Bruce D. McCarthy

Missed diagnoses of acute myocardial infarction in the emergency department: Results from a multicenter study

STUDY OBJECTIVE To determine the rate of missed acute myocardial infarction (AMI) in the emergency department and the factors related to missed diagnoses. STUDY DESIGN Observational and case-control study. SETTING Data were analyzed from a multicenter study of coronary care unit admitting practices that included patients who presented to the ED with chest pain or other symptoms suggestive of acute cardiac ischemia (N = 5,773). Patients with missed AMI (cases) were compared with control patients admitted with AMI and to a second control group of patients discharged without AMI. RESULTS Of 1,050 patients with AMI, 20 (1.9%; 95% confidence interval, 1.2-2.9%) were not admitted. Patients with missed AMI were significantly less likely to have ECG changes and a history of AMI or nitroglycerin use than patients admitted with AMI. However, they were significantly more likely to have ECG changes than patients discharged without AMI. Five patients with missed AMI (25%) had ST-segment elevation, and seven (35%) were discharged with a diagnosis of ischemic heart disease by the physician in the ED. Death or potentially lethal complications occurred in 25% of missed AMI patients. CONCLUSION The rate of missed AMI in the ED was only 1.9%. However, 25% of these might have been prevented had ST-elevation not been missed, and another 25% might have been prevented had patients who were recognized to have ischemic heart disease by the physician in the ED been admitted.

Hypertension Knowledge, Awareness, and Attitudes in a Hypertensive Population

OBJECTIVE: Improved recognition of the importance of systolic blood pressure (SBP) has been identified as one of the major public health and medical challenges in the prevention and treatment of hypertension (HTN). SBP is a strong independent risk factor for cardiovascular disease but no information is available on whether patients understand the importance of their SBP level. The purpose of this study was to assess HTN knowledge, awareness, and attitudes, especially related to SBP in a hypertensive population.DESIGN/SETTING/PATIENTS: We identified patients with HTN (N=2,264) in the primary care setting of a large midwestern health system using automated claims data (International Classification of Diseases, Ninth Revision [ICD-9] codes 401.0–401.9). We randomly selected 1,250 patients and, after excluding ineligible patients, report the results on 826 completed patient telephone interviews (72% response rate [826/1,151]).MAIN RESULTS: Ninety percent of hypertensive patients knew that lowering blood pressure (BP) would improve health and 91% reported that a health care provider had told them that they have HTN or high BP. However, 41% of patients did not know their BP level. Eighty-two percent of all patients correctly identified the meaning of HTN as “high blood pressure.” Thirty-four percent of patients correctly identified SBP as the “top” number of their reading; 32% correctly identified diastolic blood pressure (DBP) as the “bottom” number; and, overall, only 30% of patients were able to correctly identify both systolic and diastolic BP measures. Twenty-seven percent of patients with elevated SBP and DBP (as indicated by their medical records) perceived that their BP was high. Twenty-four percent of patients did not know the optimal level for either SBP or DBP. When asked whether the DBP or SBP level was more important in the control and prevention of disease, 41% reported DBP, 13% reported SBP, 30% reported that both were important, and 17% did not know.CONCLUSIONS: These results suggest that, although general knowledge and awareness of HTN is adequate, patients do not have a comprehensive understanding of this condition. For instance, patients do not recognize the importance of elevated SBP levels or the current status of their BP control. An opportunity exists to focus patient education programs and interventions on the cardiovascular risk associated with uncontrolled HTN, particularly elevated SBP levels.

Prophylaxis for stress-related gastrointestinal hemorrhage: A cost effectiveness analysis

OBJECTIVE To assess the cost-effectiveness of prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to the intensive care unit. DESIGN Decision model of the cost and efficacy of sucralfate and cimetidine, two commonly used drugs for prophylaxis of stress-related hemorrhage. Outcome estimates were based on data from published studies. Cost data were based on cost of medications and costs of treatment protocols at our institutions. MEASUREMENTS AND MAIN RESULTS The marginal cost-effectiveness of prophylaxis, as compare with no prophylaxis, was calculated separately for sucralfate and cimetidine and expressed as cost per bleeding episode averted. An incremental cost-effectiveness analysis was subsequently employed to compare the two agents. Sensitivity analyses of the effects of the major clinical outcomes on the cost per bleeding episode averted were performed. At the base-case assumptions of 6% risk of developing stress-related hemorrhage and 50% risk-reduction due to prophylaxis, the cost of sucralfate was

Evaluation of factors potentially associated with inadequate follow-up of mammographic abnormalities

1,144 per bleeding episode averted. The cost per bleeding episode averted was highly dependent on the risk of hemorrhage and, to a lesser degree, on the efficacy of sucralfate prophylaxis, ranging from a cost per bleeding episode averted of

Influenza Immunization in a Managed Care Organization

103,725 for low-risk patients to cost savings for very high-risk patients. The cost per bleeding episode averted increased significantly if the risk of nosocomial pneumonia was included in the analysis. The effect of pneumonia was greater for populations at low risk of hemorrhage. Assuming equal efficacy, the cost per bleeding episode averted of cimetidine was 6.5-fold greater than the cost per bleeding episode averted of sucralfate. CONCLUSIONS The cost of prophylaxis in patients at low risk of stress-related hemorrhage is substantial, and may be prohibitive. Further research is needed to identify patient populations that are at high risk of developing stress-related hemorrhage, and to determine whether prophylaxis increases the risk of nosocomial pneumonia.

Barriers to the initiation of, and persistence with, insulin therapy

To increase the proportion of women who receive the recommended follow‐up for mammographic abnormalities, factors which inhibit follow‐up must be identified. Patient and health care delivery related factors were evaluated, stratified by type of follow‐up recommendation, to determine reasons for inadequate follow‐up.

The use of computerized birthday greeting reminders in the management of diabetes

OBJECTIVE: To compare the effects of different types of computer-generated, mailed reminders on the rate of influenza immunization and to analyze the relative cost-effectiveness of the reminders. DESIGN: Randomized controlled trial. SETTING: Multispeciality group practice. PATIENTS: We studied 24,743 high-risk adult patients aligned with a primary care physician. INTERVENTION: Patients were randomized to one of four interventions: (1) no reminder, which served as control; (2) a generic postcard; (3) a personalized postcard from their physician; and (4) a personalized letter from their physician, tailored to their health risk. MEASUREMENTS: The immunization rate was measured using billing data. A telephone survey was conducted in a subgroup of patients to measure reactions to the mailed reminders. To evaluate the cost-effectiveness, a model was constructed that integrated the observed effect of the interventions with published data on the effect of immunization on future inpatient health care costs. MAIN RESULTS: All three of the reminders studied increased the influenza vaccination rate when compared with the control group. The vaccination rate was 40.6% in the control group, 43.5% in the generic postcard group, 44.7% in the personalized postcard group, and 45.2% in the tailored letter group. The rates of immunization increased as the intensity of the intervention increased (p < .0001). Seventy-eight percent of patients in the letter group deemed the intervention useful, and 86% reported that they would like to get reminders in the future. The cost-effectiveness analysis estimated that in a nonepidemic year, the net savings per 100 reminders sent would be

Sustained Hyperglycemia Among Patients With Diabetes What matters when action is needed

659 for the personalized postcard intervention and

Continuously improving primary care.

735 for the tailored letter intervention. When these net cost-savings rates were each applied to the entire high-risk cohort of 24,743 patients, the estimated total net savings was

PDB54 FACTORS ASSOCIATED WITH CONTINUED CLINICAL INERTIA AMONG PATIENTS WITH TYPE 2 DIABETES

162,940 for the postcard and