Trends in hospital treatments for peripheral arterial disease in the United States and association between payer status and quality of care/outcomes, 2007-2011.

OBJECTIVE: This study sought to identify the temporal trends of presenting diagnoses and vascular procedures performed for peripheral arterial disease (PAD) along with the rates of procedures and in-hospital outcomes by payer status. BACKGROUND: Previous studies suggest that patients with Medicare, Medicaid, or lack of insurance receive poorer quality of care leading to worse outcomes. METHODS: We analyzed 196,461,055 discharge records to identify all hospitalized patients with PAD records (n=1,687,724) from January 2007 through December 2011 in the Nationwide Inpatient Sample database. RESULTS: The annual frequency of vascular procedures remained unchanged during the study period. Patients with Medicaid were more likely to present with gangrenes, whereas patients with Medicare were more likely to present with ulcers. After adjustment, patients with Medicare and Medicaid were more likely to undergo amputations when compared with private insurance/HMO (OR=1.13, 95% CI=1.10-1.16 and OR=1.24, 95% CI=1.20-1.29, respectively). Patients with both Medicare and Medicaid were less likely to undergo bypass surgery (OR=0.82, 95% CI=0.81-0.84 and OR=0.87, 95% CI=0.85-0.90, respectively), but more likely to undergo endovascular procedures (OR=1.18, 95% CI=1.17-1.20 and OR=1.03, 95% CI=1.01-1.06, respectively). Medicare and Medicaid status versus private insurance/HMO was associated with worse adjusted odds of in-hospital outcomes, including mortality after amputations, endovascular procedures, and bypass surgeries. CONCLUSIONS: In this analysis, patients with Medicare and Medicaid had more comorbid conditions at baseline when compared with private insurance/HMO cohorts, were more likely to present with advanced stages of PAD, undergo amputations, and develop in-hospital complications. These data unveil a critical gap and an opportunity for quality improvement in the elderly and those with poor socioeconomic status.

Diagnostic impact of SPECT image display on assessment of obstructive coronary artery disease.

BACKGROUND: Diagnostic assessment of myocardial perfusion impacts the management of patients with suspected coronary artery disease (CAD). Although various image displays are available for single photon emission computed tomography (SPECT) interpretation, the effects of display differences on SPECT interpretation remain undetermined. METHODS AND RESULTS: We studied 183 patients undergoing SPECT, including 131 consecutive patients referred for angiography and 52 at low CAD risk. Studies were visually interpreted by use of color and gray images, with readers blinded to the results of the other display. In accordance with established criteria, a summed stress score (SSS) of 4 or greater was considered abnormal. The prevalence of abnormal SPECT findings was higher with gray images than with color images (54% vs 48%, P < .001) based on a uniform criterion (SSS > or =4). However, color images yielded equivalent sensitivity (79% vs 82%, P = .7) and improved specificity for global (50% vs 33%, P = .02) and vessel-specific CAD involving the right coronary artery (P < .01) and left anterior descending artery (P < .05). When the criterion for gray images was adjusted upward (SSS > or =5) to reflect increased mean defect severity (SSS of 5.1 vs 4.4, P = .01), gray and color images provided equivalent sensitivity and specificity for global and vessel-specific CAD. CONCLUSIONS: SPECT interpretation can vary according to image display as a result of differences in perfusion defect severity. Adjustment of abnormality criteria for gray images to reflect minor increases in defect severity provides equivalent diagnostic performance of gray and color displays for CAD assessment.