Deborah A. Taira

The Primary Care Assessment Survey: tests of data quality and measurement performance.

OBJECTIVES The authors examine the data quality and measurement performance of the Primary Care Assessment Survey (PCAS), a patient-completed questionnaire that operationalizes formal definitions of primary care, including the definition recently proposed by the Institute of Medicine Committee on the Future of Primary Care. METHODS The PCAS measures seven domains of care through 11 summary scales: accessibility (organizational, financial), continuity (longitudinal, visit-based), comprehensiveness (contextual knowledge of patient, preventive counseling), integration, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Data from a study of Massachusetts state employees (n = 6094) were used to evaluate key measurement properties of the 11 PCAS scales. Analyses were performed on the combined population and for each of the 16 subgroups defined according to sociodemographic and health characteristics. RESULTS The 11 PCAS scales demonstrated consistently strong measurement characteristics across all subgroups of this adult population. Tests of scaling assumptions for summated rating scales were well satisfied by all Likert-scaled measures. Assessment of data completeness, scale score dispersion characteristics, and inter-scale correlations provide strong evidence for the soundness of all scales, and for the value of separately measuring and interpreting these concepts. CONCLUSIONS With public and private sector policies increasingly emphasizing the importance of primary care, the need for tools to evaluate and improve primary care performance is clear. The PCAS has excellent measurement properties, and performs consistently well across varied segments of the adult population. Widespread application of an assessment methodology, such as the PCAS, will afford an empiric basis through which to measure, monitor, and continuously improve primary care.

Percutaneous coronary revascularization in Elderly patients: Impact on functional status and quality of life

Ischemic heart disease affects more than 25% of persons older than 65 years of age in the United States. Although elderly patients with coronary artery disease tend to be treated less aggressively than nonelderly patients, the use of percutaneous coronary intervention (PCI) in the elderly is increasing rapidly; it more than doubled between 1979 and 1986 (1). Previous studies have examined the risks for PCI-related complications among elderly patients and found that elderly patients have a higher risk for vascular complications and in-hospital death than younger patients (2). Nonetheless, little is known about the critical outcomes of these procedures from the patients perspective. Although short- and long-term mortality rates are important outcomes to consider, PCI is generally done to improve the patients quality of life by relieving the signs and symptoms of myocardial ischemia. Improvement in quality of life may be particularly germane to older patients, for whom competing risks tend to limit any potential gains in longevity (3). We examined changes in health-related quality of life among elderly patients after PCI and compared these changes with those in nonelderly patients. Methods Study Sample Patients in this study had PCI as part of two randomized multicenter clinical trials: the Balloon versus Optimal Atherectomy Trial (BOAT; n =989), which compared directional atherectomy with balloon angioplasty (4), and the Advanced Cardiovascular System Multi-Link-Stent System Trial (ASCENT; n =1040), which compared the ACS Multi-Link stent to the PalmazSchatz stent (5). Only patients enrolled in U.S. hospitals who completed a baseline health-related quality-of-life survey (n =1789) were eligible for our substudy. Inclusion and exclusion criteria for the trials were similar. All patients had symptomatic coronary artery disease that required percutaneous revascularization of a single native coronary artery. Patients with a myocardial infarction within 5 days of treatment, stroke within the preceding 3 months, bifurcation lesions, or severe proximal tortuosity were excluded. The institutional review boards of each institution approved the studies, and all patients provided informed consent before participation. Quality-of-Life Assessment Health-related quality of life was assessed by using the physical and mental health summary scales of the Medical Outcomes Study Short-Form Survey (SF-36) (6, 7). These summary scales are standardized such that the mean ( SD) for the U.S. population is 50 10. Higher scores indicate better health. Patients in ASCENT also completed the Seattle Angina Questionnaire (SAQ), a validated disease-specific instrument that measures five health-related quality-of-life domains specific for coronary artery disease (physical functioning, anginal stability, anginal frequency, disease perception, and treatment satisfaction) (8, 9). The SAQ scores range from 0 to 100, and higher scores indicate better levels of functioning (that is, less physical limitation and less frequent angina). Baseline health-related quality of life was assessed by using self-administered questionnaires that were completed immediately before the index revascularization procedure. Follow-up measurements were obtained by surveys mailed to participants 6 months and 1 year after initial treatment. Patients who did not respond to the mailed survey within 2 weeks were administered the same instrument by telephone when possible. Statistical Analysis Baseline patient characteristics of elderly ( 70 years of age) and nonelderly (<70 years of age) patients were compared by using t-tests and Wilcoxon rank-sum tests for continuous variables and Fisher exact tests for categorical variables. Logistic regression was used to determine whether the likelihood of substantial improvement in health-related quality of life after PCI differed between elderly and nonelderly patients (10). For each health-related quality-of-life scale, each patient was classified as improved or not improved according to the level of change at which patients in previous studies had reported substantial improvement. Previous studies involving the SF-36 have demonstrated that changes in the physical component score of 3.8 points or more and changes in the mental component score of 7.2 points or more were meaningful to patients (6). For the SAQ subscales, an improvement of 10 or more points has been found to correlate with clinically meaningful changes (9) and was used to classify patients as improved or not improved for our analysis. Each regression model adjusted for patient demographic characteristics (sex, marital status, education, race or ethnicity) and medical conditions (previous myocardial infarction, congestive heart failure, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, arthritis, vision problems, number of comorbid conditions, smoking status). Standardized predicted probabilities derived from these models were used to estimate the percentage of patients in each age group who were expected to demonstrate substantial improvement after PCI. We also calculated standardized risk differences and associated confidence intervals (11). The main results were not altered in analyses that adjusted for clustering (data not shown). All analyses were done by using Stata software, version 6.0 (Stata Corp., College Station, Texas). P values less than 0.05 were considered statistically significant. Significance tests were not adjusted for multiple comparisons. All data were collected and analyzed by an independent data coordinating center (Cardiovascular Data Analysis Center, Boston, Massachusetts), without direct input from the study sponsor. Twenty percent of the data were missing because of patient nonresponse at follow-up. To examine whether our results were sensitive to differences between respondents and nonrespondents, we imputed the change scores of nonrespondents by using multiple imputation techniques (12) and re-estimated the models for the full study sample. Because the results of these sensitivity analyses were similar to our primary results, we report only the primary results. Results Of the patients who completed the baseline survey, 1445 (80%) completed the 6-month follow-up survey. These patients made up our analytic cohort. Compared with nonrespondents, respondents were more likely to be nonwhite and unmarried and were less likely to have congestive heart failure. Among respondents, the median age of the nonelderly group was 57 years (range, 38 to 69 years) and the median age of the elderly group was 74 years (range, 70 to 89 years). Compared with nonelderly patients, elderly patients were more likely to be female, white, and unmarried and were less well-educated. Elderly patients were less likely to smoke cigarettes but were more likely to have hypertension and congestive heart failure and had more comorbid conditions (data not shown). Clinical Events During the initial hospitalization and 1-year follow-up period, the incidence of major adverse cardiac events, including myocardial infarction, bypass surgery, and repeated PCI, was low in both groups. However, during the initial hospitalization, older patients were more likely than younger patients to sustain a major vascular complication (3.7% compared with 1.7%; P =0.04). Effect of Percutaneous Coronary Intervention on Health-Related Quality of Life At baseline, both elderly and nonelderly patients had substantial impairments in physical health and modest impairments in mental health relative to the overall U.S. population (Table). The SAQ subscales also demonstrated substantial physical limitations and impaired quality of life due to angina in both age groups. At 6-month follow-up, both elderly and nonelderly patients demonstrated substantial improvement in each quality-of-life domain, and these gains persisted at 1 year (Table). At both 6 months and 1 year, approximately 60% of patients reported no angina. Table. Distribution of Health-Related Quality-of-Life Scores at Baseline, 6 Months, and 1 Year In adjusted analyses, the change in health-related quality of life associated with PCI did not significantly differ between elderly and nonelderly patients (Figure). At 6-month follow-up, physical health improved substantially for 51% of elderly patients and 58% of nonelderly patients (difference, 7 percentage points [95% CI, 15 to 1 percentage point]). Similarly, mental health improved substantially for 29% of elderly patients and 30% of nonelderly patients (difference, 1 percentage point [CI, 9 to 6 percentage points]). At 6-month follow-up, most patients demonstrated substantial improvement in all three aspects of disease-specific quality of life, with nearly identical benefits regardless of age. Physical limitations related to angina improved substantially for 58% of elderly patients and 54% of younger patients (difference, 4 percentage points [CI, 7 to 13 percentage points]). Elderly and nonelderly patients demonstrated similar rates of improvement in frequency of angina (75% compared with 74% [difference, 1 percentage point; CI, 6 to 10 percentage points]) and in disease burden (77% compared with 71% [difference, 6 percentage points; CI, 6 to 10 percentage points]). Only 4% to 13% of patients reported meaningful declines in cardiovascular-specific quality of life, and the proportion did not vary with age. Similar changes were observed at 1-year follow-up as well (data not shown). Figure. Standardized estimates of the percentage of patients expected to have improvements in health-related quality of life ( QOL ) 6 months after percutaneous coronary intervention, according to age. Discussion We found that PCI resulted in substantial population-level benefits for elderly patients with regard to both physical and mental health as well as reductions in physical limitations due to angina, frequency of angina, and the perceived burden of coronary artery disease. During 6- to 12-

Cost-Effectiveness of Transesophageal Echocardiographic-Guided Cardioversion: A Decision Analytic Model for Patients Admitted to the Hospital With Atrial Fibrillation ☆

OBJECTIVES Using a decision-analytic model, we sought to examine the cost-effectiveness of three strategies for cardioversion of patients admitted to the hospital with atrial fibrillation. BACKGROUND Transesophageal echocardiographic (TEE)-guided cardioversion has been proposed as a method for early cardioversion of patients with atrial fibrillation. The cost-effectiveness of this approach, relative to conventional therapy, has not been studied. METHODS We ascertained the cost per quality-adjusted life-year (QALY) of three strategies: 1) conventional therapy--transthoracic echocardiography (TTE) and warfarin therapy for 1 month before cardioversion; 2) initial TTE, followed by TEE and early cardioversion if no thrombus is detected; 3) initial TEE, with early cardioversion if no thrombus is detected. With strategies 2 and 3, if a thrombus is seen, follow-up TEE is performed. If no thrombus is seen, cardioversion is then performed. All strategies utilized anticoagulation before and extending for 1 month after cardioversion. Life expectancy, utilities (quality-of-life weights) and event probabilities were ascertained from published reports. Cost estimates were based on published data and hospital accounting information. RESULTS Transesophageal echocardiographic-guided early cardioversion (strategy 3: cost

Influenza vaccination, hospitalizations, and costs among members of a Medicare managed care plan.

2,774, QALY 8.49) dominates TTE/TEE-guided cardioversion (strategy 2: cost

Effect of physician gender on the prescription of estrogen replacement therapy

3,106, QALY 8.48) and conventional therapy (strategy 1: cost

Seasonal variation in coronary artery disease mortality in Hawaii : observational study

3,070, QALY 8.48) because it is the least costly with similar effectiveness. Sensitivity analyses demonstrated that TEE-guided cardioversion (strategy 3) dominates conventional therapy if the risk of stroke after TEE negative for atrial thrombus is slightly less than that after conventional therapy (baseline estimate 0.8%). The results also depend on the risk of major hemorrhage but are less sensitive to baseline estimates of morbidity from TEE, cost of TTE, cost of hospital admission for cardioversion and utilities for health states. CONCLUSIONS On the basis of a decision-analytic model, TEE-guided early cardioversion, without TTE, is a reasonable cost-saving alternative to conventional therapy for patients admitted to the hospital with atrial fibrillation. Such a strategy appears particularly beneficial for patients with an increased risk of hemorrhagic complications. Future clinical studies examining the TEE strategy should consider eliminating initial TTE and carefully assess both the thromboembolic and hemorrhagic risk.

Cardioversion in Patients with Atrial Fibrillation and Left Atrial Thrombi on Initial Transesophageal Echocardiography: Should Transesophageal Echocardiography Be Repeated Before Elective Cardioversion? A Cost-Effectiveness Analysis

Objective. To evaluate the effectiveness and possible cost savings of influenza vaccination. Subjects. Members age 65 and older in a Medicare managed care plan during the 1994–1995, 1995–1996, and 1996–1997 influenza seasons. Research Design. The study examined administrative data on influenza vaccination and subsequent hospitalizations. Outcomes included hospitalization with pneumonia or influenza, with any respiratory condition, and with congestive heart failure (CHF). Results. Vaccinated subjects experienced fewer hospitalizations with respiratory conditions or CHF than had unvaccinated subjects (OR=0.8 (95% CI, 0.7, 0.9) in analyses adjusted for age, sex, pneumococcal vaccination, health utilization, and morbidity). Analyses adjusted in addition for ethnicity obtained similar results among the subgroup of members whose ethnicity was known. Subjects without major disease in the previous 12 months had lower odds ratios for vaccination than subjects with major disease (OR values of 0.5 [95% CI, 0.4, 0.7] and 0.9 [95% CI, 0.8, 1.1], respectively). Subjects ages 65 to 79 had lower odds ratios for vaccination than subjects ages 80 and older (OR values of 0.7 [95% CI, 0.6, 0.9] and 0.9 [95% CI, 0.8, 1.1], respectively). Estimated cost savings averaged about

954-1 Cost-Effectiveness of Early Cardioversion Guided by Transesophageal Echocardiography for Hospitalized Patients with Atrial Fibrillation

80 per vaccinated subject. Conclusions. Subjects ages 65 to 79 who had received influenza vaccination experienced fewer hospitalizations and had lower costs than had unvaccinated subjects. Associations were weaker for subjects age 80 and older. The results, consistent with recommendations for the use of influenza vaccine, suggest that people ages 65 to 79 should be heavily targeted for vaccination.

The impact of seeing physicians new to a patient on the response to screening reminders.

OBJECTIVE: To determine if women cared for by female physicians are more likely to receive postmenopausal estrogen replacement therapy than women cared for by male physicians.DESIGN: Case-control study with follow-up telephone survey.SETTING: An outpatient practice at an urban teaching hospital in Boston, Massachusetts.PARTICIPANTS: Subjects were women begun on estrogen replacement therapy during an 18-month period; controls were matched on age and month of visit. Seventy-one cases (mean age 60 years, 41% nonwhite) and 142 controls (mean age 60 years, 48% nonwhite) were identified. Fifty-two (82%) of 64 eligible case patients and 89 (80%) of 111 eligible control patients completed a follow-up telephone interview assessing their preferences for female physicians and interest in estrogen replacement therapy.MAIN RESULTS: After adjusting for potential confounders using conditional logistic regression, patients with female physicians were more likely to begin estrogen replacement therapy than those seen by male physicians (odds ratio [OR] 5.4; 95% confidence interval [CIJ 1.8, 15.3). Case patients selected their primary care physician more often than control patients and were more interested in estrogen replacement therapy. After adjusting for potential confounders including patients’ preferences to select their physician and their interest in estrogen replacement therapy, patients with female physicians were still more likely to begin estrogen replacement therapy than those seen by male physicians (OR 11.4, 95% CI 1.1, 113.6).CONCLUSIONS: We conclude that female patients are more likely to be prescribed estrogen replacement therapy if they are cared for by female physicians rather than male physicians even after accounting for patient preferences. Further research is required to determine whether these differences reflect differences in physicians’ knowledge or attitudes regarding estrogen replacement therapy or reflect gender differences in how physicians discuss estrogen replacement therapy with their patients.

Patient “Dumping” of Poor Families

A seasonal variation in cardiac mortality has been noted in both the northern 1 2 and southern3 hemispheres, with higher death rates during winter than summer. Previous studies reporting seasonal variation in mortality from coronary artery disease examined data from regions with distinct seasonal changes in temperature. To determine whether seasonality in mortality exists in a tropical climate with little variation in temperature we examined the monthly mortality from coronary artery disease among residents of Hawaii. Hawaii consists of six main islands, with a population of 1.1 million.4 We obtained monthly rates of deaths from coronary artery disease (ICD-9 410-414) as recorded on death certificates during 1984-93 from the state of Hawaii. All non-residents of Hawaii were excluded. Because the likelihood of a diagnosis of a respiratory infection might vary by season, we used mortality from …