Erica S. Spatz

What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study

BACKGROUND Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation. OBJECTIVE To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates. DESIGN Qualitative study that used site visits and in-depth interviews. SETTING Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics. PARTICIPANTS 158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals. MEASUREMENTS Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method. RESULTS Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals. LIMITATION The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed. CONCLUSION High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.

Statin myopathy: A common dilemma not reflected in clinical trials

Although statins are remarkably effective, they are still underprescribed because of concerns about muscle toxicity. We review the aspects of statin myopathy that are important to the primary care physician and provide a guide for evaluating patients on statins who present with muscle complaints. We outline the differential diagnosis, the risks and benefits of statin therapy in patients with possible toxicity, and the subsequent treatment options. When a patient taking a statin complains of muscle aches, is he or she experiencing statin-induced myopathy or some other problem? Should the statin be discontinued?

Loop Diuretic Efficiency A Metric of Diuretic Responsiveness With Prognostic Importance in Acute Decompensated Heart Failure

Background— Rather than the absolute dose of diuretic or urine output, the primary signal of interest when evaluating diuretic responsiveness is the efficiency with which the kidneys can produce urine after a given dose of diuretic. As a result, we hypothesized that a metric of diuretic efficiency (DE) would capture distinct prognostic information beyond that of raw fluid output or diuretic dose. Methods and Results— We independently analyzed 2 cohorts: (1) consecutive admissions at the University of Pennsylvania (Penn) with a primary discharge diagnosis of heart failure (n=657) and (2) patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) data set (n=390). DE was estimated as the net fluid output produced per 40 mg of furosemide equivalents, then dichotomized into high versus low DE based on the median value. There was only a moderate correlation between DE and both intravenous diuretic dose and net fluid output (r2⩽0.26 for all comparisons), indicating that DE was describing unique information. With the exception of metrics of renal function and preadmission diuretic therapy, traditional baseline characteristics, including right heart catheterization variables, were not consistently associated with DE. Low DE was associated with worsened survival even after adjusting for in-hospital diuretic dose, fluid output, in addition to baseline characteristics (Penn: hazards ratio [HR], 1.36; 95% confidence interval [CI], 1.04−1.78; P=0.02; ESCAPE: HR, 2.86; 95% CI, 1.53−5.36; P=0.001). Conclusions— Although in need of validation in less-selected populations, low DE during decongestive therapy portends poorer long-term outcomes above and beyond traditional prognostic factors in patients hospitalized with decompensated heart failure.Background— Rather than the absolute dose of diuretic or urine output, the primary signal of interest when evaluating diuretic responsiveness is the efficiency with which the kidneys can produce urine after a given dose of diuretic. As a result, we hypothesized that a metric of diuretic efficiency (DE) would capture distinct prognostic information beyond that of raw fluid output or diuretic dose. Methods and Results— We independently analyzed 2 cohorts: (1) consecutive admissions at the University of Pennsylvania (Penn) with a primary discharge diagnosis of heart failure (n=657) and (2) patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) data set (n=390). DE was estimated as the net fluid output produced per 40 mg of furosemide equivalents, then dichotomized into high versus low DE based on the median value. There was only a moderate correlation between DE and both intravenous diuretic dose and net fluid output (r2≤0.26 for all comparisons), indicating that DE was describing unique information. With the exception of metrics of renal function and preadmission diuretic therapy, traditional baseline characteristics, including right heart catheterization variables, were not consistently associated with DE. Low DE was associated with worsened survival even after adjusting for in-hospital diuretic dose, fluid output, in addition to baseline characteristics (Penn: hazards ratio [HR], 1.36; 95% confidence interval [CI], 1.04−1.78; P =0.02; ESCAPE: HR, 2.86; 95% CI, 1.53−5.36; P =0.001). Conclusions— Although in need of validation in less-selected populations, low DE during decongestive therapy portends poorer long-term outcomes above and beyond traditional prognostic factors in patients hospitalized with decompensated heart failure.

Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction

BACKGROUND Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs. OBJECTIVE To identify hospital strategies that were associated with lower RSMRs. DESIGN Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs. SETTING Acute care hospitals with an annualized AMI volume of at least 25 patients. PARTICIPANTS Patients hospitalized with AMI between 1 January 2008 and 31 December 2009. MEASUREMENTS Hospital performance improvement strategies, characteristics, and 30-day RSMRs. RESULTS In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies. LIMITATION The cross-sectional design demonstrates statistical associations but cannot establish causal relationships. CONCLUSION Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI. PRIMARY FUNDING SOURCE The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.

Sex Differences in Perceived Stress and Early Recovery in Young and Middle-Aged Patients With Acute Myocardial Infarction

Background— Younger age and female sex are both associated with greater mental stress in the general population, but limited data exist on the status of perceived stress in young and middle-aged patients presenting with acute myocardial infarction. Methods and Results— We examined sex difference in stress, contributing factors to this difference, and whether this difference helps explain sex-based disparities in 1-month recovery using data from 3572 patients with acute myocardial infarction (2397 women and 1175 men) 18 to 55 years of age. The average score of the 14-item Perceived Stress Scale at baseline was 23.4 for men and 27.0 for women (P<0.001). Higher stress in women was explained largely by sex differences in comorbidities, physical and mental health status, intrafamily conflict, caregiving demands, and financial hardship. After adjustment for demographic and clinical characteristics, women had worse recovery than men at 1 month after acute myocardial infarction, with mean differences in improvement score between women and men ranging from −0.04 for EuroQol utility index to −3.96 for angina-related quality of life (P<0.05 for all). Further adjustment for baseline stress reduced these sex-based differences in recovery to −0.03 to −3.63, which, however, remained statistically significant (P<0.05 for all). High stress at baseline was associated with significantly worse recovery in angina-specific and overall quality of life, as well as mental health status. The effect of baseline stress on recovery did not vary between men and women. Conclusions— Among young and middle-aged patients, higher stress at baseline is associated with worse recovery in multiple health outcomes after acute myocardial infarction. Women perceive greater psychological stress than men at baseline, which partially explains women’s worse recovery.

From Here to JUPITER Identifying New Patients for Statin Therapy Using Data From the 1999–2004 National Health and Nutrition Examination Survey

Background—Guidelines for statin use currently focus on patients with elevated low-density lipoprotein levels. Recent findings from the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER), however, indicate that statin therapy to reduce cardiovascular risk is also effective among older persons with at-goal low-density lipoprotein but elevated high-sensitivity C-reactive protein levels. We estimate the size of and describe this new population for whom statin therapy may now be indicated based on JUPITER’s findings. Methods and Results—Using data from the 1999 to 2004 National Health and Nutrition Examination Survey, we estimate that 57.9% of older adults (men ≥50 years and women ≥60 years), or 33 547 000 (95% CI, 32 217 000 to 34 877 000) Americans, are currently taking a statin (24.4%) or indicated for statin therapy (33.5%). In addition, we estimate that 19.2%, or 11 144 000 (95% CI, 10 053 000 to 12 235 000), may become newly eligible for statin therapy. This includes 8 071 000 (13.9%; 95% CI, 7 173 000 to 8 969 000) with high-sensitivity C-reactive protein ≥2 mg/L and low-density lipoprotein <130 mg/dL (ie, those meeting “strict” JUPITER criteria) and an additional 3 073 000 (5.3%; 95% CI, 2 404 000 to 3 743 000) with high-sensitivity C-reactive protein ≥2 mg/L and low-density lipoprotein of 130 to 160 mg/dL for whom JUPITER’s findings might reasonably be extended. Thus, ≈80% of older persons may now have an indication for statin therapy. Compared with those who would continue to have no indication for statin therapy, the JUPITER group was more likely to be female, to be older, and to have obesity, hypertension, and the metabolic syndrome. Conclusions—JUPITER’s findings have the potential to impact treatment recommendations for ≈20% of middle-aged to elderly adults, thus increasing the proportion of this segment of the population with an indication for statin therapy to nearly 80%.Background— Guidelines for statin use currently focus on patients with elevated low-density lipoprotein levels. Recent findings from the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER), however, indicate that statin therapy to reduce cardiovascular risk is also effective among older persons with at-goal low-density lipoprotein but elevated high-sensitivity C-reactive protein levels. We estimate the size of and describe this new population for whom statin therapy may now be indicated based on JUPITER’s findings. Methods and Results— Using data from the 1999 to 2004 National Health and Nutrition Examination Survey, we estimate that 57.9% of older adults (men ≥50 years and women ≥60 years), or 33 547 000 (95% CI, 32 217 000 to 34 877 000) Americans, are currently taking a statin (24.4%) or indicated for statin therapy (33.5%). In addition, we estimate that 19.2%, or 11 144 000 (95% CI, 10 053 000 to 12 235 000), may become newly eligible for statin therapy. This includes 8 071 000 (13.9%; 95% CI, 7 173 000 to 8 969 000) with high-sensitivity C-reactive protein ≥2 mg/L and low-density lipoprotein <130 mg/dL (ie, those meeting “strict” JUPITER criteria) and an additional 3 073 000 (5.3%; 95% CI, 2 404 000 to 3 743 000) with high-sensitivity C-reactive protein ≥2 mg/L and low-density lipoprotein of 130 to 160 mg/dL for whom JUPITER’s findings might reasonably be extended. Thus, ≈80% of older persons may now have an indication for statin therapy. Compared with those who would continue to have no indication for statin therapy, the JUPITER group was more likely to be female, to be older, and to have obesity, hypertension, and the metabolic syndrome. Conclusions— JUPITER’s findings have the potential to impact treatment recommendations for ≈20% of middle-aged to elderly adults, thus increasing the proportion of this segment of the population with an indication for statin therapy to nearly 80%. Received October 31, 2008; accepted November 19, 2008. # CLINICAL PERSPECTIVE {#article-title-2}

The New Era of Informed Consent: Getting to a Reasonable-Patient Standard Through Shared Decision Making

This Viewpoint discusses the benefits of developing a patient-centered informed consent standard and the resources it would take to achieve it in practice.

National Trends in Statin Use and Expenditures in the US Adult Population From 2002 to 2013: Insights From the Medical Expenditure Panel Survey

Importance Statins remain a mainstay in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD). Objective To detail the trends in use and total and out-of-pocket (OOP) expenditures associated with statins in a representative US adult population from 2002 to 2013. Design, Setting, and Participants This retrospective longitudinal cohort study was conducted from January 2002 to December 2013. Demographic, medical condition, and prescribed medicine information of adults 40 years and older between 2002 and 2013 were obtained from the Medical Expenditure Panel Survey database. Main Outcomes and Measures Estimated trends in statin use, total expenditure, and OOP share among the general adult population, those with established ASCVD, and those at risk for ASCVD. Costs were adjusted to 2013 US dollars using the Gross Domestic Product Index. Results From 2002 to 2013, more than 157 000 Medical Expenditure Panel Survey participants were eligible for the study (mean [SD] age, 57.7 [39.9] years; 52.1% female). Overall, statin use among US adults 40 years of age and older in the general population increased 79.8% from 21.8 million individuals (17.9%) in 2002-2003 (134 million prescriptions) to 39.2 million individuals (27.8%) in 2012-2013 (221 million prescriptions). Among those with established ASCVD, statin use was 49.8% and 58.1% in 2002-2003 and 2012-2013, respectively, and less than one-third were prescribed as a high-intensity dose. Across all subgroups, statin use was significantly lower in women (odds ratio, 0.81; 95% CI, 0.79-0.85), racial/ethnic minorities (odds ratio, 0.65; 95% CI, 0.61-0.70), and the uninsured (odds ratio, 0.33; 95% CI, 0.30-0.37). The proportion of generic statin use increased substantially, from 8.4% in 2002-2003 to 81.8% in 2012-2013. Gross domestic product–adjusted total cost for statins decreased from

Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project)

17.2 billion (OOP cost,

Beyond insurance coverage: Usual source of care in the treatment of hypertension and hypercholesterolemia. Data from the 2003-2006 National Health and Nutrition Examination Survey

7.6 billion) in 2002-2003 to