Fred T. Nobrega

Is Percutaneous Coronary Angioplasty Less Expensive Than Bypass Surgery

Percutaneous transluminal coronary angioplasty is widely considered to be an acceptable and less expensive alternative to bypass surgery in carefully selected patients. We compared expenditures related to cardiac care for 79 unselected patients undergoing coronary angioplasty with expenditures for 89 unselected patients undergoing elective coronary bypass surgery without a previous attempt at angioplasty. All the patients had single-vessel disease. The mean aggregate one-year monetary outlay was 15 per cent lower in the angioplasty group than in the bypass-surgery group. A major component of the expense of angioplasty was the treatment of restenosis in the 33 per cent of patients in this group in whom this late complication occurred. We conclude that percutaneous transluminal coronary angioplasty has potential for reducing expenditures for cardiac revascularization and that a further reduction may be obtainable when the rates of restenosis are improved.

Quality assessment in hypertension: analysis of process and outcome methods.

Despite efforts to develop methods for measuring the quality of medical care, no satisfactory mechanism has been established. Our study, using hypertension as a clinical model, evaluated process and outcomes separately and then compared the two. Physician adherence to an extensive process list varied substantially from established criteria. No statistically significant association was detected between process and outcome. Regression analysis examined the relation between outcome diastolic pressure and 12 predictive variables that included patient satisfaction and social class. The only statistically significant variables (P less than 0.05) related to outcome blood pressure were age, initial blood pressure and weight. The inability to identify a relation between various process items and outcome suggests that, in determining a successful outcome for hypertensive patients, the selective use of process by the physician may be more effective than adherence to a rigid criteria list.

Acute and Chronic Pancreatitis in Rochester, Minnesota, 1940 To 1969

Records of all residents of Rochester; Minnesota, who had acute and chronic pancreatitis between 1940 and 1969 were reviewed and abstracted; 151 clinical cases had been diagnosed, and 170 more were included as examples of incidental pancreatitis noted at laparotomy or autopsy. Incidence rates based only on the clinical cases revealed an increased incidence from the first to the second decade, but the rates during the last two decades remained fairly stable. These rates are thought to be minimal in view of the difficulties in diagnosing pancreatitis. Incidence rates of acute pancreatitis did not differ by sex during the last two decades, although among men there was a slightly greater role of chronic pancreatitis. Age-specific rates showed a gradual rise from 4 per 100,000, for those younger than 30, to 62 per 100,000, for those over 70 years old. Acute pancreatitis is more frequent than chronic pancreatitis in a ratio of slightly more than 3:1. Etiologically, biliary tract disease was present in 37% of the patients and alcohol abuse was identified in 19%. Nine clinical cases of pancreatitis had pre-existing diabetes mellitus, and 10 subsequently developed the disease. The association of these two diseases was appreciably greater than would be expected by chance.

Inflammatory colon disease in Rochester, Minnesota, 1935-1964.

The medical records of the residents of Rochester, Minnesota, who depend largely on the Mayo Clinic for their , medical care, offer a unique opportunity to study the epidemiology of inflammatory disease of the colon over a 30-year period from 1935 through 1964. Local residents with this condition were divided into the following four arbitrary but distinct anatomic groups: type A, transient proctitis; type B, chronic or recurrent proctitis; type C, typical mucosal ulcerative colitis involving the rectum and continuous portions of the colon above the proctoscopic level; and type D, segmental disease (largely Crohns disease of the colon). During the study period the disease was newly diagnosed in 108 residents and, in an additional 32 patients who took up residence after the diagnosis had been established. Of the 108 cases, 23 (21%) were type A, 35 (32%) were type B, 31 (29%) were type C, and 19 (18%) were type D. The average annual incidence rate for all four types combined was 11.8 per 100,000 with rates for the four subtypes of 2.5, 3.8, 3.4, and 2.1 per 100,000, respectively. Incidence rates over the 30-year period showed a slight rise for all types except D. Fifty-three per cent of all cases represented disease which never progressed beyond proctoscopic level. Carcinoma of the colon occurred subsequently in 5 cases, all type C, which was a significantly higher number than would be expected in the general population.

Assessment of Prediction of Mortality by Using the APACHE II Scoring System in Intensive-Care Units

Some investigators have suggested that information on quality of care in intensive-care units (ICUs) may be inferred from mortality rates. Specifically, the ratio of actual to predicted hospital mortality (A/P) has been proposed as a valid measure for comparing ICU outcomes when predicted mortality has been derived from data collected during the first 24 hours of ICU therapy with use of a severity scoring tool, APACHE II (acute physiology and chronic health evaluation). We present a comparison of mortality ratios (A/P) in four ICUs under common management, in two hospitals within a single institution. Significant differences in A/P were detected for nonoperative patients (0.99 versus 0.67;P = 0.014) between the two hospitals. This variation was traced to uneven representation of a subset of patients who had chronic health problems related to diseases that necessitated admission to the hematology-oncology or hepatology service. No differences in A/P were seen between the two hospitals for operative patients or for nonoperative patients on services other than hematology-oncology or hepatology. Thus, differences in A/P detected by using the APACHE II system not only may reside in operational factors within the ICU organization but also may be related to weaknesses in the APACHE II model to measure factors intrinsic to the disease process in some patients. We suggest that case-mix must be examined in detail before concluding that differences in A/P are caused by differences in quality of care.

Cardiac-catheterization and cardiac-surgical facilities: use, trends, and future requirements.

Cardiac catheterizations and cardiac operations were evaluated in the population of Olmsted County, Minnesota, from 1973 through 1980, and trends in this region were compared with nationwide trends based on data from several sources. The rates of coronary arteriography and coronary-artery bypass operations in Olmsted county have increased over time, but overall, the rates of catheterization and operation appeared to be leveling off. For the country as a whole, the data appear to show similar trends, but there are wide differences among regions in the rates of operation and catheterization. In 1980 40 per cent of hospitals with cardiac-catheterization laboratories and 55 per cent of those with facilities for open-heart surgery were doing fewer than the suggested minimum numbers of these procedures necessary to achieve optimum results. The data support the view that further growth in the number of cardiac centers should be avoided. We believe there is a need for continued evaluation of the use of cardiac services if quality is to be protected and costs controlled.

Initial functional and economic status of patients with multivessel coronary artery disease randomized in the Bypass angioplasty revascularization investigation (BARI)

Randomized trials of coronary angioplasty and bypass surgery have hypothesized that these procedures will have equivalent long-term rates of death and myocardial infarction. Functional status, quality of life, employment, and healthcare cost will therefore be critical measures of the efficacy of these alternative revascularization procedures. Patients at 7 sites in the Bypass Angioplasty Revascularization Investigation (BARI) were enrolled in an ancillary Study of Economics and Quality of Life (SEQOL). Physical function was assessed by the Duke Activity Status Index and emotional status by the Mental Health Inventory. Employment patterns and health care utilization were also measured at study entry and at 3-month intervals in follow-up. The 934 patients enrolled in SEQOL were similar to the 895 remaining BARI randomized patients. Most patients (63%) aged < or = 64 years were working, and almost all working patients (96%) intended to return to work. Patients aged > or = 65 years had lower household incomes but better health insurance coverage. Overall health ratings were significantly correlated with both physical and emotional status (p < 0.001). Patients enrolled in SEQOL are representative of the overall BARI population. Data collected in SEQOL will provide a detailed picture of the physical, emotional, and economic well-being after coronary angioplasty and bypass surgery.

Utilization Trends and Risk Factors for Hospitalization in Diabetes Mellitus

A population-based prevalence cohort of 1,111 residents of Rochester, Minnesota, who had diabetes mellitus on Jan. 1, 1975, was subjected to follow-up assessment for hospitalizations through Dec. 31, 1980. On the basis of these data, hospitalization rates were calculated for various clinical types of diabetes, and a risk factor analysis was done for non-insulin-dependent diabetes mellitus (NIDDM) to identify high-risk persons for subsequent intervention studies. The adjusted incidence density of hospitalization was 141.6 per 1,000 person-years for NIDDM and 331.3 per 1,000 person-years for insulin-dependent diabetes. Although the modeled clinical characteristics accounted for little variability in NIDDM-related hospitalization, age modified by the effect of gender was the strongest risk factor found (multivariate hazard ratios: 1.0 and 1.43, respectively, for male and female patients younger than 65 years old; 1.88 and 1.83, respectively, for male and female patients 65 years old or older); coronary heart disease, diabetic retinopathy, and persistent proteinuria were associated with a 50% increased risk. Although older patients with NIDDM (especially men) are at greatest risk for a first hospitalization, clinical factors alone seem inadequate to account for these hospitalizations. The effect of Medicares prospective payment systems (PPS) was studied by using a data base for Olmsted County, Minnesota, to determine whether PPS decreased the rate of hospitalizations among patients with diabetes. Among Olmsted County residents 65 years of age or older, the adjusted rate of diabetes-associated hospitalizations decreased from 26.5 per 1,000 person-years in 1980 to 16.7 in 1985, whereas the adjusted rate of all other hospitalizations increased from 259.5 per 1,000 person-years to 261.9. Thus, PPS may have reduced hospitalization rates in elderly patients with diabetes.

Altering Residency Curriculum in Response to a Changing Practice Environment: Use of the Mayo Internal Medicine Residency Alumni Survey

To elicit the opinions of practicing internists who had graduated from a single internal medicine residency program about the adequacy of their training and its relevance to their medical practice, we mailed a survey to 1,342 physicians who had spent at least 1 year in the Mayo internal medicine residency training program. Of this group, 703 alumni (52%) responded to the survey, 532 of whom were currently practicing internal medicine. Our detailed analysis was based on responses from these 532 and, for some aspects of evaluation, on the 121 general internists who had completed residency training after 1970. Of the respondents, 42% spent more than 80% of their time in general medicine, and 53% had at least some subspecialty practice; 55% were involved in teaching, 20% in some research, and 37% in various administrative duties. In 27%, all patient-care activities involved primary care, an increase from 18% in a 1979 survey and 9% in 1972. Of those who were subspecialists, 67% spent more than half their time in subspecialty practice. Of those who were trained after 1970, 90% were board certified. Most respondents thought that their training in the internal medicine subspecialties was adequate, that additional procedure training was needed in joint aspiration, line placement, and flexible sigmoidoscopy, and that many allied medical areas were important to their practice and necessitated additional training. Although virtually all respondents assessed their inpatient training as adequate, only 42% were fully satisfied with their outpatient training. Alumni surveys can be useful in restructuring a residency program to meet the needs of the trainees.

Use of the cardiac-catheterization laboratory in a defined population.

We evaluated trends in the use of the cardiac-catheterization laboratory from 1973 through 1977 in a well-circumscribed population in southeastern Minnesota. A total of 346 patients (248 male and 98 female patients) underwent coronary arteriography, left ventriculography, or cardiac catheterization, and there were 369 visits to the catheterization laboratory. The total number of catheterization-laboratory visits per 10,000 population increased from 4.3 in 1973 to 11.5 in 1977. According to individual category, the rates for coronary arteriography increased more than fourfold during the five-year period, whereas the rates for cardiac catheterization period, whereas the rates for cardiac catheterization showed no substantial change. On the basis of the 1977 rate for all visits to the catheterization laboratory and under conditions similar to those in this community, a population of approximately 230,000 would be required to ensure use of a catheterization laboratory at the suggested minimum level of 300 adult examinations per year.