Identification of Hospital Cardiac Services for Acute Myocardial Infarction Using Individual Patient Discharge Data.

BACKGROUND: The availability of hospital cardiac services may vary between hospitals and influence care processes and outcomes. However, data on available cardiac services are restricted to a limited number of services collected by the American Hospital Association (AHA) annual survey. We developed an alternative method to identify hospital services using individual patient discharge data for acute myocardial infarction (AMI) in the Premier Healthcare Database. METHODS AND RESULTS: Thirty-five inpatient cardiac services relevant for AMI care were identified using American Heart Association/American College of Cardiology guidelines. Thirty-one of these services could be defined using patient-level administrative data codes, such as International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology codes. A hospital was classified as providing a service if it had ≥5 instances for the service in the Premier database from 2009 to 2011. Using this system, the availability of these services among 432 Premier hospitals ranged from 100% (services such as chest X-ray) to 1.2% (heart transplant service). To measure the accuracy of this method using administrative data, we calculated agreement between the AHA survey and Premier for a subset of 16 services defined by both sources. There was a high percentage of agreement (≥80%) for 11 of 16 (68.8%) services, moderate agreement for 3 of 16 (18.8%) services, and low agreement (≤50%) for 2 of 16 services (12.5%). CONCLUSIONS: The availability of cardiac services for AMI care varies widely among hospitals. Using individual patient discharge data is a feasible method to identify these cardiac services, particularly for those services pertaining to inpatient care.

Challenges with the establishment of congenital cardiac surgery centers in Nigeria: survey of cardiothoracic surgeons and residents.

BACKGROUND: There are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors. METHODS: A descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package. RESULT: Thirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit. CONCLUSIONS: The obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service.

Spatial distribution of specialized cardiac care units in the state of Santa Catarina / Distribuição espacial de serviços especializados em cardiologia no estado de Santa Catarina

OBJECTIVE To analyze the methodology used for assessing the spatial distribution of specialized cardiac care units. METHODS A modeling and simulation method was adopted for the practical application of cardiac care service in the state of Santa Catarina, Southern Brazil, using the p-median model. As the state is divided into 21 health care regions, a methodology which suggests an arrangement of eight intermediate cardiac care units was analyzed, comparing the results obtained using data from 1996 and 2012. RESULTS Results obtained using data from 2012 indicated significant changes in the state, particularly in relation to the increased population density in the coastal regions. The current study provided a satisfactory response, indicated by the homogeneity of the results regarding the location of the intermediate cardiac care units and their respective regional administrations, thereby decreasing the average distance traveled by users to health care units, located in higher population density areas. The validity of the model was corroborated through the analysis of the allocation of the median vertices proposed in 1996 and 2012. CONCLUSIONS The current spatial distribution of specialized cardiac care units is more homogeneous and reflects the demographic changes that have occurred in the state over the last 17 years. The comparison between the two simulations and the current configuration showed the validity of the proposed model as an aid in decision making for system expansion. .

OBJETIVO Analisar metodologia para distribuição espacial de serviços especializados em cardiologia. MÉTODOS Foi utilizado método de modelagem e simulação de aplicação prática para o serviço de atendimento cardiológico do estado de Santa Catarina, por meio do modelo de p-medianas. Considerando-se a divisão do estado em 21 regiões de saúde, foi analisada uma metodologia que propõe a instalação de oito centros de atendimento cardiológico intermediários, comparando-se os resultados de 1996 e 2012. RESULTADOS A aplicação com dados de 2012 refletiu mudanças ocorridas no estado, principalmente quanto ao adensamento populacional na região litorânea. A proposta atual apresentou uma resposta eficiente, observada pela homogeneidade dos resultados referentes à localização dos centros de atendimento cardiológico intermediários e às regiões que ficam a eles alocadas, com redução da distância média percorrida às unidades de serviço em regiões com maior densidade demográfica. A validade do modelo foi confirmada na análise da alocação dos vértices medianos propostos em 1996 e 2012. CONCLUSÕES A distribuição espacial de serviços especializados em cardiologia apresenta configuração mais homogênea e reflete as mudanças demográficas ocorridas no estado nos últimos 17 anos. A comparação entre as duas simulações realizadas e a configuração atual mostrou a validade do modelo como ferramenta auxiliar na tomada de decisão para a expansão do sistema. .

Survival and neurologic outcome after out-of-hospital cardiac arrest: results one year after regionalization of post-cardiac arrest care in a large metropolitan area.

BACKGROUND: Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients. METHODS: Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2. RESULTS: The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%. CONCLUSION: We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Spatial distribution of specialized cardiac care units in the state of Santa Catarina.

OBJECTIVE To analyze the methodology used for assessing the spatial distribution of specialized cardiac care units. METHODS A modeling and simulation method was adopted for the practical application of cardiac care service in the state of Santa Catarina, Southern Brazil, using the p-median model. As the state is divided into 21 health care regions, a methodology which suggests an arrangement of eight intermediate cardiac care units was analyzed, comparing the results obtained using data from 1996 and 2012. RESULTS Results obtained using data from 2012 indicated significant changes in the state, particularly in relation to the increased population density in the coastal regions. The current study provided a satisfactory response, indicated by the homogeneity of the results regarding the location of the intermediate cardiac care units and their respective regional administrations, thereby decreasing the average distance traveled by users to health care units, located in higher population density areas. The validity of the model was corroborated through the analysis of the allocation of the median vertices proposed in 1996 and 2012. CONCLUSIONS The current spatial distribution of specialized cardiac care units is more homogeneous and reflects the demographic changes that have occurred in the state over the last 17 years. The comparison between the two simulations and the current configuration showed the validity of the proposed model as an aid in decision making for system expansion.

Do we need cardiac arrest centres in Australia?

The mortality rate post admission to hospital after successful resuscitation from out-of-hospital cardiac arrest is high, with significant variation between regions and individual institutions. While prehospital factors such as age, bystander cardiopulmonary resuscitation and total cardiac arrest time are known to influence outcome, several aspects of post-resuscitative care including therapeutic hypothermia, coronary intervention and goal-directed therapy may also influence patient survival. Regional systems of care have improved provider experience and patient outcomes for those with ST elevation myocardial infarction and life-threatening traumatic injury. In particular, hospital factors such as hospital size and interventional cardiac care capabilities have been found to influence patient mortality. This paper reviews the evidence supporting the possible development and implementation of Australian cardiac arrest centres.

Status and future needs of regional adult congenital heart disease centers in Japan.

BACKGROUND: Although the prevalence of adult congenital heart disease (ACHD) in Japan continues to rise, the number and geographic distribution of facilities potentially serving as regional ACHD centers remains unknown. We examined trends in ACHD care in Japan to identify needs and to determine potential regional responses to this growing patient population. METHODS AND RESULTS: A descriptive, cross-sectional, nationwide survey was conducted to assess the status and needs of cardiology specialists related to providing ACHD care. Questionnaires were mailed to 138 cardiology departments located in 8 geographical regions throughout Japan; respondents were asked to document the status and future direction of ACHD care for each facility. Of the 109 facilities that responded, approximately one-third currently treat or plan to treat all ACHD patients. Fourteen facilities (12.8%) fulfilled all criteria for becoming regional ACHD centers. Although each regional center was projected to serve a population of 9.1 million, in 2 regions, no centers possessed the necessary care structure. CONCLUSIONS: Our findings revealed a shortage of adult cardiologists dedicated to ACHD care. Moreover, basic as well as formal fellowship ACHD training was deemed necessary. In Japan, the number of potential regional ACHD centers has just reached international standards. However, based on the geographic gaps documented here, a strategy other than regional centralization might be required to deliver adequate ACHD care to rural areas.

Geographic analysis of cardiac interventional services in Alabama.

BACKGROUND: Cardiovascular disease is the leading cause of death in the state of Alabama. The purpose of this study was to explore the geographical accessibility of the Alabama population to cardiac interventional services (CISs) for the treatment of acute myocardial infarction. METHODS: A descriptive ecological study design was used. Census tract-level population census data were used to describe access to CIS in Alabama. Descriptive analysis was conducted within a geographical information system (GIS) and provided empirical measures of travel time, calculated population proportions, and generated maps for visual identification of areas of low access. Descriptive statistics are reported as proportions (percentages) of the population with access by travel time. FINDINGS: The GIS analysis revealed that 58.2%, 85.9%, and 96.0% of the total Alabama population were within 30-, 60-, or 90-minute travel time, respectively, of a hospital with CIS. Maps provided visualization of CIS coverage areas for Alabama. One distinct area within the Alabama Black Belt was at greater than 90 minutes from a hospital with CIS. This area is known as a mostly black, impoverished population subject to health disparities. CONCLUSIONS: The GIS showed that 96% of the Alabama population is within 90-minute travel time of a hospital with CIS. For the best outcomes to occur allowing adequate time for symptom recognition, travel time, and 30-minute door-to-needle time, only 85.9% and 58.2% are within 60- and 30-minute travel time, respectively.

Cardiac Certificate of Need regulations and the availability and use of revascularization services.

BACKGROUND: Many states enforce Certificate of Need (CON) regulations for cardiac procedures, but little is known about how CON affects utilization. We assessed the association between cardiac CON regulations, availability of revascularization facilities, and revascularization rates. METHODS: We determined when state cardiac CON regulations were active and obtained data for Medicare beneficiaries > or = 65 years old who received coronary artery bypass graft surgery (CABG) or a percutaneous coronary intervention (PCI) between 1989 and 2002. We compared the number of hospitals performing revascularization and patient utilization in states with and without CON regulations, and in states which discontinued CON regulations during 1989 to 2002. RESULTS: Each year, the per capita number of hospitals performing CABG and PCI was higher in states without CON (3.7 per 100,000 elderly for CABG, 4.5 for PCI in 2002), compared with CON states (2.5 for CABG, 3.0 for PCI in 2002). Multivariate regressions that adjusted for market and population characteristics found no difference in CABG utilization rates between states with and without CON (P = .7). However, CON was associated with 19.2% fewer PCIs per 1000 elderly (P = .01), equivalent to 322,526 fewer PCIs for 1989 to 2002. Among most states that discontinued CON, the number of hospitals performing PCI rose in the mid 1990s, but there were no consistent trends in the number of hospitals performing CABG or in PCIs or CABGs per capita. CONCLUSIONS: Certificate of Need restricts the number of cardiac facilities, but its effect on utilization rates may vary by procedure.

Opening of specialty cardiac hospitals and use of coronary revascularization in medicare beneficiaries.

CONTEXT: Although proponents argue that specialty cardiac hospitals provide high-quality cost-efficient care, strong financial incentives for physicians at these facilities could result in greater procedure utilization. OBJECTIVE: To determine whether the opening of cardiac hospitals was associated with increasing population-based rates of coronary revascularization. DESIGN, SETTING, AND PATIENTS: In a study of Medicare beneficiaries from 1995 through 2003, we calculated annual population-based rates for total revascularization (coronary artery bypass graft [CABG] plus percutaneous coronary intervention [PCI]), CABG, and PCI. Hospital referral regions (HRRs) were used to categorize health care markets into those where (1) cardiac hospitals opened (n = 13), (2) new cardiac programs opened at general hospitals (n = 142), and (3) no new programs opened (n = 151). MAIN OUTCOME MEASURES: Rates of change in total revascularization, CABG, and PCI using multivariable linear regression models with generalized estimating equations. RESULTS: Overall, rates of change for total revascularization were higher in HRRs after cardiac hospitals opened when compared with HRRs where new cardiac programs opened at general hospitals and HRRs with no new programs (P<.001 for both comparisons). Four years after their opening, the relative increase in adjusted rates was more than 2-fold higher in HRRs where cardiac hospitals opened (19.2% [95% confidence interval {CI}, 6.1%-32.2%], P<.001) when compared with HRRs where new cardiac programs opened at general hospitals (6.5% [95% CI, 3.2%-9.9%], P<.001) and HRRs with no new programs (7.4% [95% CI, 3.2%-11.5%], P<.001). These findings were consistent when rates for CABG and PCI were considered separately. For PCI, this growth appeared largely driven by increased utilization among patients without acute myocardial infarction (42.1% [95% CI, 21.4%-62.9%], P<.001). CONCLUSION: The opening of a cardiac hospital within an HRR is associated with increasing population-based rates of coronary revascularization in Medicare beneficiaries.

U.S. trends in CABG hospital volume: the effect of adding cardiac surgery programs.

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality.

The rise and fall of cardiac rehabilitation in the United Kingdom since 1998.

BACKGROUND: Provision of cardiac rehabilitation is inadequate in all countries in which it has been measured. This study assesses the provision in the United Kingdom and the changes between 1998 and 2004. METHODS: All UK cardiac rehabilitation programmes were surveyed annually. Figures for each year were up-rated to account for missing data and compared with national data for acute myocardial infarction, coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The total numbers and percentage of eligible patients included were charted for 7 years. RESULTS: For centres giving figures, the total number treated rose from 29,890 in 1998 to 37,129 in 2004. The up-rated figures show that the percentage of eligible patients enrolled rose from 25.0% in 1998 to 31.5% in 1999 and has changed little since, falling from 31.3% in 2002 to 28.5% in 2004. About 25% of myocardial infarction patients, 75% of CABG patients and 20% of PCI patients joined cardiac rehabilitation programmes. CONCLUSIONS: The National Service Framework for Coronary Heart Disease set a target for 85% of myocardial infarct and coronary revascularization patients to be enrolled in rehabilitation programmes. Only one-third of this number is currently being enrolled and the percentage is falling.

Access to myocardial revascularization procedures: closing the gap with time?

BACKGROUND: Early access to revascularization procedures is known to be related to a more favorable outcome in myocardial infarction (MI) patients, but access to specialized care varies widely amongst the population. We aim to test if the early gap found in the revascularization rates, according to distance between patients' location and the closest specialized cardiology center (SCC), remains on a long term basis. METHODS: We conducted a population-based cohort study using data from the Quebec's hospital discharge register (MED-ECHO). The study population includes all patients 25 years and older living in the province of Quebec, who were hospitalized for a MI in 1999 with a follow up time of one year after the index hospitalization. The main variable is revascularization (percutaneous transluminal coronary angioplasty or a coronary artery bypass graft). The population is divided in four groups depending how close they are from a SCC (< 32 km, 32-64 km, 64-105 km and > or = 105 km). Revascularization rates are adjusted for age and sex. RESULTS: The study population includes 11,802 individuals, 66% are men. The one-year incidence rate of MI is 244 individuals per 100,000 inhabitants. At index hospitalization, a significant gap is found between patients living close (< 32 km) to a SCC and patients living farther (> or = 32 km). During the first year, a gap reduction can be observed but only for patients living at an intermediate distance from the specialized center (64-105 km). CONCLUSION: The gap observed in revascularization rates at the index hospitalization for MI is in favour of patients living closer (< 32 km) to a SCC. This gap remains unchanged over the first year after an MI except for patients living between 64 and 105 km, where a closing of the gap can be noticed.

[The Spanish registry of organization, resources and activities in pediatric cardiology]. / Registro español sobre organización, recursos y actividades en Cardiología Pediátrica.

INTRODUCTION: We present the findings of the registry of activities and resources of the Spanish Society of Pediatric Cardiology in 2002, with the objective of providing a national reference for professionals and entities involved in the study and treatment of congenital heart defects. METHODS: Data were retrospectively collected through questionnaires sent from the Spanish Society of Pediatric Cardiology to the heads of pediatric cardiology units with medical and surgical activities, as well as to all the members of the Society and those of the Pediatric Cardiology Section of the Spanish Society of Cardiology. RESULTS: Thirty-eight centers, including 17 national centers with medical and surgical activities, completed the questionnaire. Human resources consisted of 110 cardiologists, 43 surgeons and 12 residents in training. All the centers had the elementary tools for diagnosis and all except one had Echo-2D-Doppler. There were eight catheterization laboratories exclusively used for pediatric activities and nine further laboratories that combined adult and pediatric activities. A total of 83,061 patients were attended in outpatient clinics and there were 6,938 hospital admissions in 22 centres. A total of 279 ablation procedures were performed in 12 electrophysiology laboratories. The seventeen centres with surgical activities performed 2,498 cardiac catheterisms (968 interventional) and 2,292 cardiac surgical interventions. CONCLUSIONS: Given the large number of participating centers, the present report provides exhaustive information on the organization, resources and activities of pediatric cardiology in Spain. Pediatric cardiology should be granted official recognition of its work so that teaching hospitals, organization, resources and activities can be regulated.