Recent trends in hospitalization for acute myocardial infarction.

Rates of acute myocardial infarction (AMI) hospitalizations for elderly Medicare patients decreased during the previous decade. However, trends in population rates of AMI hospitalizations for all adults by subgroups have not been described. Using data from a large all-payer administrative database of hospitalizations, we calculated annual AMI hospitalization rates from 2001 through 2007. Trend analysis was performed across age, gender, and ethnicity categories using survey regression. Overall rate decreased from 314 to 222 AMI hospitalizations per 100,000 patients from 2001 through 2007, representing a 29.2% decrease. Significant decreases were observed in AMI hospitalization rate for each group by age categories (p <0.001) and by gender (p <0.001). When stratified by ethnicity and gender, age-adjusted AMI hospitalization rates in white men and women decreased by 30.8% and 31.4%, whereas black men and women had significantly slower rates of decrease of 13.6% and 12.6%, respectively. In conclusion, although the overall rate of AMI hospitalizations decreased from 2001 through 2007, the observed decrease was smaller for black patients compared to white patients across all age groups studied.

Expanding the safety net of specialty care for the uninsured: a case study.

OBJECTIVE: To describe core principles and processes in the implementation of a navigated care program to improve specialty care access for the uninsured. STUDY SETTING: Academic researchers, safety-net providers, and specialty physicians, partnered with hospitals and advocates for the underserved to establish Project Access-New Haven (PA-NH). PA-NH expands access to specialty care for the uninsured and coordinates care through patient navigation. STUDY DESIGN: Case study to describe elements of implementation that may be relevant for other communities seeking to improve access for vulnerable populations. PRINCIPAL FINDINGS: Implementation relied on the application of core principles from community-based participatory research (CBPR). Effective partnerships were achieved by involving all stakeholders and by addressing barriers in each phase of development, including (1) assessment of the problem; (2) development of goals; (3) engagement of key stakeholders; (4) establishment of the research agenda; and (5) dissemination of research findings. CONCLUSIONS: Including safety-net providers, specialty physicians, hospitals, and community stakeholders in all steps of development allowed us to respond to potential barriers and implement a navigated care model for the uninsured. This process, whereby we integrated principles from CBPR, may be relevant for future capacity-building efforts to accommodate the specialty care needs of other vulnerable populations.

Project Access-New Haven: improving access to specialty care for patients without insurance.

BACKGROUND: Poor access to specialty care among uninsured adults threatens the delivery of quality health care and may contribute to the misuse and overuse of emergency departments and hospitals. INTERVENTION: We sought to improve access to specialty care through a program called Project Access-New Haven (PA-NH),which engages specialty physicians and hospitals to volunteer in a coordinated-care model for the uninsured. Patient navigators guide patients through the health-care network and help to alleviate administrative obstacles. RESULTS: Project Access-New Haven has been operational since August 2010. With >200 specialty physicians volunteering and strong commitments from local hospitals, comprehensive specialty care has been provided to 78 patients. Average wait-time for appointments is 17 days. CONCLUSION: PA-NH provides timely medical care and patient navigation foruninsured patientswith specialty-care needs. In the process, more physicians are participating in the care of vulnerable populations. Further data are needed to assess the potential cost-savings of PA-NH.

Mortality and readmission for patients with heart failure among U.S. News & World Report's top heart hospitals.

BACKGROUND: The rankings of "America's Best Hospitals" by U.S. News & World Report are influential, but the performance of ranked hospitals in caring for patients with routine cardiac conditions such as heart failure is not known. METHODS AND RESULTS: Using hierarchical regression models based on medical administrative data from the period July 1, 2005, to June 30, 2006, we calculated risk-standardized mortality rates and risk-standardized readmission rates for ranked and nonranked hospitals in the treatment of heart failure. The mortality analysis examined 14 813 patients in 50 ranked hospitals and 409 806 patients in 4761 nonranked hospitals. The readmission analysis included 16 641 patients in 50 ranked hospitals and 458 473 patients in 4627 nonranked hospitals. Mean 30-day risk-standardized mortality rates were lower in ranked versus nonranked hospitals (10.1% versus 11.2%, P<0.01), whereas mean 30-day risk-standardized readmission rates were no different between ranked and nonranked hospitals (23.6% versus 23.8%, P=0.40). The 30-day risk-standardized mortality rates varied widely for both ranked and nonranked hospitals, ranging from 7.9% to 12.4% for ranked hospitals and from 7.1% to 17.5% for nonranked hospitals. The 30-day risk-standardized readmission rates also spanned a large range, from 18.7% to 29.3% for ranked hospitals and from 19.2% to 29.8% for nonranked hospitals. CONCLUSIONS: Hospitals ranked by U.S. News & World Report as "America's Best Hospitals" in "Heart & Heart Surgery" are more likely than nonranked hospitals to have a significantly lower than expected 30-day mortality rate, but there was much overlap in performance. For readmission, the rates were similar in ranked and nonranked hospitals.

"America's Best Hospitals" in the treatment of acute myocardial infarction.

BACKGROUND: The ranking of "America's Best Hospitals" by U.S. News & World Report for "Heart and Heart Surgery" is a popular hospital profiling system, but it is not known if hospitals ranked by the magazine vs nonranked hospitals have lower risk-standardized, 30-day mortality rates (RSMRs) for patients with acute myocardial infarction (AMI). METHODS: Using a hierarchical regression model based on 2003 Medicare administrative data, we calculated RSMRs for ranked and nonranked hospitals in the treatment of AMI. We identified ranked and nonranked hospitals with standardized mortality ratios (SMRs) significantly less than the mean expected for all hospitals in the study. RESULTS: We compared 13 662 patients in 50 ranked hospitals with 254 907 patients in 3813 nonranked hospitals. The RSMRs were lower in ranked vs nonranked hospitals (16.0% vs 17.9%, P<.001). The RSMR range for ranked vs nonranked hospitals overlapped (11.4%-20.0% vs 13.1%-23.3%, respectively). In an RSMR quartile distribution of all hospitals, 35 ranked hospitals (70%) were in the lowest RSMR or best performing quartile, 11 (22%) were in the middle 2 quartiles, and 4 (8%) were in the highest RSMR or worst performing quartile. There were 11 ranked hospitals (22%) and 28 nonranked hospitals (0.73%) that each had an SMR significantly less than 1 (defined by a 95% confidence interval with an upper limit of <1.0). CONCLUSIONS: On average, admission to a ranked hospital for AMI was associated with a lower risk of 30-day mortality, although about one-third of the ranked hospitals fell outside the best performing quartile based on RSMR. Although ranked hospitals were much more likely to have an SMR significantly less than 1, many more nonranked hospitals had this distinction.