Pre-procedural high-pitch coronary CT angiography assessment of patients undergoing transcatheter aortic valve implantation (TAVI) without patient-specific adjustment: analysis of diagnostic performance.

AIM: To evaluate the ability to assess the coronary arteries using pre-procedural computed tomography (CT; high-pitch mode) in patients referred for transcatheter aortic valve implantation (TAVI). METHODS AND MATERIALS: CT and invasive coronary angiography (ICA) were performed pre-TAVI in 100 patients (46 women; 79 ± 5.9 years). CT was performed in prospectively ECG-triggered high-pitch mode after intravenous administration of 70 ml iodinated contrast medium. Image quality was assessed using a four-point scale (graded 0-3). Significant coronary artery stenosis (≥50% diameter) was graded as either present or absent by one observer and in one-third of patients by two observers independently. ICA was the standard of reference. Results were reported per segment and per patient. RESULTS: Twenty-two percent of patients had known coronary artery disease (CAD). In two cases, a coronary anomaly was detected. Diagnostic image quality (grade 1-3) was achieved in 30.3% of segments. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75%, 80.5%, 16%, and 98.5%, respectively. Significant coronary stenosis could be ruled out completely in all segments in three patients. The interrater agreement per patient was excellent (kappa = 1). CONCLUSION: Relevant coronary findings can frequently be observed in high-pitch TAVI-planning CT. Despite the limitations of the technique and in patients referred to pre-TAVI evaluation (rapid heart rate, coronary calcifications, etc.), a valid evaluation of coronary arteries is possible in a considerable proportion of segments with a high NPV; however, few studies were completely free of motion artefacts to dependably exclude CAD using this technique in this challenging group of patients.

Economic outcomes of a targeted intervention program: the costs of treating allergic rhinitis patients.

OBJECTIVES: To determine the annual costs of treating allergic rhinitis patients in a managed care environment and to assess the effect of a treatment intervention program on direct and indirect costs. DESIGN: Two arms of an economics study were designed to calculate annual costs of treating allergic rhinitis in Lovelace Health Systems. Direct and indirect costs were also reviewed for patients participating in an intervention program designed to improve patient outcomes during the 1996 fall allergy season. PATIENTS AND METHODS: Annual medical costs of treating allergic rhinitis within the Lovelace system were reviewed using a patient database. A total of 7936 patients with allergic rhinitis symptoms were identified in the database using a case-finding algorithm. An equal number of patients without allergy conditions were selected for the comparison group. In addition to calculating annual costs of treating allergic rhinitis, direct and indirect costs were reviewed for patients participating in a rhinitis intervention program to determine differences in cost between the treatment and control groups. An intervention group of 247 patients was selected to receive care at clinics randomized to use practice guidelines to improve treatment, while 255 patients were treated in the control group clinics, which did not alter treatment practices. RESULTS: Annual expenditures were nearly $2 million more for the allergic rhinitis group than for the control group. In the intervention study, treatment and control groups expended the same in direct costs, but the intervention group showed a trend toward decreased indirect costs. CONCLUSION: Costs of allergic rhinitis are not trivial to a managed care organization; a specifically designed intervention program shows potential for minimizing the costs associated with the ailment.

Innovations in human service technologies. Strengthening health care delivery systems.

The authors report on innovative approaches to the organization of health services and the delivery of patient care in 19 U.S. hospitals and hospital networks. Strengthening patient care is the focus of this initiative. Hospital-wide interdisciplinary planning and the subsequent trial of new human service technologies are explored.