Precordial electrocardiographic recording and QT measurement from a novel wearable ring device.

Background: The availability of portable and wearable electrocardiographic (ECG) devices has increased secondary to technological development. Single-lead ECG recordings have been shown to reliably detect and characterize cardiac rhythms such as atrial fibrillation. Acquisition of precordial electrodes for full 12-lead ECG reconstruction from bipolar recordings is complicated by the absence of a body ground/Wilson central terminal electrode. The extent of difference between standard precordial leads and those from a wearable bipolar ECG recorder has not been characterized. Objective: The purpose of this study was to characterize the precordial ECG lead set from sequential bipolar recordings from an ECG ring wearable device. Methods: In 70 patients who wore an ECG device on a right-hand finger, sequential precordial leads (CR1-CR6) were obtained along with chest electrodes (V1-V6). During acquisition of the modified precordial lead CR6, a full standardized 12-lead ECG capture was obtained. Signal quality was assessed using automated analysis software, and correlation values between the ring-derived ECG precordial leads and standard ECG leads were compared with regard to QRS duration, QT width, and RR interval. Results: High concordance in the morphologies of precordial ECG leads obtained in a standard fashion and those recorded through an ECG ring was observed. Morphologic alignment improved with increasing laterality of the precordial lead with chest to right arm ring recording (CR5, CR6) compared with anterior chest leads to right arm (CR1, CR2). Segmental measurements of QRS duration and QT segment were well aligned and of high correlation. Conclusion: Wearable ring-based ECG technology is capable of high-fidelity recordings of precordial leads for nonsimultaneous reconstruction of complete ECG sets. These recordings correlate highly with surface-obtained QRS and QT duration measurements and have significant implications for clinical applications. Uninterpretable tracings were primarily due to electrode noise from poor electrode contact.

Healthcare resource utilization in patients receiving idarucizumab for reversal of dabigatran anticoagulation due to major bleeding, urgent surgery, or procedural interventions: interim results from the RE-VERSE AD™ study.

AIMS: Patients treated with anticoagulants may experience serious bleeding or require urgent surgery or intervention, and may benefit from rapid anticoagulant reversal. This exploratory analysis assessed healthcare resource utilization (HCRU) in patients treated with idarucizumab, a specific reversal agent for dabigatran etexilate. MATERIALS AND METHODS: RE-VERSE AD™ (NCT02104947), a prospective, multi-center open-label study, is evaluating idarucizumab for dabigatran reversal in patients with serious bleeding (Group A) or undergoing emergency surgery/procedures (Group B). HCRU outcome measures evaluated in the first 90 patients enrolled were use of blood products and pro-hemostatic agents, length of stay (LOS) in hospital, and LOS in intensive care unit (ICU). RESULTS: Blood products or pro-hemostatic agents were given to 63% (32/51) of patients in Group A and 23% (9/39) of patients in Group B on the day of/day after surgery. An overnight hospital stay was reported for 82% (42/51) of patients in Group A with median LOS = 7 (range = 1-71) bed-days. For Group B, 92% (36/39) had an overnight hospital stay with a median LOS = 9 (range = 1-92) bed-days. In Group A, 17 patients were admitted to the ICU for at least 1 day with median LOS = 4 (range = 1-44) days; in Group B the number was 15 with median LOS = 2 (range = 1-92) days. LIMITATIONS: The lack of a control group and the small patient numbers limit the strength of the conclusions. CONCLUSIONS: The use of idarucizumab may simplify emergency management of dabigatran-treated patients with life-threatening bleeds and reduce perioperative complications in patients undergoing emergency surgery.

Identification of Patient Characteristics Influencing Setting of Care Decisions for Patients With Acute Bacterial Skin and Skin Structure Infections: Results of a Discrete Choice Experiment.

PURPOSE: Rates of acute bacterial skin and skin structure infections (ABSSSI) have sharply increased since 2000. Treatment may be administered in the inpatient or outpatient setting; clinical decision-making regarding hospitalization is inconsistent, often leading to hospitalization of some patients with ABSSSI who qualify for outpatient parenteral antimicrobial therapy, which leads to increased overall care costs. New antibiotics such as oritavancin are hypothesized to be a cost-effective option improving accessibility to ambulatory treatment of ABSSSI. The goal of this study was to understand the patient attributes that affect clinical decision-making regarding the setting of care for ABSSSI treatment. METHODS: An observational, cross-sectional study was conducted that surveyed clinicians of various specialties from the United States and the United Kingdom. The survey collected quantitative responses and used a series of choice-based experimental designs to evaluate patient attributes influencing clinical treatment decisions. FINDINGS: Infection severity, severe comorbidities, and age ≥ 75 years were observed to have the greatest impact on treatment location decisions (odds ratio [OR], 0.000-0.004 [95% CI, 0.000-0.011], vs mild ABSSSI; OR, 0.246-0.484 [95% CI, 0.154-0.788], vs no active comorbidities; OR, 0.136-0.523 [95% CI, 0.070-0.888], vs ≤ 18 years, respectively). The majority of respondents indicated they would consider oritavancin to avoid postdischarge outpatient parenteral antimicrobial therapy or oral therapy, regardless of the pathogen (63.5%-83.5%). IMPLICATIONS: Key factors influencing ABSSSI treatment setting were severity of infection, severity of comorbidities, and age. Clinicians surveyed identified patient profiles in which single-dose oritavancin might enable wholly outpatient or shortened inpatient management. Additional studies to elucidate the ABSSSI care pathways that include oritavancin and other novel antibiotics are needed.

Coagulation assessment with the new generation of oral anticoagulants.

Long-term oral anticoagulant (OAC) therapy is used for the treatment and prevention of thrombosis and thromboembolism. As OAC use is so widespread, emergency physicians are likely to encounter patients on anticoagulant therapy in the emergency department (ED) on a regular basis, either for the same reasons as the population in general or as a result of the increased bleeding risk that OAC use entails.The vitamin K antagonist warfarin has been the standard OAC for several decades, but recently, the newer agents dabigatran etexilate, rivaroxaban and apixaban (collectively, novel OACs, non-vitamin K OACs, or simply 'NOACs') have become available for long-term use. Protocols for assessing and managing warfarin-treated patients in the ED are well established and include international normalised ratio (INR) testing, which helps guide patient management. However, the INR does not give an accurate evaluation of coagulation status with NOACs, and alternative tests are therefore needed for use in emergency settings. This paper discusses what information the INR provides for a patient taking warfarin and which coagulation tests can guide the physician when treating patients on one of the NOACs, as well as other differences in emergency anticoagulation management.

Costs of hospital visits among patients with deep vein thrombosis treated with rivaroxaban and LMWH/warfarin.

BACKGROUND: For many years, the standard of care for patients diagnosed with deep vein thrombosis (DVT) has been low-molecular-weight heparin (LMWH) bridging to an oral Vitamin-K antagonist (VKA). The availability of new non-VKA oral anticoagulants (NOAC) agents as monotherapy may reduce the likelihood of hospitalization for DVT patients. OBJECTIVE: To compare hospital visit costs of DVT patients treated with rivaroxaban and LMWH/warfarin. METHODS: A retrospective claim analysis was conducted using the MarketScan Hospital Drug Database for care provided between January 2011 and December 2013. Adult patients using rivaroxaban or LMWH/warfarin with a primary diagnosis of DVT during the first day of a hospital visit were identified (i.e., index hospital visit). Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients. The hospital-visit cost difference between these groups was evaluated for the index hospital visit, as well as for total hospital-visit costs (i.e., including index and subsequent hospital visit costs). RESULTS: All rivaroxaban users (n = 134) in the database were well-matched with four LMWH/warfarin users (n = 536). The mean hospital-visit costs were $5257 for the rivaroxaban cohort and $6764 in the matched-cohort of patients using LMWH/warfarin. The $1508 cost difference was statistically significant between cohorts (95% CI = [-$2296; -$580]; p-value = 0.002). Total hospital-visit costs were lower for rivaroxaban compared to LMWH/warfarin users within 1, 2, 3, and 6 months after index visit (significantly lower within 1 and 3 months, p-values <0.05) LIMITATIONS: Limitations were inherent to administrative-claims data, completeness of baseline characteristics, adjustments restricted to observational factors, and lastly the sample size of the rivaroxaban cohort. CONCLUSION: The availability of rivaroxaban significantly reduced the costs of hospital visits in patients with DVT treated with rivaroxaban compared to LMWH/warfarin.

Acute bacterial skin and skin structure infections (ABSSSI): practice guidelines for management and care transitions in the emergency department and hospital.

BACKGROUND: Acute bacterial skin and skin structure infections (ABSSSI), formally referred to as complicated skin and soft tissue infections, include infections with resistance to previously effective antimicrobials. Increasing dramatically in incidence, they have become a challenging medical problem associated with high direct and indirect costs to both the medical system and society. OBJECTIVES: To describe the burden of ABSSSI and to explore multidisciplinary approaches to its management and new treatments that can be initiated in the emergency department. DISCUSSION: We offer a best practice model aimed at providing risk-stratified and convenient care for ABSSSI at the lowest possible cost, while minimizing complications, readmissions, and inappropriate antibiotic use. In doing so, we focus on the care provided by emergency physicians and hospitalists and the transition of management between them for inpatient care, as well as the facilitation of observation or direct-to-outpatient care for suitable patients. CONCLUSIONS: A standard, consistent, and multidisciplinary approach to ABSSSI can streamline care, reduce admissions, support antimicrobial stewardship, and improve clinical and resource consumption outcomes.

The role of the Society for Academic Emergency Medicine in the development of guidelines and performance measures.

Measurement of adherence to clinical standards has become increasingly important to the practice of emergency medicine (EM). In recent years, along with a proliferation of evidence-based practice guidelines and performance measures, there has been a movement to incorporate measurement into reimbursement strategies, many of which affect EM practice. On behalf of the Society for Academic Emergency Medicine (SAEM) Guidelines Committee 2009-2010, the purposes of this document are to: 1) differentiate the processes of guideline and performance measure development, 2) describe how performance measures are currently and will be used in pay-for-performance initiatives, and 3) discuss opportunities for SAEM to affect future guideline and performance measurement development for emergency care. Specific recommendations include that SAEM should: 1) develop programs to sponsor guideline and quality measurement research; 2) increase participation in the process of guideline and quality measure development, endorsement, and maintenance; 3) increase collaboration with other EM organizations to review performance measures proposed by organizations outside of EM that affect emergency medical care; and 4) answer calls for participation in the selection and implementation of performance measures through The Joint Commission and the Centers for Medicare and Medicaid Services (CMS).

Hospitals with and without percutaneous coronary intervention capability: considerations for treating acute coronary syndromes.

The crucial aim in the emergency management of patients presenting with chest pain is the identification of acute coronary syndromes (ACS) and the initiation of appropriate treatment. Institution-specific triage to initial medical or interventional therapies is influenced by the availability of percutaneous coronary intervention (PCI) facilities. Although the use of invasive strategies has increased, most US hospitals do not have PCI facilities. Pharmacological management is an integral part of all treatment strategies, regardless of the availability of interventional capability. Given the growing importance of invasive management strategies, a therapy that is compatible with both medical and invasive therapy options is becoming increasingly important. Aspirin and clopidogrel are recommended for patients with ACS regardless of the conservative or invasive management strategy. With enoxaparin, patients with ACS can seamlessly transition from the medical management phase to the interventional management phase without the need for introducing a second anticoagulant in the cardiac catheterization laboratory. Fondaparinux can be used for patients with ACS treated medically, but should not be used alone during PCI because of the risk of catheter thrombosis. Bivalirudin can be used in non-ST-segment elevation myocardial infarction patients who are managed invasively.

Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006.

BACKGROUND: Trends in the use of guideline-based treatment for acute myocardial infarction (AMI) as well as its association with patient outcomes have not been summarized in a large, longitudinal study. Furthermore, it is unknown whether gender-, race-, and age-based care disparities have narrowed over time. METHODS AND RESULTS: Using the National Registry of Myocardial Infarction database, we analyzed 2,515,106 patients with AMI admitted to 2,157 US hospitals between July 1990 and December 2006 to examine trends overall and in select subgroups of guideline-based admission, procedural, and discharge therapy use. The contribution of temporal improvements in acute care therapies to declines in in-hospital mortality was examined using logistic regression analysis. From 1990 to 2006, the use of all acute guideline-recommended therapies administered rose significantly for patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction but remained below 90% for most therapies. Cardiac catheterization and percutaneous coronary intervention use increased in patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction, whereas coronary bypass surgery use declined in both groups. Despite overall care improvements, women, blacks, and patients > or =75 years old were significantly less likely to receive revascularization or discharge lipid-lowering therapy relative to their counterparts. Temporal improvements in acute therapies may account for up to 37% of the annual decline in risk for in-hospital AMI mortality. CONCLUSION: Adherence to American Heart Association/American College of Cardiology practice guidelines has improved care of patients with AMI and is associated with significant reductions in in-hospital mortality rates. However, persistent gaps in overall care as well as care disparities remain and suggest the need for ongoing quality improvement efforts.

The impact of for-profit hospital status on the care and outcomes of patients with non-ST-segment elevation myocardial infarction: results from the CRUSADE Initiative.

OBJECTIVES: We sought to determine whether for-profit status influenced hospitals' care or outcomes among non-ST-segment elevation myocardial infarction (NSTEMI) patients. BACKGROUND: While for-profit hospitals potentially have financial incentives to selectively care for younger, healthier patients, perform highly reimbursed procedures, reduce costs by limiting access to expensive medications, and encourage shorter in-patient length of stay, there are limited data available to investigate these issues objectively. METHODS: Using data from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines) Initiative, we investigated whether for-profit status influenced hospitals' patient case mix, care, or outcomes among 145,357 patients with NSTEMI treated between January 1, 2001, and December 31, 2005, at 532 U.S. hospitals. Impact of for-profit status on care and outcomes was analyzed overall and after adjustment for clinical and facility factors using regression modeling. RESULTS: Patients (n = 11,658) treated at 58 for-profit hospitals were of similar age and gender, but were more likely to be nonwhite (black, Asian, Hispanic, and other) and have health maintenance organization/private insurance, diabetes mellitus, congestive heart failure, hypertension, and renal insufficiency compared with 133,699 patients treated at 474 nonprofit hospitals. For-profit hospitals were less likely to use discharge beta-blockers, but all other treatments were similar including the use of interventional procedures (cardiac catheterization and revascularization procedures) compared with nonprofit centers. In-hospital length of stay and mortality were also similar by hospital type. CONCLUSIONS: We found no evidence that for-profit hospitals selectively treat less sick patients, provide less evidence-based care, limit in-hospital stays, or have patients with worse acute outcomes than nonprofit centers.

The role of cardiac risk factor burden in diagnosing acute coronary syndromes in the emergency department setting.

STUDY OBJECTIVE: We seek to determine whether cardiac risk factor burden (defined as the number of conventional cardiac risk factors present) is useful for the diagnosis of acute coronary syndromes in the emergency department (ED) setting. METHODS: This was a post hoc analysis of the Internet Tracking Registry of Acute Coronary Syndromes (i*trACS) registry, which had 17,713 ED visits for suspected acute coronary syndromes. First visit for US patients who were not cocaine or amphetamine users, who did not leave against medical advice, and for whom ECG and demographic data were complete were included. Acute coronary syndrome was defined by 30-day revascularization, diagnostic-related group codes, or death within 30 days, with positive cardiac biomarkers at index hospitalization. Cardiac risk factors were diabetes, hypertension, smoking, hypercholesterolemia, and family history of coronary artery disease. Cardiac risk factor burden was defined as the number of risk factors present. Because multiple logistic regression analysis revealed that age modified the relationship between cardiac risk factor burden and acute coronary syndromes, a stratified analysis was performed for 3 age categories: younger than 40, 40 to 65, and older than 65 years. Positive likelihood ratios and negative likelihood ratios with their 95% confidence intervals (CIs) were calculated for each total risk factor cutoff. RESULTS: Of 10,806 eligible patients, 871 (8.1%) had acute coronary syndromes. In patients younger than 40 years, having no risk factors had a negative likelihood ratio of 0.17 (95% CI 0.04 to 0.66), and having 4 or more risk factors had a positive likelihood ratio of 7.39 (95% CI 3.09 to 17.67). In patients between 40 and 65 years of age, having no risk factors had a negative likelihood ratio of 0.53 (95% CI 0.40 to 0.71), and having 4 or more risk factors had a positive likelihood ratio of 2.13 (95% CI 1.66 to 2.73). In patients older than 65 years, having no risk factors had a negative likelihood ratio of 0.96 (95% CI 0.74 to 1.23), and having 4 or more risk factors had a positive likelihood ratio of 1.09 (95% CI 0.64 to 1.62). CONCLUSION: Cardiac risk factor burden has limited clinical value in diagnosing acute coronary syndromes in the ED setting, especially in patients older than 40 years.

Clinical characteristics, process of care, and outcomes of Hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE).

BACKGROUND: Data regarding the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) in Hispanic patients, the largest and fastest-growing minority in the United States, are scarce. METHODS: We sought to describe the clinical characteristics, process of care, and outcomes of Hispanics presenting with NSTE ACS at US hospitals. We compared baseline characteristics, resource use, and inhospital mortality among 3936 Hispanics and 90280 non-Hispanic whites with NSTE ACS from the CRUSADE Quality Improvement Initiative. RESULTS: The regional distribution of Hispanics in CRUSADE paralleled that in the US Census. Hispanics were younger (65 vs 70 years, P < .0001) and had less hyperlipidemia (45.4% vs 49.0%, P < .0001) but were more likely to be hypertensive (72.2% vs 67.9%, P < .0001) and diabetic (46.5% vs 30.9%, P < .0001). Hispanics were also more likely to be uninsured (12.5% vs 5.1%, P < .001). During hospitalization, Hispanics were more often managed conservatively, undergoing stress tests more frequently (13.0% vs 10.1%, P < .0001), with less use of cardiac catheterization within 48 hours (48.7% vs 55.5%, P < .0001) or percutaneous coronary intervention (39.6% vs 46.4%, P < .0001) at any time. Hispanics received similar discharge treatments but were less frequently referred for cardiac rehabilitation (38.5% vs 49.2%, P < .0001). Adjusted inhospital mortality was similar in both groups (odds ratio 0.87, 95% CI 0.72-1.05). CONCLUSIONS: Although hispanics have a different risk factor profile and are treated less aggressively during hospitalization when they present with NSTE ACS, these treatment differences do not appear to affect inhospital outcomes. Further research is warranted to explore the long-term consequences of these findings.

Prospective multicenter study of quantitative pretest probability assessment to exclude acute coronary syndrome for patients evaluated in emergency department chest pain units.

STUDY OBJECTIVE: We compare the diagnostic accuracy of 3 methods--attribute matching, physician's written unstructured estimate, and a logistic regression formula (Acute Coronary Insufficiency-Time Insensitive Predictive Instrument, ACI-TIPI)--of estimating a very low pretest probability (< or = 2%) for acute coronary syndromes in emergency department (ED) patients evaluated in chest pain units. METHODS: We prospectively studied 1,114 consecutive patients from 3 academic EDs, evaluated for acute coronary syndrome. Physicians collected data required for pretest probability assessment before protocol-driven chest pain unit testing. A pretest probability greater than 2% was considered "test positive." The criterion standard was the outcome of acute coronary syndrome (death, myocardial infarction, revascularization, or > 60% stenosis prompting new treatment) within 45 days, adjudicated by 3 independent reviewers. RESULTS: Fifty-one of 1,114 enrolled patients (4.5%; 95% confidence interval [CI] 3.4% to 6.0%) developed acute coronary syndrome within 45 days, including 4 of 991 (0.4%; 95% CI 0.1% to 1.0%) patients, discharged after a negative chest pain unit evaluation result, who developed acute coronary syndrome. Unstructured estimate identified 293 patients with pretest probability less than or equal to 2%, 2 had acute coronary syndrome, yielding sensitivity of 96.1% (95% CI 86.5% to 99.5%) and specificity of 27.4% (95% CI 24.7% to 30.2%). Attribute matching identified 304 patients with pretest probability less than or equal to 2%; 1 had acute coronary syndrome, yielding a sensitivity of 98.0% (95% CI 89.6% to 99.9%) and a specificity of 26.1% (95% CI 23.6% to 28.7%). ACI-TIPI identified 56 patients; none had acute coronary syndrome, yielding sensitivity of 100% (95% CI 93.0% to 100%) and specificity of 6.1% (95% CI 4.7% to 7.9%). CONCLUSION: In a low-risk ED population with symptoms suggestive of acute coronary syndrome, patients with a quantitative pretest probability less than or equal to 2%, determined by attribute matching, unstructured estimate, or logistic regression, may not require additional diagnostic testing.

Pretest probability assessment derived from attribute matching.

BACKGROUND: Pretest probability (PTP) assessment plays a central role in diagnosis. This report compares a novel attribute-matching method to generate a PTP for acute coronary syndrome (ACS). We compare the new method with a validated logistic regression equation (LRE). METHODS: Eight clinical variables (attributes) were chosen by classification and regression tree analysis of a prospectively collected reference database of 14,796 emergency department (ED) patients evaluated for possible ACS. For attribute matching, a computer program identifies patients within the database who have the exact profile defined by clinician input of the eight attributes. The novel method was compared with the LRE for ability to produce PTP estimation <2% in a validation set of 8,120 patients evaluated for possible ACS and did not have ST segment elevation on ECG. 1,061 patients were excluded prior to validation analysis because of ST-segment elevation (713), missing data (77) or being lost to follow-up (271). RESULTS: In the validation set, attribute matching produced 267 unique PTP estimates [median PTP value 6%, 1st-3rd quartile 1-10%] compared with the LRE, which produced 96 unique PTP estimates [median 24%, 1st-3rd quartile 10-30%]. The areas under the receiver operating characteristic curves were 0.74 (95% CI 0.65 to 0.82) for the attribute matching curve and 0.68 (95% CI 0.62 to 0.77) for LRE. The attribute matching system categorized 1,670 (24%, 95% CI = 23-25%) patients as having a PTP < 2.0%; 28 developed ACS (1.7% 95% CI = 1.1-2.4%). The LRE categorized 244 (4%, 95% CI = 3-4%) with PTP < 2.0%; four developed ACS (1.6%, 95% CI = 0.4-4.1%). CONCLUSION: Attribute matching estimated a very low PTP for ACS in a significantly larger proportion of ED patients compared with a validated LRE.

Racial variations in treatment and outcomes of black and white patients with high-risk non-ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?).

BACKGROUND: Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevation acute coronary syndromes (NSTE ACS) and how different treatments affect outcomes. METHODS AND RESULTS: Using data from 400 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37,813 (87.3%) white and 5504 (12.7%) black patients. Black patients were younger; were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, beta-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients. CONCLUSIONS: Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.

Racial and ethnic differences in time to acute reperfusion therapy for patients hospitalized with myocardial infarction.

CONTEXT: Nonwhite patients experience significantly longer times to fibrinolytic therapy (door-to-drug times) and percutaneous coronary intervention (door-to-balloon times) than white patients, raising concerns of health care disparities, but the reasons for these patterns are poorly understood. OBJECTIVES: To estimate race/ethnicity differences in door-to-drug and door-to-balloon times for patients receiving primary reperfusion for ST-segment elevation myocardial infarction; to examine how sociodemographic factors, insurance status, clinical characteristics, and hospital features mediate racial/ethnic differences. DESIGN, SETTING, AND PATIENTS: Retrospective, observational study using admission and treatment data from the National Registry of Myocardial Infarction (NRMI) for a US cohort of patients with ST-segment elevation myocardial infarction or left bundle-branch block and receiving reperfusion therapy. Patients (73,032 receiving fibrinolytic therapy; 37,143 receiving primary percutaneous coronary intervention) were admitted from January 1, 1999, through December 31, 2002, to hospitals participating in NRMI 3 and 4. MAIN OUTCOME MEASURE: Minutes between hospital arrival and acute reperfusion therapy. RESULTS: Door-to-drug times were significantly longer for patients identified as African American/black (41.1 minutes), Hispanic (36.1 minutes), and Asian/Pacific Islander (37.4 minutes), compared with patients identified as white (33.8 minutes) (P<.01 for all). Door-to-balloon times for patients identified as African American/black (122.3 minutes) or Hispanic (114.8 minutes) were significantly longer than for patients identified as white (103.4 minutes) (P<.001 for both). Racial/ethnic differences were still significant but were substantially reduced after accounting for differences in mean times to treatment for the hospitals in which patients were treated; significant racial/ethnic differences persisted after further adjustment for sociodemographic characteristics, insurance status, and clinical and hospital characteristics (P<.01 for all). CONCLUSION: A substantial portion of the racial/ethnic disparity in time to treatment was accounted for by the specific hospital to which patients were admitted, in contrast to differential treatment by race/ethnicity inside the hospital.

Insurance status and the treatment of myocardial infarction at academic centers.

UNLABELLED: Numerous studies have documented treatment disparities in patients with acute coronary syndromes based on race and gender. Other causes for treatment disparities may exist. OBJECTIVES: To determine if insurance status affects quality of care in patients with acute myocardial infarction (AMI) presenting to academic health centers. METHODS: The Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospective multicenter registry of patients with chest pain presenting to the emergency department who receive an electrocardiogram, was used as the database (N = 17,737). A subset of patients who were diagnosed as having AMI were selected from the database (n = 936). Patients were classified as having either ST-segment elevation MI (n = 178) or non-ST-segment elevation MI (n = 758). Insurance status, age, race, and gender were extracted as predictor variables. The influence of predictor variables on treatment modality was investigated using logistic regression, adjusted for clustering within sites. RESULTS: The odds of a self-pay patient with ST-segment elevation MI receiving fibrinolytics were 3.23 (95% CI = 1.56 to 6.69) times higher than for other patients. Patients with Medicare coverage were less likely to receive fibrinolytics (odds ratio [OR] 0.35, 95% CI = 0.19 to 0.65) and tended to undergo percutaneous coronary intervention less often (OR 0.60, 95% CI = 0.36 to 1.01). The odds of a privately insured patient's receiving coronary artery bypass grafting (OR 2.76, 95% CI = 1.62 to 4.72) or percutaneous coronary intervention (OR 1.47, 95% CI = 1.03 to 2.11) were higher than for other patients. CONCLUSIONS: Insurance coverage appears to affect treatment in patients with AMI, with self-pay patients more likely to receive less-expensive therapies and insured patients more likely to receive invasive treatments.

The impact of race on the acute management of chest pain.

OBJECTIVES: African Americans with acute coronary syndromes receive cardiac catheterization less frequently than whites. The objective was to determine if such disparities extend to acute evaluation and non interventional treatment. METHODS: Data on adults with chest pain (N = 7,935) presenting to eight emergency departments (EDs) were evaluated from the Internet Tracking Registry of Acute Coronary Syndromes. Groups were selected from final ED diagnosis: 1) acute myocardial infarction (AMI), n = 400; 2) unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), n = 1,153; and 3) nonacute coronary syndrome chest pain (non-ACS CP), n = 6,382. American College of Cardiology/American Heart Association guidelines for AMI and UA/NSTEMI were used to evaluate racial disparities with logistic regression models. Odds ratios (ORs) were adjusted for age, gender, guideline publication, and insurance status. Non-ACS CP patients were assessed by comparing electrocardiographic (ECG)/laboratory evaluation, medical treatment, admission rates, and invasive and noninvasive testing for coronary artery disease (CAD). RESULTS: African Americans with UA/NSTEMI received glycoprotein IIb/IIIa receptor inhibitors less often than whites (OR, 0.41; 95% CI = 0.19 to 0.91). African Americans with non-ACS CP underwent ECG/laboratory evaluation, medical treatment, and invasive and noninvasive testing for CAD less often than whites (p < 0.05). Other nonwhites with non-ACS CP were admitted and received invasive testing for CAD less often than whites (p < 0.01). African Americans and other nonwhites with AMI underwent catheterization less frequently than whites (OR, 0.45; 95% CI = 0.29 to 0.71 and OR, 0.40; 95% CI = 0.17 to 0.92, respectively). A similar disparity in catheterization was noted in UA/NSTEMI therapy (OR, 0.53; 95% CI = 0.40 to 0.68 and OR, 0.68; 95% CI = 0.47 to 0.99). CONCLUSIONS: Racial disparities in acute chest pain management extend beyond cardiac catheterization. Poor compliance with recommended treatments for ACS may be an explanation.

Status report: Development of emergency medicine research since the Macy Report.

In Williamsburg, VA, April 17 to 20, 1994, the Josiah Macy, Jr. Foundation sponsored a conference entitled "The Role of Emergency Medicine in the Future of American Medical Care," a report on which was published in Annals in 1995. This report promulgated recommendations for the development and enhancement of academic departments of emergency medicine and a conference to develop an agenda for research in emergency medicine. The American College of Emergency Physicians' Research Committee, along with several ad hoc members, presents updates in several of the areas addressed by the Macy Report and subsequent conferences, as a status report for the development of emergency medicine research as a whole, as of late 2002.