Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction.

OBJECTIVES: We sought to determine the effect of specialty care on in-hospital mortality in patients with acute myocardial infarction. BACKGROUND: There has been increasing pressure to limit access to specialists as a method to reduce the cost of health care. There is little known about the effect on outcome of this shift in the care of acutely ill patients. METHODS: We analyzed the data from 30,715 direct hospital admissions for the treatment of acute myocardial infarction in Pennsylvania in 1993. A risk-adjusted in-hospital mortality model was developed in which 12 of 20 clinical variables were significant independent predictors of in-hospital mortality. To determine whether there were factors other than patient risk that significantly influenced in-hospital mortality, multiple logistic regression analysis was performed on physician, hospital and payer variables. RESULTS: After adjustment for patient characteristics, a multiple logistic regression analysis identified treatment by a cardiologist (odds ratio=0.83 [confidence interval ¿CI¿=0.74 to 0.94] p < 0.003) and physicians treating a high volume of acute myocardial infarction patients (odds ratio=0.89 [CI=0.80 to 0.99] p < 0.03) as independent predictors of lower in-hospital mortality. Treatment by a cardiologist as compared to primary care physicians was also associated with a significantly lower length of stay for both medically treated patients (p < 0.01) and those undergoing revascularization (p < 0.01). CONCLUSIONS: Treatment by a cardiologist is associated with approximately a 17% reduction in hospital mortality in acute myocardial infarction patients. In addition, patients of physicians treating a high volume of patients have approximately an 11% reduction in mortality. This has important implications for the optimal treatment of acute myocardial infarction in the current transformation of the health care delivery system.

Echocardiographic score as a predictor of in-hospital cost in patients undergoing percutaneous balloon mitral valvuloplasty.

Percutaneous balloon mitral valvuloplasty (PBMV) is an effective means of palliating mitral stenosis, but it sometimes leads to adverse clinical outcomes and exorbitant in-hospital costs. Because echocardiographic score is known to be predictive of clinical outcome in patients undergoing PBMV, we examined whether it could also be used to predict in-hospital cost. Preprocedure echocardiographic scores, baseline clinical characteristics, and total in-hospital costs were examined among 45 patients who underwent PBMV between January 1, 1992, and January 1, 1994. Patients ranged in age from 18 to 71 years and had preprocedure echocardiographic scores that ranged from 4 to 12. Following PBMV, mean mitral valve area increased from 1.1 +/- 0.3 to 2.4 +/- 0.6 cm2 (p = 0.0001), and mean pressure gradient decreased from 18.3 +/- 5.9 to 6.7 +/- 2.7 mm Hg (p = 0.0001). In-hospital cost for the 45 patients ranged from $3,591 to $70,975 (mean $9,417; median $5,311). Univariate and multiple linear regression analyses demonstrated that among the variables examined, echocardiographic score (p = 0.0007), age (p = 0.01), and preprocedure mitral valve gradient (p = 0.03) were associated with in-hospital cost. Regression modeling suggested that every increase in preprocedure echocardiographic score of one grade was associated with an increase in in-hospital cost of $2,663. Because echocardiographic score is predictive of both clinical outcome and in-hospital cost, we conclude that patients with elevated scores should be considered for alternative therapy.

Cost-effectiveness of echocardiography and electrocardiography for detection of left ventricular hypertrophy in patients with systemic hypertension.

Although echocardiography is more accurate than electrocardiography for detection of left ventricular hypertrophy, it is also more expensive, making it uncertain whether echocardiography is cost-effective for detection of this abnormality in hypertensive patients. Accordingly, the sensitivity of M-mode echocardiographic and electrocardiographic criteria for left ventricular hypertrophy was determined in necropsied patients with anatomic hypertrophy of mild (n = 26), moderate (n = 21) or severe (n = 46) degree, and the prevalence of each degree of hypertrophy was determined in 561 hypertensive adults drawn from clinical and employed population samples. The sensitivity of echocardiographic left ventricular mass index criteria was 57% in necropsied patients with mild hypertrophy and 98% in patients with moderate or severe hypertrophy. All electrocardiographic criteria exhibited lower sensitivity: 15 to 42% for mild, 10 to 38% for moderate, and 30 to 57% for severe hypertrophy. Cost estimates from three sources were $160 for M-mode echocardiography and $48 to $64 for 12-lead electrocardiography. In populations with a 12 to 40% prevalence of hypertrophy, echocardiography was calculated to cost less than electrocardiography per instance of hypertrophy detected ($390-$1013 vs $800-$1829), yielded better separation in predicted incidence of morbid events between hypertensive patients with or without hypertrophy (3.4-4.7 vs 1.5-2.1 per 100 patient-years as opposed to 3.0-4.4 vs 1.9-2.9 per 100 patient-years), and required smaller case and control samples for hypothetical research studies (n = 254-309 vs 397-3478).(ABSTRACT TRUNCATED AT 250 WORDS)