Improved outcomes associated with stenting in the healthcare cost and utilization project.

Recent results from Medicare indicated that both hospital mortality and the use of same admission coronary artery bypass graft (CABG) surgery were lower in patients receiving stents, and that stenting did not alter the finding of improved outcomes at high volume centers. The purpose of this report is to compare outcomes in a national sample of patients of all ages receiving stents with those undergoing conventional balloon angioplasty. A second purpose is to evaluate the volume outcome hypothesis. This study included 100,318 angioplasties from 191 hospitals in 19 states; 43,966 (44%) involved stent placement. The major outcomes of interest were same admission hospital death and same admission CABG surgery. In comparison to patients with conventional angioplasty, patients receiving stents were younger, less often female and nonwhite, and had less diabetes and hypertension. In the group without infarction, hospital mortality was lower in the stent group (0.7% vs 0.9%, P = 0.01), as was the use of same admission bypass surgery (1.4% vs 2.7%, P < 0.0001). The same pattern was true for myocardial infarction; hospital mortality (2.7% vs 4.2%, P < 0.0001) and bypass surgery rates (1.6% vs 5.3%, P < 0.0001) were lower in the stent group. These results persisted after adjustment for important predictors of outcome. In general, outcomes were better in high volume centers, although in the stent group, there was no clear relationship between volume and outcome. These results support earlier findings that hospital mortality and particularly same admission surgery rates are lower with stenting. Although the volume outcome association for stenting was less clear in this study than in Medicare, these results do not mean that the fundamental volume outcome relationship has been changed by stenting.

Outcomes of coronary angioplasty procedures performed in rural hospitals.

PURPOSE: To determine how many rural hospitals in the United States performed coronary angioplasty; to compare patient outcomes in rural and urban hospitals; and to assess whether outcomes were better in rural hospitals in which more procedures were performed. SUBJECTS AND METHODS: In 1996, among patients 65 years of age and older, 201,869 coronary angioplasties were performed in 996 hospitals that were included in the Medicare Provider Analysis and Review files. Geographic location was defined as rural or urban, according to U.S. Census Bureau criteria. Outcome variables were in-hospital death and coronary artery bypass surgery performed during the same admission. Hospital volumes were categorized as low (< or = 100 cases or fewer per year), medium (101 to 200 cases per year), or high (> 200 cases per year). RESULTS: Fifty-one rural hospitals accounted for 4% of all angioplasties performed. After angioplasty, in-hospital mortality was greater in rural hospitals (8.1% versus 6.4%, P = 0.001) among patients with acute myocardial infarction, but was not different for patients without infarction (1.4% versus 1.3%, P = 0.41). Coronary artery bypass surgery rates during the same admission were similar in rural and urban hospitals. In general, in-hospital mortality and same-admission surgery rates were lower in high-volume centers in both rural and urban areas. CONCLUSION: Although in-hospital mortality after angioplasty for acute myocardial infarction was worse in low- and medium-volume rural centers, overall outcomes in rural and urban hospitals were similar.

A randomized controlled trial of a clinic-based support staff intervention to increase the rate of fecal occult blood test ordering.

BACKGROUND: Colorectal cancer is the second most common fatal malignancy in the United States. Early detection using fecal occult blood tests has been shown to reduce mortality, but these tests are underutilized among those eligible for this screening. Attempts to increase use of fecal occult blood tests in eligible populations have focused on the provider, patient, or system. But none have examined whether a support-staff intervention is effective in achieving this aim. We therefore conducted a randomized controlled trial to test the impact of authorizing support staff to order fecal occult blood tests in a general internal medicine clinic organized into four teams. METHODS: A total of 1,109 patients were included in the study, 545 of whom were in the two teams randomized to treatment. Univariate and multivariate regression analyses were used to evaluate the impact of the intervention. RESULTS: The intervention resulted in significantly more fecal occult blood test ordering in the treatment group than in the control group for all patients (52% vs 15%, P < 0.001). Treatment fecal occult blood test cards were returned as frequently as the control cards for all patients (44% vs 48%, P = 0.571). CONCLUSION: Delegation of selected screening tasks to support staff can enhance patient access to preventive care.

Institutional volumes and coronary angioplasty outcomes before and after the introduction of stenting.

CONTEXT: An increasing number of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) are receiving coronary stents. OBJECTIVES: To assess whether the introduction of coronary stenting has changed hospital mortality or same-admission coronary artery bypass grafting (CABG) and whether the hospital's procedure volume affects these outcomes. DESIGN: Observational study using hospital claims. SETTING: Nonfederal hospitals that performed PTCA in California in 1993 and 1996. PATIENTS: 35,350 patients who underwent PTCA in 1993 (before the introduction of stenting) and 43,040 patients who had PTCA in 1996 (43% of whom received stents). MEASUREMENTS: Hospital stenting volumes for 1996 were divided into terciles; total PTCA procedures per year were categorized as low (< or = 200), medium (201 to 400), or high (> 400). Outcome variables included hospital death and coronary artery bypass grafting (CABG) performed during the same admission. Patients with a principal diagnosis of acute myocardial infarction (AMI) were analyzed separately from those without such a diagnosis. RESULTS: From 1993 to 1996, the characteristics of patients undergoing PTCA did not change substantially. The use of same-admission CABG decreased by 13% (from 6.0% to 5.2%; P = 0.008) in the AMI group and by 30% (from 3.7% to 2.6%; P < 0.001) in the no-AMI group. Hospital mortality did not change significantly in either group. Procedure volume was not related to hospital mortality. However, rates of same-admission CABG were significantly lower at hospitals with high annual stenting volumes than at low-volume centers (1.3% vs. 2.3% among patients in the no-AMI group; P < 0.001). CONCLUSIONS: Hospital mortality rates after PTCA have not changed considerably since the introduction and diffusion of coronary stenting. However, rates of same-admission CABG have decreased in recent years and are lowest at hospitals with high procedure volumes.

Coronary artery stent outcomes in a Medicare population: less emergency bypass surgery and lower mortality rates in patients with stents.

BACKGROUND: Randomized trials of coronary stents versus conventional balloon angioplasty have demonstrated improved short- and long-term outcomes for selected patients receiving stents. The purpose of this study was to compare outcomes in patients receiving stents with those undergoing conventional balloon angioplasty in everyday clinical practice. METHODS AND RESULTS: This study uses information from the Medicare Provider Analysis and Review files for fiscal years 1994 and 1996, the first year the coronary stent code was used. For patients 65 years of age and older, 165,657 cases in 1994 and 201,869 in 1996, including 74,836 cases with stent placement, were identified. Outcomes included hospital deaths, use of same- admission coronary artery bypass surgery, and either or both. Analyses were performed separately for those with and those without a principal diagnosis of acute myocardial infarction. Hospital mortality rates were similar in both years, but the use of same-admission coronary artery bypass surgery was lower in 1996. In that year, for both patients with and those without acute myocardial infarction, hospital death and the use of same-admission coronary artery bypass surgery were lower in the stent group. Additionally, results in the stent group were generally better at high-volume (>200 cases per year) institutions, as was the case for the prestent, 1994 results. CONCLUSIONS: This study documents improved short-term outcomes in older patients who undergo coronary stent placement. Stenting did not eliminate the finding of improved outcomes at high-volume centers.

Association between percutaneous transluminal coronary angioplasty volumes and outcomes in the Healthcare Cost and Utilization Project 1993-1994.

Studies from a variety of settings have indicated that outcomes for coronary angioplasty are improved when performed in institutions with high caseloads (> 400/year). The purpose of this investigation was to examine the volume outcome hypothesis for coronary angioplasty in a 20% stratified sample of acute care, non-federal hospitals in 17 states. Data were derived from the Nationwide Inpatient Sample from the Health Care Cost and Utilization Project releases 2 and 3. From these records, 163,527 angioplasties from 214 hospitals were selected. Outcomes included hospital mortality, same-admission coronary artery bypass surgery, and a combined end point of either death or same-admission surgery, or both. Hospital volumes were defined as low (< or = 200 cases/year), medium (201 to 400), and high (> 400). Analyses were conducted separately for patients with and without a principal discharge diagnosis of acute myocardial infarction (AMI). For both AMI and no-AMI groups, the rates of adverse outcomes were generally lower in high-volume institutions, and this finding was true in both univariate and multivariate analyses. Although 27% of hospitals were in the low-volume category, only 5% of all procedures were performed in these institutions. Projecting to all United States hospitals for the 2 years, if all procedures performed in low-volume centers had been done in high-volume institutions, 137 deaths could have been averted (90 AMIs, 47 no-AMIs) as well as 404 (46 AMIs, 358 no-AMIs) same-admission surgeries. The results of this study support the hypothesis that better results are obtained in higher volume institutions, but also show that in 1993 and 1994, relatively few patients had their procedures performed in low-volume institutions.

Prevalence and predictors of sexual dysfunction in long-term survivors of marrow transplantation.

PURPOSE: To describe the prevalence of sexual difficulties in men and women after marrow transplantation (MT), and to define medical, demographic, sexual, and psychologic predictors of sexual dysfunction 3 years after MT. PATIENTS AND METHODS: Four hundred seven adult MT patients were assessed pretransplantation. Survivors repeated measures of psychologic and sexual functioning at 1 and 3 years posttransplantation. RESULTS: Data were analyzed from 102 event-free 3-year survivors who defined themselves as sexually active. Men and women did not differ in sexual satisfaction pretransplantation. At 1 and 3 years posttransplantation, women reported significantly more sexual dysfunction than men. Eighty percent of women and 29% of men reported at least one sexual problem by 3 years after MT. No pretransplantation variables were significant predictors of 3-year sexual satisfaction for women. For men, pretransplantation variables of older age, poorer psychologic function, not being married, and lower sexual satisfaction predicted sexual dissatisfaction at 3 years (R2=.28; P < .001). Women who were more dissatisfied 3 years after MT did not receive hormone replacement therapy (HRT) at 1 -year posttransplantation and were less satisfied at 1 year, but not pretransplantation (R2=.35; P < .001). CONCLUSION: Sexual problems are significant in the lives of MT survivors, particularly for women. Although HRT before 1 year posttransplantation improves sexual function, it does not ensure sexual quality of life. Intervention for women is needed to apply hormonal, mechanical, and behavioral methods to prevent sexual difficulties as early after transplantation as possible.

A comparison of percutaneous transluminal coronary angioplasty in the Department of Veterans Affairs and in the private sector in the State of Washington.

Coronary angioplasty is performed > 1,000 times daily in a variety of health care settings in the public and private sectors in the USA. How outcomes for this procedure differ in the Department of Veterans Affairs and the private sector is unknown. The purpose of this study was to compare outcomes of coronary angioplasty performed in hospitals in the Department of Veterans Affairs and the State of Washington. This study used administrative data from the Department of Veterans Affairs patient treatment file (n = 8,326) and the State of Washington episode of illness file (n = 6,666) and included men who underwent coronary angioplasty in 1993 and 1994. Outcomes included (1) in-hospital mortality and mortality at 10 and 30 days after hospital admission, and (2) the use of coronary artery bypass surgery at similar intervals. Patients with a principal diagnosis of acute myocardial infarction were analyzed separately. Men in the Department of Veterans Affairs had more comorbid conditions than their counterparts in Washington State, and the length of hospital stay was longer in the former group. After using logistic regression to adjust for patient differences, mortality rates for the 2 groups of patients with acute myocardial infarction were similar, although bypass surgery was used more frequently in patients in Washington State. For patients without myocardial infarction, hospital and 10-day mortality did not differ with respect to health care system, and the use of bypass surgery subsequent to angioplasty was similar. In the Department of Veterans Affairs, most hospitals had low institutional caseloads (< 150 procedures per year), whereas > 40% of Washington State hospitals performed > or = 300 procedures per year. Although there were greatly differing institutional caseloads, mortality and the need for early bypass surgery were similar in the 2 systems.

Coronary angioplasty outcomes in the Healthcare Cost and Utilization Project, 1993-1994.

It is estimated that >400,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in the Unites States annually. This study reports patient characteristics and outcomes for 163,527 PTCAs performed in 214 hospitals in 17 states from 1993 to 1994. These hospitals were a 20% random sample of hospitals in the Healthcare Cost and Utilization Project, which was designed to reflect hospitalization in the United States, generally. Cases with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes 36.01, 36.02, and 36.05 were defined as PTCA and were categorized as to whether acute myocardial infarction (AMI) was the principal discharge diagnosis. The average age of 44,270 AMI discharges (27%) was 62 +/- 12 years and that of 119,257 no-AMI cases (73%) was 64 +/- 11 years; 1/3 of both groups were women, 88% were white, and almost 90% had Medicare or private insurance as the primary payer. The states contributing the most cases were Florida (26%), California (12%), and Wisconsin (10%). Hospital mortality was 1.7% overall and was 3.8% for AMI and 0.8% for no-AMI cases. Bypass surgery performed during the same admission was 3.4% overall and was 4.5% and 3.0% for AMI and no-AMI cases, respectively. Multivariate analysis showed that advanced age, diabetes, female gender, and Medicaid payer status were associated with increased risk of mortality. National estimates from this 20% sample indicate that >850,000 PTCAs were performed in the 2 years, with 452,319 cases estimated for 1994. In 1994 there were an estimated 2,789 deaths and 9,903 bypass surgeries in the no-AMI subset of 327,856 procedures. For the AMI group of 124,463 procedures, there were 4,486 deaths and 5,799 bypass surgeries in 1994. This study of PTCA outcomes contains the largest number of cases as well as the most representative sample reported to date.

Recovery after allogeneic marrow transplantation: prospective study of predictors of long-term physical and psychosocial functioning.

No prospective data have documented the physical and psychosocial functioning of patients before and after BMT. In this study 67 allogeneic transplant patients completed standardized self-report measures pre-transplant. Survivors were re-assessed at 90 days (n = 34) and 1 year (n = 31) post-transplant. Telephone interviews established 4-year work history and performance status. Physical function was most impaired at 90 days post-transplant, with a return to pre-transplant levels of functioning by 1 year in most areas. By 2 years post-transplant, 68% of patients had returned to full-time work. Only 9% of 4-year survivors failed to return to full-time occupations. Mean levels of anxiety and depression did not change over the first year. Pre-transplant, 27% of patients reported depression and 41% reported elevated anxiety. Greater emotional distress at 1 year was predicted by pre-transplant family conflict, non-married status and development of less severe chronic GVHD. Impaired physical recovery at 1 year was predicted by more severe chronic GVHD, pre-transplant physical impairment and family conflict. The large majority of long-term survivors returned to full-time employment with normal physical and psychosocial functioning, although recovery took longer than 1 year for approximately 40%. Family relationships were important determinants of physical and emotional recovery.

Clinical assessment scale for the rating of oral mucosal changes associated with bone marrow transplantation. Development of an oral mucositis index.

Oral complications can be serious and disabling problems for patients undergoing cancer therapy. Therefore, the authors wanted to develop a sensitive and specific instrument to measure oral mucosal changes during therapy. The Oral Mucosa Rating Scale (OMRS) has an examination rating scale to quantify the type and severity of clinically evident oral mucosal changes (atrophy, erythema, ulceration, and pseudomembranous, hyperkeratotic, lichenoid, and edematous changes), with a scale ranging from 0 to 3 (normal to severe). Separate visual analogue scales are obtained for oral pain and dryness. One hundred eighty-eight bone marrow transplant recipients were studied from before transplant through day 42 after transplant. The OMRS then was used to develop a specific index for assessing acute oral mucositis after bone marrow transplant--the Oral Mucositis Index (OMI). The OMI internal consistency measures (Chronbach alpha and Guttman split-half coefficients) were strong (range, 0.84 to 0.93). Support for the validity of the OMI is presented. These scales should help improve the study of oral complications of cancer therapy.

Hospitalizations in Niger (West Africa) for complications from arterial hypertension.

Fifty-four patients hospitalized in Niger for complications from hypertension between September 1988 and October 1989 were studied. The following complications were observed: left ventricular hypertrophy (56%), coronary vascular defect (35%), left heart deficiency (26%), cardiac failure (32%), retinopathy (56%), renal insufficiency (35%), and stroke (24%). The most frequent risk factor was Type A personality (76%), followed by stress (48%), excess weight (37%), tobacco use (35%), hyperuricemia (35%), hypercholesteremia (17%), and diabetes (15%). Complications from hypertension may well become a major problem for African countries as they develop.

Development of a behavioral measure of mouth pain, nausea, and wellness for patients receiving radiation and chemotherapy.

Toxicities from the chemotherapy and irradiation preparative regimen for bone marrow transplantation include nausea, emesis, and oral pain. Behavioral measures were developed as alternatives to paper and pencil measures of these symptoms because patients are sometimes too ill, unavailable, or unwilling to complete self-report scales. Behavioral observations also provide supplements to self-report for these multidimensional symptoms. For 24 days during the acute phase of transplantation, nurses rated the behavior of adult patients on: (a) oral pain (for example, requests pain medication or refuses mouth examination), (b) nausea (for instance, retches or keeps emesis basin near), (c) wellness (for example, talks voluntarily or smiles), (d) verbal complaints of pain, and (e) verbal complaints of nausea. The behavioral measures demonstrated good interday reliability (range, 0.70-0.86) and construct validity as demonstrated by a multitrait, multimethod correlation matrix.

Chemoradiotherapy toxicity during bone marrow transplantation: time course and variation in pain and nausea.

Chemoradiotherapy-induced toxicity following unmodified allogeneic marrow grafting was studied. Patients with hematologic malignancy (n = 157) received cyclophosphamide (120 mg/kg) followed by single or fractionated total body irradiation (TBI); aplastic anemia patients (n = 41) received only cyclophosphamide (200 mg/kg). Physicians rated mucositis, pain and nausea daily as (0) none, (1) mild, (2) moderate, (3) severe, (4) life threatening. Oral mucositis pain began several days prior to transplant, peaked during the second week after transplant, and declined thereafter. Patients with hematologic malignancies (maximum mean rating of 1.6, day 11) experienced more pain than aplastic anemia patients (maximum mean rating of 0.7, day 6). Nausea peaked before transplant and gradually declined. Nausea was higher (p less than 0.001) in patients with aplastic anemia (maximum mean rating of 1.3, day -2) than with hematologic malignancies (maximum mean rating of 0.9, day -6). There was no significant difference between single dose 1000 cGy and 6-day 1200 cGy irradiation. Recipients of 1575 cGy rather than 1200 cGy TBI had significantly (p less than 0.01) higher levels of pain (mean rating 1.25 and 0.82, respectively) and nausea (mean rating 1.27 and 0.72, respectively). Additional research is needed to determine the predictors, consequences and best methods of controlling these toxicities.