDIOGRAPHY, Volume 13, May 1996)

Identification of Perfusion Abnormalities Using FSO69, a Novel Contrast Agent, in Conscious Dogs.

Recent advances in the production of echocardiographic contrast agents has resulted in the ability to delineate areas of hypoperfusion after coronary occlusions and stenoses following their intravenous injection. Most of these studies though have been done in open chest animals. This study was done to determine if we could assess myocardial perfusion following the intravenous administration of FSO69, a suspension of perfluoropropane filled albumin microspheres (3.6 µm average microbubble size, concentration 8 x 10(8)), in spontaneously breathing closed chest dogs. Twenty-seven mongrel dogs were instrumented on day 1. The chest was then closed and the dogs were restudied 3-7 days later, while spontaneously breathing. Homogeneous perfusion was observed in most dogs by all three independent and blinded observers. Perfusion abnormalities were likewise identified in most instances by all blinded reviewers on interventions designed to decrease regional blood flow. A good correlation between perfusion defect size between investigators was observed. In summary, our data suggest that FSO69 can be used to assess regional myocardial perfusion in spontaneously breathing dogs. These results support its use in humans.