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Relationship between coronary angioplasty laboratory volume and outcomes after hospital discharge

AMERICAN HEART JOURNAL 2002年第5期143卷 833-840页

作者： Kimmel, SE Sauer, WH Brensinger, C Hirshfeld, J Haber, HL Localio, AR Univ Penn Sch Med Ctr Clin Epidemiol & Biostat Philadelphia PA 19104 USA Univ Penn Sch Med Dept Biostat & Epidemiol Philadelphia PA 19104 USA Hosp Univ Penn Dept Med Div Cardiovasc Philadelphia PA 19104 USA

Background Although an inverse association has been established between short-term complications of percutoneous coronary interventions (PCIs) and the volume of angioplasty procedures performed by catheterization laboratories, no data are available on the association between laboratory volume and long-term outcomes. Methods A cohort study of 25,222 patients undergoing PCI in 43 laboratories in Pennsylvania from October 1994 to December 1995 was performed by use of the Pennsylvania Health Care Cost Containment Council database. The association of laboratory volume with inhospital, 1-month, and 6-month events was estimated by use of multivariable analyses adjusting for patient and procedural characteristics. Results Although a higher volume of procedures was associated with reduced inhospital coronary bypass ([CABG] 0.6 odds ratio [OR] for 400 vs <400 PCIs/year;95% CI 0.4, 0.8), it was not associated with CABG occurring within 1 month after discharge (P = .71;OR 1.0, 95% CI 0.6, 1.7). Laboratory volume was also not significantly associated with postdischarge revascularization (PCI or CABG) at 1 month (P = .58;OR 1.1, 95% CI 0.8, 1.4) or 6 months (P = .47;OR 1.04, 95% CI 0.91, 1.19). In addition, laboratory volume was not associated with rates of myocardial infarction (P =.14), death (P =.28), or the combined outcome of PCI, CABG, myocardial infarction, or death (P = .90) at 1 month after hospital discharge. Conclusions Although our study confirmed the volume/complication relationship for inhospital CABG, it did not reveal an association between volume and postdischarge events. These results suggest that inhospital complications will remain the standard for assessing laboratory volume and that selective use of higher-volume laboratories may not improve long-term outcomes.

关键词：队列研究冠状动脉分流术/标准冠状动脉分流术/利用冠状动脉再狭窄/流行病学冠状动脉再狭窄/治疗医院/统计学和数值数据多元分析心肌梗死/流行病学心肌梗死/死亡率比值比宾夕法尼亚/流行病学时间因素治疗结果女(雌)性人类男(雄)性中年人

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Effect of variability in the interpretation of coronary angiograms on the appropriateness of use of coronary revascularisation procedures

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AMERICAN HEART JOURNAL 2000年第1期139卷 106-113页

作者： Leape, LL Park, RE Bashore, TM Harrison, JK Davidson, CJ Brook, RH Harvard Univ Sch Publ Hlth Dept Hlth Policy & Management Boston MA 02115 USA RAND Corp Santa Monica CA USA Duke Univ Med Ctr Durham NC USA Northwestern Univ Med Ctr Chicago IL 60611 USA Univ Calif Los Angeles Sch Med Los Angeles CA USA Univ Calif Los Angeles Sch Publ Hlth Los Angeles CA 90024 USA

Background Evidence from numerous studies of coronary angiography show differences between observers' assessments of 15% to 45%. The implication of this variation is serious: If readings are erroneous, some patients will undergo revascularization procedures unnecessarily and others will be denied an essential treatment. We evaluated the variation in interpretation of angiograms and its potential effect on appropriateness of use of revascularization procedures. Methods and Results Angiograms of 308 randomly selected patients previously studied for appropriateness of angiography, coronary artery bypass grafting (CABG), and percutaneous transluminal coronary angioplasty (PTCA) were interpreted by a blinded panel of 3 experienced angiographers and compared with the original interpretations. The potential effect on differences on the appropriateness of revascularization was assessed by use of the RAND criteria. Technical deficiencies were found in 52% of cases. Panel readings fended to show less significant disease (none in 16% of vessels previously read as showing significant disease), less severity of stenosis (43% lower, 6% higher), and lower extent of disease (23% less, 6% more). The classification of CABG changed from necessary/appropriate to uncertain/inappropriate for 17% to 33% of cases when individual ratings were replaced by panel readings. Conclusions The general level of technical quality of coronary angiography is unsatisfactory, Variation in the interpretation of angiograms was substantial in all measures and tended to be higher in individual than in panel readings. The effect was to lead to a potential overestimation of appropriateness of use of CABG by 17% and of PTCA by 10%. These findings indicate the need for increased attention to the technical quality of studies and an independent second reading for angiograms before recommending revascularization.

关键词：血管成形术经腔经皮冠状动脉/标准电影血管造影术临床工作能力冠状血管造影术冠状动脉分流术/标准冠心病/分类冠心病/放射摄影术冠心病/治疗纽约观察者偏差可重复性结果回顾性研究疾病严重程度指数人类

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The LAST operation is safe and effective: MIDCABG clinical and angiographic evaluation

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ANNALS OF THORACIC SURGERY 2000年第1期70卷 74-78页

作者： Repossini, A Moriggia, S Cianci, V Parodi, O Sganzerla, P Baldrighi, G Bortone, F Arena, V Clin Gavazzeni Dipartimento Cardiovasc I-24100 Bergamo Italy

Background. The aim of this study was to prospectively evaluate the angiographic results of a cohort of consecutive patients who underwent minimally invasive coronary artery revascularization. Methods. From May 1997 to December 1998, 150 consecutive patients underwent left internal mammary artery to left anterior descending artery anastomosis through a left minithoracotomy on a beating heart in the Cardiovascular Department of Cliniche Gavazzeni, Bergamo, Italy. The mean age was 61.6 years (range, 36 to 84 years);121 patients (81%) were men. Isolated left anterior descending artery disease was present in 74 patients. Results. In-hospital patency was observed in 100% of the 149 angiographically controlled patients with no anomalies in 99.3% of the anastomoses. Anastomosis was performed on a diseased tract of the target vessel in 3 patients and a stenosis of the target vessel beyond the anastomosis was documented in 3 patients. In one case early angiographic control was not performed due to death of the patient on the Ist postoperative day. The morbidity included postoperative bleeding that required reopening (3.3%) and intraoperative myocardial infarction (2%). Conclusions. A left internal mammary artery to left anterior descending artery anastomosis on a beating heart through a left minithoracotomy is an alternative approach to myocardial revascularization. Surgical invasiveness is limited, cardiopulmonary bypass risks are avoided, and the procedure is safe and effective. In our consecutive series, postoperative angiographic controls demonstrated graft patency in all patients and very high quality anastomoses. Midterm clinical follow-up (14 months) appears favorable. (Ann Thorac Surg 2000;70:74-8) (C) 2000 by The Society of Thoracic Surgeons.

关键词：冠状血管造影术冠状动脉分流术/方法冠状动脉分流术/标准冠心病/外科学随访研究前瞻性研究质量控制成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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A Canadian comparison of data sources for coronary artery bypass surgery outcome "report cards"

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AMERICAN HEART JOURNAL 2000年第3期140卷 402-408页

作者： Ghali, WA Rothwell, DM Quan, H Brant, R Tu, JV Univ Calgary Fac Med Dept Med Calgary AB T2N 4N1 Canada Univ Calgary Dept Community Hlth Sci Calgary AB T2N 4N1 Canada Inst Clin Evaluat Sci Toronto ON Canada Univ Toronto Sunnybrook & Womens Coll Hlth Sci Ctr Dept Med Toronto ON Canada

Background Prior comparisons of administrative versus clinical data for creating coronary artery bypass graft (CABG) surgery outcome "report cards" are all From the United States and yield inconsistent conclusions regarding the validity of administrative data report cards. In this study, we compared 2 CABG surgery outcome report cards For Ontario, Canada. one derived from clinical data from the Cardiac Care Network of Ontario and one derived From administrative data from the Canadian Institute for Health Information. Methods Data from 4 fiscal years, 1992-93 through 1995-96, were used. The Canadian Institute for Health Information report card was derived from administrative data only. The Cardiac Care Network report card drew on prospectively collected clinical information that included variables such as left ventricular ejection fraction but also required linkages to the Canadian institute for Health Information data for ascertainment of selected comorbidities and in-hospital mortality rates. Logistic regression models were used to calculate risk-adjusted death rates for each of the 9 hospitals performing CABG surgery in Ontario. Results The risk-adjusted death rates were quite similar between data sources for 7 of the 9 hospitals. For 2 hospitals, rather large absolute differences in adjusted death rates of 0.58% and 0.64% were seen between report cards. There was a strong correlation between data sources for risk-adjusted hospital death rates (intraclass correlation coefficient = 0.927, P < .001) and for rankings of adjusted hospital death rates (Spearman correlation coefficient = 0.828, P = .02). Conclusion These results from Ontario, Canada, reveal general similarities between administrative and clinical data report cards for CABG surgery. However, clinical data are likely needed if individual hospitals are to be publicly scrutinized in outcome report cards.

关键词：加拿大冠状动脉分流术/标准医院死亡率医院/标准信息服务医学审核结果评价(卫生保健)/统计学和数值数据手术后并发症危险性评估成年人老年人人类中年人

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Using administrative data to assess health care outcomes

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EUROPEAN HEART JOURNAL 1999年第23期20卷 1689-1691页

作者： Ayanian, JZ Brigham & Womens Hosp Div Gen Med Boston MA 02115 USA Harvard Univ Sch Med Dept Hlth Care Policy Boston MA 02115 USA

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Health maintenance organizations and hospital quality for coronary artery bypass surgery

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MEDICAL CARE RESEARCH AND REVIEW 1999年第3期56卷 340-362页

作者： Escarce, J Van Horn, RL Pauly, MV Williams, SV Shea, JA Chen, W Rand Corp Hlth Program Santa Monica CA 90407 USA Univ Rochester Rochester NY USA Univ Penn Philadelphia PA 19104 USA

This study uses hospital discharge data for 1992-1994 to assess differences between HMO and insured non-HMO patients in California and Florida with regard to the quality of the hospitals used for coronary artery bypass graft (CABG) surgery. The authors found that commercially insured HMO patients in California used higher quality hospitals than commercially insured non-HMO patients, controlling for patient distance to the hospital. In contrast, commercially insured HMO and non-HMO patients in Florida were similarly distributed across hospitals of different quality levels, whereas Medicare HMO patients in Florida used lower quality hospitals than patients in the standard Medicare program. The authors conclude that the association between HMO coverage and hospital quality may differ across geographic areas and patient populations, possibly related to the maturity and structure of managed care markets.

关键词：加利福尼亚合同业务冠状动脉分流术/死亡率冠状动脉分流术/标准佛罗里达健康维护组织/标准健康维护组织/统计学和数值数据卫生服务研究医院死亡率医院/分类医院/标准医院/利用保险住院/标准保险住院/统计学和数值数据 Logistic模型 Medicare/标准 Medicare/统计学和数值数据卫生保健质量/分类美国老年人女(雌)性人类男(雄)性中年人

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Assessment of coronary bypass surgery and percutaneous transluminal coronary angioplasty

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International Journal of Technology Assessment in Health Care 1989年第3期5卷 431-442页

作者： Preston, Thomas A. Pacific Medical Center University of Washington Seattle United States

Coronary bypass surgery developed as another in a line of surgical procedures dating back more than 60 years. The medical profession at first assessed this procedure with time-honored anecdotal techniques. Gradually, for a variety of reasons, improved methods of comparisons worked their way into assessments of bypass surgery. Randomized controlled trials met resistance but have been very influential. Assessment of percutaneous transluminal coronary angioplasty has benefited from the knowledge generated during the last 25 years, but clinicians have been slower to apply the most advanced techniques. © 1989, Cambridge University Press. All rights reserved.

关键词：血管成形术气囊/标准冠状动脉分流术/标准数据收集评价研究统计数据技术评估生物医学/发展趋势美国人类

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The case of cardiovascular disease: Evaluating Complex Health Programs Targeted at Prevention, Remediation, and Rehabilitation

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Evaluation & the Health Professions 1984年第2期7卷 157-180页

作者： Stevenson, Robert H. Center for Health Services and Policy Research Northwestern University Human Resources Daughters of Charity Health System Inc. Evansville Indiana United States

This report analyzes the complexities of evaluatingprevention, remediation, and rehabilitation treatments for cardiovascular disease. A comparison oftreatments revealed that distinct differences exist in terms of motivation ofsubjects to participate and steps required for a maximum treatment effect. Large-scale prevention programs are generally the most complex of all interventions to complete. If complex health programs are initially subdivided into theirdetailed planning and implementation steps, proper assessments of each step will lead to a much less difficult comprehensive evaluation. © 1984, SAGE Publications. All rights reserved.

关键词：心血管疾病/预防和控制冠状动脉分流术/标准评价研究国家卫生规划结果与过程评价(卫生保健) 康复/标准美国人类

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Adherence to practice guidelines: The role of specialty society guidelines

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American Heart Journal 2003年第1期145卷 19-26页

作者： Leape, Lucian L. Weissman, Joel S. Schneider, Eric C. Piana, Robert N. Gatsonis, Constantine Epstein, Arnold M. Department of Health Policy Harvard School of Public Health Boston MA 02115 677 Huntington Ave United States Department of Health Policy Massachusetts General Hospital Boston MA United States Division of Gen. Internal Medicine Section on Health Services Brigham and Women's Hospital Boston MA United States Division of Cardiology Vanderbilt University Medical Center Nashville TN United States Department of Statistics Brown University Providence RI United States Department of Health Care Policy Harvard Medical School Boston MA United States

Background: Physician adherence to guidelines is often poor, but the reasons have not been completely studied. We investigated whether physician adherence to guidelines for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) varied by source, development methods, or the extent of their evidence-base. Methods and Results: We assessed adherence to guidelines developed by the American College of Cardiology/American Heart Association (ACC/AHA) for PTCA (1988 and 1993) and for CABG (1990) and guidelines developed by RAND for PTCA and CABG in 1990. We randomly sampled patients on Medicare who were undergoing coronary angiography in 5 states in 1991 and 1992, extracting clinical and laboratory data from medical records and using computer programs to classify the appropriateness of each procedure. A total of 543 PTCA and 676 CABG procedures were studied. By use of the 1988 ACC/AHA guidelines, 30% of PTCAs were rated class III (inappropriate), whereas 24% were class III by use of the 1993 guidelines. Only 1.5% of CABG procedures were class III with ACC/AHA guidelines. By use of RAND guidelines, 12% of PTCA and 9% of CABG procedures were classified as inappropriate. Conclusions: Adherence to guidelines is higher when the recommendations are supported by evidence from randomized clinical trials (CABG). The credibility of the source and familiarity with the guidelines do not ensure compliance. When evidence is lacking, as with PTCA at the time of this study, guideline recommendations may lag behind appropriate changes in clinical practice. More frequent revisions coupled with on-line access have the potential to make guidelines more useful.

关键词：冠状动脉分流术/标准冠状动脉分流术/统计学和数值数据循证医学坚持准则/利用随机分配学会医学/组织和管理美国女(雌)性人类男(雄)性

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Physician adherence to clinical practice guidelines: Does it really matter?

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AMERICAN HEART JOURNAL 2003年第1期145卷 13-15页

作者： Brindis, RG Sennett, C Kaiser Permanente San Francisco Med Ctr San Francisco CA USA Amer Coll Cardiol Fdn Bethesda MD USA

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