The training of physicians outside the hospital.

The current ambulatory training of medical residents in the primary care program and the traditional program of the Massachusetts General Hospital, Boston, are described. All residents are assigned to work in a single medical group practice unit during their three years of training. Block outpatient rotations make up 32% of the primary care program and 6% of the traditional program schedules, while total ambulatory experiences, including weekly continuity sessions, make up 39% and 15%, respectively. Several components are important for a successful program. Above all is a vigorous group practice providing a sizable panel of patients with complex clinical problems from which residents can learn. Also important are financial support from the hospital and government or private grants and a commitment to outpatient teaching by the medical and nonmedical specialty staff.

Left ventricular ejection fraction. Physician estimates compared with gated blood pool scan measurements.

Gated blood pool scanning (GBPS) is an expensive, frequently used test to assess the left ventricular ejection fraction (LVEF). To determine whether a simpler method of evaluating LVEFs was reliable, we compared the LVEFs derived by GBPS with those estimated in a cardiologist's examination in 125 hospitalized patients. Of the physician estimates, 56% were accurate to within 7.5%, while 17% were underestimates and 27% were overestimates. The variables that were most predictive of reduced LVEF included cardiomegaly and pulmonary venous congestion on chest roentgenogram and S3 gallop, hypotension, and sustained left ventricular apex beat on examination. Prior hypertension was correlated with an increased LVEF. Variables associated with physician error in estimating the LVEF included a history of hypertension, bronchodilator therapy, and right bundle-branch block seen on the electrocardiogram. These data suggest that although qualitatively accurate estimates of the LVEF can sometimes be made on the basis of clinical findings, GBPS should be performed when management decisions hinge on a precise knowledge of this value.

Chest pain with angiographically insignificant coronary arterial obstruction. Clinical presentation and long-term follow-up.

Among 3,242 coronary angiograms performed from November 1972 through October 1975 at the Massachusetts General Hospital, 175 patients had normal coronary arteries or luminal narrowings of less than 30 per cent. All patients were studied for chest pain, and none had experienced prior myocardial infarction. Subsequent information was available in 159 patients over a mean follow-up period of 42.7 months. There were no deaths, and only one myocardial infarction occurred during this period. However, among the patients followed, continued chest pain with episodes occurring at least once monthly was present in 54 per cent. In addition, 17 per cent of all patients required subsequent hospitalization and 44 per cent continued to receive antianginal medication. Nearly half of the group (46 per cent) suffered some limitation of activity, and 22 per cent stated that they had either changed jobs or stopped work because of chest pain. Continuing chest pain was significantly more common in women and in patients who had experienced chest pain for more than one year before angiography. However, typicality of chest pain for angina or the occurrence of electrocardiographic changes of ischemia prior to angiography did not predict continued chest pain during the follow-up period. Thus, although mortality and morbidity are low in this group of patients, the syndrome of chest pain with angiographically insignificant coronary artery obstruction has an important impact on the lives of a majority of those affected.

Making the coronary care unit cost-effective.

Coronary care units (CCUs) have now been in use for 20 years, and it is generally acknowledged that they have helped to reduce hospital mortality for patients with acute myocardial infarction. In recent years the indications for admission to a CCU have been greatly expanded to include all patients with suspected myocardial infarction and a variety of other manifestations of cardiovascular disease including primary arrhythmias and heart failure. The focus of the CCU has also broadened to include the prevention of major complications and the use of a variety of invasive and noninvasive diagnostic and therapeutic interventions before, as well as in response to, complications. With the changing indications for CCU admissions and the changing use of the CCU, new problems have arisen. The number of patients who might benefit from CCU care is now much larger and may at any given time greatly exceed the number of beds available. Decisions regarding who should be admitted to the CCU, how long a patient should stay in the CCU and which of the large and growing armamentarium of diagnostic and therapeutic interventions should be used are now increasingly important. These decisions have not only medical but also economic implications. Based on a 5-year experience with an intensive care unit computer data bank, strategies for more cost-effective CCU use have been explored. This has involved identification of high- and low-risk subsets of patients and modifications of standard operating procedures. The common clinical problems of chest pain, arrhythmias, syncope, pulmonary edema and myocardial infarction will be used as examples.

Age and the declining rate of autopsy.

To better understand declining autopsy rates, data have been gathered prospectively on 1080 consecutive deaths over six years among patients admitted to a medical intensive care/coronary care unit. Overall autopsy rate was 36%. Autopsy rates declined sharply with age from 60% for those aged 16 to 34 years to 23% for those 85 and over (P less than .001). The highest rates by diagnosis were aortic aneurysm (70%), hepatic failure (52%), heart rhythm disturbance (48%), pulmonary embolism (45%), and sepsis (41%). Patients receiving major procedures had a significantly higher autopsy rate (38 versus 29%, P less than .05) but rates bore little relation to prognoses given at admission by house officers, suddenness of death, sex, marital status or year of admission. Even among intensively treated patients, autopsy rates decline strikingly with age, demanding honest re-appraisal to restore the place of autopsy in medical education, clinical research, and quality of care assessment for an increasingly elderly population.

Where do elderly veterans obtain care for acute myocardial infarction: Department of Veterans Affairs or Medicare?

OBJECTIVE: To examine Department of Veterans Affairs (VA) and Medicare hospitalizations for elderly veterans with acute myocardial infarction (AMI), their use of cardiac procedures in both systems, and patient mortality. DATA SOURCES: Merging of inpatient discharge abstracts obtained from VA Patient Treatment Files (PTF) and Medicare MedPAR Part A files. STUDY DESIGN: A retrospective cohort study of male veterans 65 years or older who were prior users of the VA medical system (veteran-users) and who were initially admitted to a VA or Medicare hospital with a primary diagnosis of AMI at some time from January 1, 1988 through December 31, 1990 (N = 25,312). We examined the use of cardiac catheterization, coronary bypass surgery, and percutaneous transluminal coronary angioplasty in the 90 days after initial admission for AMI in both VA and Medicare systems, and survival at 30 days, 90 days, and one year. Other key measures included patient age, race, marital status, comorbidities, cardiac complications, prior utilization, and the availability of cardiac technology at the admitting hospital. PRINCIPAL FINDINGS: More than half of veteran-users (54 percent) were initially hospitalized in a Medicare hospital when they suffered an AMI. These Medicare index patients were more likely to receive cardiac catheterization (OR 1.24, 95% C.I. 1.17-1.32), coronary bypass surgery (OR 2.01, 95% C.I. 1.83-2.20), and percutaneous transluminal coronary angioplasty (OR 2.56, 95% C.I. 2.30-2.85) than VA index patients. Small proportions of patients crossed over between systems of care for catheterization procedures (VA to Medicare = 3.3%, and Medicare to VA = 5.1%). Many VA index patients crossed over to Medicare hospitals to obtain bypass surgery (27.6 percent) or coronary angioplasty (12.1 percent). Mortality was not significantly different between veteran-users who were initially admitted to VA versus Medicare hospitals. CONCLUSIONS: Dual-system utilization highlights the need to look at both systems of care when evaluating access, costs, and quality either in VA or in Medicare systems. Policy changes that affect access to and utilization of one system may lead to unpredictable results in the other.

Angina patients' ratings of current health and health without angina: associations with severity of angina and comorbidity.

OBJECTIVE: To investigate the relationship between chronic stable angina patients' ratings of two health states (current health and health free of angina), the difference between these two ratings (the "anticipated gain"), and measures of anginal severity and comorbidity. DESIGN: Cross-sectional interviews and questionnaires. SETTING: Out-patient clinics and medical inpatient service of a Veterans Affairs Medical Center. PARTICIPANTS: Patients with chronic stable angina with no prior history of a revascularization procedure attending clinic appointments (n = 44) or electively admitted for cardiac catheterization (n = 11). Measurements. Ratings of current health and health free of angina using a verbal rating scale in which 0 = death and 100 = perfect health, the MOS SF-36, the Index of Coexistent Disease (a validated measure of comorbidity), and a question on the severity of anginal symptoms. RESULTS: Mean (95% CI) rating of current health was 61.8 (59.2, 64.4) and that of health free of angina was 77.0 (74.5, 79.5). Median anticipated gain between the two health ratings was 10.0 (range 0-80). Correlations between ratings for both health states and subscales of the SF-36 were positive, with some reaching statistical significance. In regression models with rating of current health, rating of life without angina, and anticipated gain as the dependent variables, severity of comorbidity was highly significant in all three, whereas severity of angina was significant only in the current-health rating model. Severity of comorbidity had much greater explanatory power in all three models than did severity of angina. CONCLUSIONS: Severity of comorbidity was a better predictor of patients' current health rating, rating for angina-free health, and anticipated gain from relief of angina than was severity of angina. Since patient perceptions of a symptom may be distinct from self-reported symptom severity, treatment-outcome studies should assess patient preferences in addition to symptom severity. Comorbidity should also be measured in such studies. Having patients rate current health and symptom-free health may be a useful measure of treatment effectiveness for specific symptoms in clinical trials and patient care, and may help patients and clinicians prioritize multiple health problems.

Refractory hypoxemia in inferior myocardial infarction from right-to-left shunting through a patent foramen ovale: a case report and review of the literature.

Right ventricular (RV) infarction is a well-recognized complication of some acute inferior myocardial infarctions. Recently, there have been numerous case reports of RV infarctions complicated by severe refractory hypoxemia secondary to right-to-left shunting through a patent foramen ovale. An additional case missed by transthoracic echocardiography and cardiac catheterization is reported and the English literature on the subject is reviewed.

Acute coronary insufficiency. Review of 46 patients.

Forty-six patients admitted with acute coronary insufficiency are reviewed. All were investigated by coronary angiography; 4 had normal coronary arteries and are included in this study; the remainder had a distribution of coronary artery disease similar to other angina patients. The clinical and angiographic findings, management, and subsequent course of the other 42 patients are presented. Fourteen patients (33%) in whom rest pain persisted after 48 hours underwent emergency coronary angiography, with 3 deaths; of the surviving 11 who had acute saphenous vein bypass grafting, 2 died at operation and 3 had perioperative myocardial infarctions. Seventeen patients (41%) who initially improved required surgery within 6 months because of symptoms. Eleven patients (26%) were not operated on. It is concluded that acute coronary insufficiency is best managed initially by intensive medical therapy but a high proportion will require surgery later because of disabling angina. Early investigation and surgery are associated with a high mortality and incidence of myocardial infarction. Survivors of surgery are symptomatically improved and there is a low incidence of late infarction and death.

Life-threatening drug overdose. Precipitants and prognosis.

During a four-year period, 255 persons were admitted to a medical intensive care unit 283 times (5% of all admissions) for treatment of drug overdose. Because of the high personal and social costs associated with overdose and the high rate of repeated overdose admissions, we prospectively studied 104 patients who had taken an overdose admitted during a 20-month period to define better the precipitants of overdose and the prognosis after intensive care unit admission for overdose. Of 103 hospital survivors, 88 consented to and could be reached for follow-up (mean duration, ten months). During that time, 8% died (5% by overdose) and 42% had been readmitted for another nonfatal overdose or for psychiatric illness. Prior psychiatric treatment was associated with subsequent readmission; 61% with a history of suicide attempt were readmitted during the follow-up period. Demographic characteristics, psychiatric evaluation, and medical history were not associated with subsequent hospitalization or death from overdose.

Smoking cessation following admission to a coronary care unit.

OBJECTIVE: To determine the impact of an episode of serious cardiovascular disease on smoking behavior and to identify factors associated with smoking cessation in this setting. DESIGN: Prospective observational study in which smokers admitted to a coronary care unit (CCU) were followed for one year after hospital discharge to determine subsequent smoking behavior. SETTING: Coronary care unit of a teaching hospital. PATIENTS: Preadmission smoking status was assessed in all 828 patients admitted to the CCU during one year. The 310 smokers surviving to hospital discharge were followed and their smoking behaviors assessed by self-report at six and 12 months. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Six months after discharge, 32% of survivors were not smoking; the rate of sustained cessation at one year was 25%. Smokers with a new diagnosis of coronary heart disease (CHD) made during hospitalization had the highest cessation rate (53% vs. 31%, p = 0.01). On multivariate analysis, smoking cessation was more likely if patients were discharged with a diagnosis of CHD, had no prior history of CHD, were lighter smokers (less than 1 pack/day), and had congestive heart failure during hospitalization. Among smokers admitted because of suspected myocardial infarction (MI), cessation was more likely if the diagnosis was CHD than if it was noncoronary (37% vs. 19%, p less than 0.05), but a diagnosis of MI led to no more smoking cessation than did coronary insufficiency. CONCLUSION: Hospitalization in a CCU is a stimulus to long-term smoking cessation, especially for lighter smokers and those with a new diagnosis of CHD. Admission to a CCU may represent a time when smoking habits are particularly susceptible to intervention. Smoking cessation in this setting should improve patient outcomes because cessation reduces cardiovascular mortality, even when quitting occurs after the onset of CHD.

Prognosis, survival, and the expenditure of hospital resources for patients in an intensive-care unit.

To define more precisely the factors determining the allocation of resources to critically ill patients, we asked physicians to estimate at the time of admission the short-term prognosis of patients who accounted for 1831 admissions to a medical intensive-care and coronary-care unit. We then examined the relations between this prognosis, the actual outcome, and the resource expenditure during a single hospitalization. We found that the care of nonsurvivors involved a significantly higher mean expenditure than did the care of survivors (P less than 0.01). Among nonsurvivors, expenditure positively correlated with the probability of survival estimated at the time of admission (P less than 0.001). Among survivors, expenditure negatively correlated with the probability of survival (P less than 0.001). Among both nonsurvivors and survivors, total expenditure and expenditure per day were greatest for patients whose outcome were most unexpected. We conclude that prognostic uncertainty is important in determining resource expenditures for the critically ill. This factor warrants greater consideration in future studies of expenditure for the care of catastrophically ill patients.

Unexpected readmissions to the coronary-care unit during recovery from acute myocardial infarction.

Because it is difficult to predict the course in a patient recovering from acute myocardial infarction who is stable enough to leave the coronary-care unit (CCU), we studied such patients in order to identify those at risk of complications. Over two years of study, 485 of 536 consecutive patients admitted with myocardial infarction survived their first stay in the CCU. Complications serious enough to warrant readmission developed in 61 (13%). Readmissions occurred early: half were within 2.7 days of initial transfer from the unit. The subsequent course was severely complicated: 16 readmitted patients (26%) died in the hospital. Physicians were not able to identify clearly these high-risk patients during their first stay in the CCU. Several previously cited indicators of poor prognosis did not help identify those later readmitted, but recurrent ischemic pain that occurred for the first time after 24 hours in the CCU did. The absence of rales on admission, coupled with absence of recurrent chest pain, was indicative of a subgroup with a favorable short-term prognosis.

Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs.

OBJECTIVE: To examine whether blacks admitted to Veterans Affairs Medical Centers (VAMCs) with an acute myocardial infarction (AMI) are less likely than whites to undergo cardiac catheterization or coronary revascularization procedures and to determine the impact of these differences on patient survival. DESIGN: A retrospective observational study of inpatient discharge abstracts from the Veterans Health Administration (VHA). SETTING: All one hundred fifty-eight acute care hospitals in the VHA. PATIENT POPULATION: Male veterans (n = 33,641) discharge from VAMCs with an International Classification of Diseases, Ninth Revision, Clinical Modification code for AMI from January 1, 1988, to December 31, 1990. INTERVENTION: None. MAIN OUTCOME MEASURES: The use of cardiac catheterization, coronary angioplasty, and/or bypass surgery in the 90 days after admission for AMI, and survival at 30 days, 1 year, and 2 years. MAIN RESULTS: Adjusting for patient and hospital characteristics, blacks with an AMI were 33% less likely than whites to undergo cardiac catheterization, 42% less likely to receive coronary angioplasty, and 54% less likely to receive coronary bypass surgery. Among patients who underwent catheterization, blacks were also less likely than whites to have a subsequent cardiac revascularization procedure. Adjusted 30-day survival for blacks was significantly greater than for whites. One- and 2-year survival rates after AMI were not significantly different between blacks and whites. CONCLUSIONS: In a health care system designed to provide equivalent availability of care to all eligible patients, blacks received substantially fewer cardiac procedures after AMI than whites. Despite undergoing fewer interventional procedures, blacks had better short-term and equivalent intermediate survival rates compared with whites.

Functional outcomes following medical intensive care.

This study describes the long-term functional outcomes of a medical and coronary care ICU population. Baseline and 1-yr follow-up data were collected prospectively from all 2213 patients admitted during a 2-yr period. Patients were stratified into three groups based on their preadmission functional status: active (n = 917), sedentary (n = 1017), or severely limited (n = 279). Those with severe functional limitation before admission were twice as likely to undergo major interventions (p less than .005). This group also had a significantly (p less than .001) higher mortality and incurred significantly (p less than .01) higher hospital charges than the other two groups, even though hospital lengths of stay were similar. Finally, cumulative mortality was significantly (p less than .001) greater for the severely limited patients: 33% expired in the ICU, 42% died while still in the hospital, and 63% died after discharge. Most survivors regained their preadmission functional status, with 60% of the previously employed returning to work. However, even for hospital survivors, mortality was high and was related to prior functional status: active 7%, sedentary 20%, severely impaired 37%.

Outcomes of acute myocardial infarction in the Department of Veterans Affairs: does regionalization of health care work?

OBJECTIVES: This study examines the association between the regional availability of cardiac technology and outcomes of care for patients admitted to Department of Veterans Affairs (VA) hospitals. Patients using the VA regional medical system initially are admitted to a hospital with or without the on-site availability of technology-intensive cardiac services. METHODS: The authors identified male veterans (n = 24,229) discharged from VA hospitals with a primary diagnosis of acute myocardial infarction (AMI) from January 1, 1988 through December 31, 1990. Analyses of mortality up to 2 years after AMI and the use of cardiac procedures were stratified by the type of VA hospitals to which patients initially were admitted. Logistic regression models adjusted for age, race, marital status, hospitalization in previous year, comorbidities, cardiac complications coded, and year of AMI. RESULTS: Adjusted mortality was significantly higher for patients initially admitted to hospitals without on-site cardiac technology at: 2 days (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.62-0.81), 90 days (OR 0.78; 95% CI 0.73-0.85); 1 year (OR 0.87, 95% CI 0.81-0.93); and 2 years (OR 0.86, 95% CI 0.81-0.92) compared with hospitals with on-site cardiac technology (ie, coronary angioplasty and cardiac surgery facilities). Patients initially admitted to hospitals without on-site cardiac technology also were less likely to undergo cardiac procedures than patients admitted to hospitals with on-site cardiac technology. CONCLUSIONS: The regional distribution of cardiac technology may restrict patient access to technology-intensive services and to "equally good medical care." Policies that promote regionalization of medical services should consider carefully the distribution of benefits and burdens to patients.

Rationing intensive care--physician responses to a resource shortage.

To determine how physicians ration limited critical resources, we studied the allocation of intensive-care-unit (ICU) beds during a shortage caused by a lack of nurses. As the bed capacity of the medical ICU decreased from 18 to 8, the percentage of days on which one or more beds were available decreased from 95 to 55 per cent, and monthly admissions decreased from 122 to 95. Physicians responded by restricting ICU admissions to acutely ill patients and reducing the proportion of patients admitted primarily for monitoring. Among patients admitted because of chest pain, the proportion actually sustaining a myocardial infarction increased linearly with the restriction in bed capacity. Although more patients with myocardial infarction were admitted to non-intensive-care areas, there was no increase in mortality. In addition, physicians transferred patients out of the ICU sooner. There was no apparent withdrawal of care from dying patients. Our results suggest that physicians can respond to moderate resource limitations by more efficient use of intensive-care resources.

Nursing home patients admitted to a medical intensive care unit.

To investigate admissions from nursing homes to a medical intensive care unit (ICU), the authors detailed the major interventions, costs, and outcomes for such patients (n = 67) over a 3-year period and then compared them with those for ICU patients receiving home care or visiting nurse services (240 patients) before admission and all others older than 65 years of age (949 patients). These three groups comprised 37% of total ICU admissions. In contrast to younger patients admitted primarily with acute ischemic heart disease, nursing home patients were more likely to be admitted with cardiopulmonary arrest, infection, and gastrointestinal bleeding. Major interventions of intubation and mechanical ventilation were most frequent for nursing home patients, but total hospital charges differed little among the groups. In-hospital mortality for the nursing home group (28%) was significantly higher than for the home care group (7%) and others older than 65 years of age (7%). Cumulative mortality for the nursing home group reached 66% by 8 months, versus 32% and 26% in the other groups, respectively.