David Bruckman

Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection (IRAD).

For acute aortic dissection, CT is selected most frequently worldwide as the initial test, followed by TEE. Aortography and MRI are performed much less often. More than two thirds of the patients required ≥2 imaging tests.

Iatrogenic aortic dissection

Given the difference in risk factors, clinical presentation, and outcomes, clinicians should be vigilant for the presence of iatrogenic AD, particularly in those patients with unexplained hemodynamic instability or myocardial ischemia following invasive vascular procedures or CABG.

Effect of postoperative atrial fibrillation on length of stay after cardiac surgery (the postoperative atrial fibrillation in cardiac surgery study [PACS2])

Atrial fibrillation (AF) after cardiac surgery is thought to increase length of stay (LOS). A clinical pathway focused on the management of postoperative AF, including prophylaxis with beta blockers, was implemented to assess the effect of AF on LOS after cardiac surgery. Data were obtained on consecutive cardiac surgery patients in preoperative normal sinus rhythm, no prior history of AF, and no chronic antiarrhythmic therapy from January to May 1995 (control) and November 1996 to June 1997 (pathway). Statistical analysis was performed to assess the effect of postoperative AF on the LOS, clinical outcomes, and cost after cardiac surgery. Despite the clinical pathway, the LOS (7 days for both periods; p = 0.12) and incidence of AF (28.9% vs 28.4%; p = 0.92) remained unchanged. Unadjusted direct costs were 15% higher in the pathway period (p <0.001). Increased rates of beta-blocker therapy had a marginal effect on the incidence of postoperative AF, except in the group who only underwent primary coronary artery bypass graft surgery (31.2% vs 25.3%; p = 0.31). Multivariate analysis revealed that AF contributed only 1 to 1.5 days to the LOS. Thus, this investigation represents the most recent analysis of the effects of postoperative AF on LOS, clinical outcomes, and cost after cardiac surgery. Unlike prior studies, the impact of postoperative AF is less prominent in the current era of cardiac surgical care regardless of the presence of a clinical pathway addressing AF.

Complete atrioventricular block after valvular heart surgery and the timing of pacemaker implantation

The natural history of patients who developed complete atrioventricular block after valvular heart surgery was investigated to determine the optimal timing for pacemaker implantation. Patients who developed complete atrioventricular block within 24 hours after operation, which then persisted for > 48 hours, were unlikely to recover; such patients could potentially undergo earlier pacemaker implantation if otherwise ready for discharge.

Association Between Outpatient Follow-Up and Pediatric Emergency Department Asthma Visits

Background. The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. Objective. To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. Design. We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from 01 1998 to 10 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. Results: A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. Conclusions. Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits.

Documentation of Asthma Severity in Pediatric Outpatient Clinics

National asthma guidelines recommend assessment and documentation of asthma severity at each clinic visit. A cross-sectional medical record review was conducted, which found that only 34% of records had any documentation of severity in the previous 2 years. However, severity documentation is associated with other indicators of quality care such as receipt of an action plan, spacer device, peak flow meter, asthma education, and influenza vaccination. These results suggest that use of a system for classifying asthma severity compels the physician to consider the long-term management of asthma, rather than just acute treatment of the disease. Interventions to improve physician practice should continue to emphasize severity assessment.

Receipt of Asthma Subspecialty Care by Children in a Managed Care Organization

BACKGROUND Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting. OBJECTIVE To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization. METHODS We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist. RESULTS Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist. CONCLUSIONS Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.

Prevalence and distribution of corrective lenses among school-age children.

Background. No population-based data are available regarding the proportion of school-age children who have corrective lenses in the U.S. The objective of this study was to quantify the proportion of children who have corrective lenses (glasses or contact lenses) and to evaluate the association of corrective lenses with age, gender, race/ethnicity, health insurance status, and family income. Methods. Children 6 to 18 years of age were identified in the 1998 Medical Expenditure Panel Survey. National estimates were made of the proportion with corrective lenses. Logistic regression modeling was used to assess factors that were associated with corrective lenses. Results. Based on the 5,141 children in the 1988 Medical Expenditure Panel Survey, an estimated 25.4% of the 52.6 million children between 6 and 18 years had corrective lenses. Girls had greater odds than boys of having corrective lenses (odds ratio, 1.41; p < 0.001). Insured children, regardless of race/ethnicity, and uninsured nonblack/non-Hispanic children had similar odds of having corrective lenses. Compared with uninsured black or Hispanic children (odds ratio, 1), greater odds of corrective lens use was found among uninsured nonblack/non-Hispanic children (odds ratio, 2.29; p = 0.002) and black or Hispanic children with public (odds ratio, 1.67; p = 0.005) or private health insurance (odds ratio,1.77; p = 0.004). Among families with an income ≥200% of the federal poverty level, the odds of having corrective lenses increased with age (p ≤ 0.04). In contrast, among those families <200% of the federal poverty level, the odds of having corrective lenses at 12 to 14 years was similar to 15- to 18-year olds (p = 0.93). Conclusions. The use of corrective lenses suggests that correctable visual impairment is the most common treatable chronic condition of childhood. Income, gender, and race/ethnicity, depending on insurance status, are associated with having corrective lenses. The underlying causes and the impacts of these differences must be understood to ensure optimal delivery of eye care.

Effects of end-of-month admission on length of stay and quality of care among inpatients with myocardial infarction

PURPOSE We studied whether transfer of care when house staff and faculty switch services affects length of stay or quality of care among hospitalized patients. SUBJECTS AND METHODS We performed a retrospective analysis in 976 consecutive patients admitted with myocardial infarction from 1995 to 1998. Patients who were admitted within 3 days of change in staff were denoted end-of-month patients. RESULTS Of 782 eligible patients, 690 (88%) were admitted midmonth and 92 (12%) at the end of the month. The median length of stay was 7 days for midmonth and 8 days for end-of-month patients (P = 0.06). End-of-month admission was an independent predictor of length of stay in multivariate models. In addition, a significant difference in length of stay was noted between patients admitted at the beginning and end of the academic year. There were no statistically significant differences in the use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, or lipid-lowering agents at discharge between midmonth and end-of-month patients. Mortality and in-hospital adverse events did not differ between the two groups, with the possible exception of a greater incidence of acute renal failure in the end-of-month patients. CONCLUSIONS Although admission during the last 3 days of the month is an independent predictor of length of stay, it does not have a large effect on quality of care among patients with myocardial infarction.

Atrial fibrillation after coronary surgery: comparison between different health care systems

AIMS No studies have evaluated the influence of management strategies in different health insurance environments on atrial fibrillation (AF). This observational study compared the incidence of and treatment strategies for postoperative AF after primary coronary bypass surgery. METHODS AND RESULTS One insurance and one public funded location was compared: University of Michigan Health Center (USA, n=272) and Tampere University Hospital (Finland, n=314). USA patients had more co-morbidities and were treated more aggressively after acute myocardial infarction. More Finns were on beta-blockers both preoperatively (93 vs. 68%, P<0.001) and postoperatively (97 vs. 66%, P<0.001). However, AF was more frequent among Finns (38 vs. 29%, P=0.037) and present on 4.6% of cases when transferred postoperatively. No USA patients had AF at time of discharge. Mean length of stay was 8.6 days at USA, and not affected by AF. The incidence of in-hospital death, strokes and multiorgan failures was similar. Multivariable analysis, adjusted for site and selection biases (propensity analysis) revealed increasing age [OR=1.063 (1.042, 1.084), P<0.0001] and use of radial arteries [OR=2.175 (1.071, 4.417), P=0.032) to be independent predictors to the incidence of postoperative AF. CONCLUSIONS We found several major differences in patient selection and treatment strategies among primary coronary bypass patients managed in the two institutions. Despite the marked practice variation, the incidence of postoperative AF was rather similar. Despite routine use of beta-blockers, AF occurred in 29-38% of patients. However, the length of stay was not particularly affected by postoperative AF.