Rhythm versus rate control in the contemporary management of atrial fibrillation in-hospital.

Little is presently known regarding whether a rhythm-control or a rate-control strategy is more frequently used in patients hospitalized for atrial fibrillation (AF). This study was conducted to assess patient and physician characteristics associated with each treatment strategy and with the use of anticoagulants. Hospitalizations for primary diagnoses of AF were examined using hospital claims from January 2000 to December 2004. Patients who received antiarrhythmic drugs, ablation, or cardioversion for AF were categorized as receiving rhythm control. Patients managed only with beta blockers, calcium channel blockers, or digoxin were categorized as receiving rate control. Characteristics associated with rhythm compared with rate control and anticoagulant use with CHADS(2) score were determined. The study cohort included 155,731 hospitalizations from 464 hospitals. Of these, 75,397 (48%) were categorized as involving rhythm control and 80,334 (52%) as involving rate control. Care by a noncardiologist (adjusted odds ratio [OR] 0.33, 95% confidence interval [CI] 0.31 to 0.36) and increasing age >65 years (adjusted OR 0.87, 95% CI 0.86 to 0.88) were associated with lower odds of rhythm versus rate control; hypertrophic cardiomyopathy was associated with greater odds (adjusted OR 2.3, 95% CI 1.81 to 2.84) of rhythm control. Warfarin use was greater in the rhythm-control group compared with the rate-control group (adjusted OR 1.56, 95% CI 1.52 to 1.60), and warfarin use was greater with a CHADS(2) score > or =2 (unadjusted OR 1.21, 95% CI 1.19 to 1.24). In conclusion, rhythm- and rate-control strategies were used equally in patients hospitalized for AF. Some observations, such as greater use of the rate-control strategy with increasing age, were consistent with recommendations, but others, such as lower use of warfarin in the rate-control group, were not.

Center variation in hospital costs for patients undergoing congenital heart surgery.

BACKGROUND: Congenital heart disease consumes significant health care resources; however, there are limited data regarding factors affecting resource utilization. The purpose of this study was to evaluate variation between centers in total hospital costs for 4 congenital heart operations of varying complexity and associated factors. METHODS AND RESULTS: The Premier Database was used to evaluate total cost in children undergoing isolated atrial septal defect (ASD) repair, ventricular septal defect (VSD) repair, tetralogy of Fallot (TOF) repair, or arterial switch operation (ASO) from 2001 to 2007. Mixed models were used to evaluate the impact of center on total hospital costs adjusting for patient and center characteristics and length of stay. A total of 2124 patients were included: 719 ASD (19 centers), 792 VSD (20 centers), 420 TOF (17 centers), and 193 ASO (13 centers). Total cost increased with complexity of operation from median $12 761 (ASD repair) to $55 430 (ASO). In multivariable analysis, models that accounted for center effects versus those that did not performed significantly better for all 4 surgeries (all P≤0.01). The proportion of total cost variation explained by center was 19% (ASD repair), 11% (VSD repair), 6% (TOF repair), and 3% (ASO). Higher-volume centers had significantly lower hospital costs for ASD and VSD repair but not for TOF repair and ASO. CONCLUSIONS: Total hospital costs varied significantly by center for all congenital heart surgeries evaluated, even after adjustment for patient and center characteristics and length of stay. Differences among centers were most prominent for lower complexity procedures.