Jeph Herrin

Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis.

Background—Treatment delays in patients with ST-segment–elevation myocardial infarction (STEMI) transferred for primary percutaneous coronary intervention (PCI) may decrease the advantage of this strategy over on-site fibrinolytic therapy that has been demonstrated in recent clinical trials. Accordingly, we sought to describe patterns of times to treatment in patients undergoing interhospital transfer for primary PCI in the United States. Methods and Results—We analyzed patients with STEMI undergoing interhospital transfer for primary PCI between January 1999 and December 2002 in the National Registry of Myocardial Infarction. The primary outcome was “total” door-to-balloon time measured from time of arrival at the initial hospital to time of balloon inflation at the PCI hospital. Multivariable hierarchical models were used to assess the relationship of total door-to-balloon time with patient and hospital characteristics. Among 4278 patients transferred for primary PCI at 419 hospitals, the median total door-to-balloon time was 180 minutes, with only 4.2% of patients treated within 90 minutes, the benchmark recommended by national quality guidelines. Comorbid conditions, absence of chest pain, delayed presentation after symptom onset, less specific ECG findings, and hospital presentation during off-hours were associated with longer total door-to-balloon times. Patients at teaching hospitals in rural areas also had significantly longer times to treatment. Conclusions—Total door-to-balloon times for transfer patients undergoing primary PCI in the United States rarely achieve guideline-recommended benchmarks, and current decision making should take these times into account. For the full benefits of primary PCI to be realized in transfer patients, improved systems are urgently needed to minimize total door-to-balloon times.

An Administrative Claims Measure Suitable for Profiling Hospital Performance on the Basis of 30-Day All-Cause Readmission Rates Among Patients With Heart Failure

Background—Readmission soon after hospital discharge is an expensive and often preventable event for patients with heart failure. We present a model approved by the National Quality Forum for the purpose of public reporting of hospital-level readmission rates by the Centers for Medicare & Medicaid Services. Methods and Results—We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with heart failure. The model was derived with the use of Medicare claims data for a 2004 cohort and validated with the use of claims and medical record data. The unadjusted readmission rate was 23.6%. The final model included 37 variables, had discrimination ranging from 15% observed 30-day readmission rate in the lowest predictive decile to 37% in the upper decile, and had a c statistic of 0.60. The 25th and 75th percentiles of the risk-standardized readmission rates across 4669 hospitals were 23.1% and 24.0%, with 5th and 95th percentiles of 22.2% and 25.1%, respectively. The odds of all-cause readmission for a hospital 1 standard deviation above average was 1.30 times that of a hospital 1 standard deviation below average. State-level adjusted readmission rates developed with the use of the claims model are similar to rates produced for the same cohort with the use of a medical record model (correlation, 0.97; median difference, 0.06 percentage points). Conclusions—This claims-based model of hospital risk-standardized readmission rates for heart failure patients produces estimates that may serve as surrogates for those derived from a medical record model.

Improvements in Door-to-Balloon Time in the United States, 2005 to 2010

Background Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know if improvements in door-to-balloon times were shared equally among patient and hospital groups.Background— Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know whether improvements in door-to-balloon times were shared equally among patient and hospital groups. Methods and Results— This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention (acute myocardial infarction-8) inpatient measure from January 1, 2005, through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure, including the number and percentage in each group, the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes (27.3% to 70.4%). The declines in median times were greatest among groups that had the highest median times during the first period: patients >75 years of age (median decline, 38 minutes), women (35 minutes), and blacks (42 minutes). Conclusion— National progress has been achieved in the timeliness of treatment of patients with ST-segment–elevation myocardial infarction who undergo primary percutaneous coronary intervention.

National Efforts to Improve Door-to-Balloon Time. Results From the Door-to-Balloon Alliance

OBJECTIVES The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance, a national quality campaign sponsored by the American College of Cardiology and 38 partner organizations, was associated with increased likelihood of patients who received primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) being treated within 90 min of hospital presentation. BACKGROUND The D2B Alliance, launched in November 2006, sought to achieve the goal of having 75% of patients with STEMI treated within 90 min of hospital presentation. METHODS We conducted a longitudinal study of D2B times in 831 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, April 1, 2005, to March 31, 2008. RESULTS By March 2008, >75% of patients had D2B times of < or = 90 min, compared with only about one-half of patients with D2B times within 90 min in April 2005. Trends since the launch of the D2B Alliance showed that patients treated in hospitals enrolled in the D2B Alliance for at least 3 months were significantly more likely than patients treated in nonenrolled hospitals to have D2B times within 90 min, although the magnitude of the difference was modest (odds ratio: 1.16; 95% confidence interval: 1.07 to 1.27). CONCLUSIONS The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008.

Health and social services expenditures: associations with health outcomes

Objective To examine variations in health service expenditures and social services expenditures across Organisation for Economic Co-operation and Development (OECD) countries and assess their association with five population-level health outcomes. Design A pooled, cross-sectional analysis using data from the 2009 release of the OECD Health Data 2009 Statistics and Indicators and OECD Social Expenditure Database. Setting OECD countries (n=30) from 1995 to 2005. Main outcomes Life expectancy at birth, infant mortality, low birth weight, maternal mortality and potential years of life lost. Results Health services expenditures adjusted for gross domestic product (GDP) per capita were significantly associated with better health outcomes in only two of five health indicators; social services expenditures adjusted for GDP were significantly associated with better health outcomes in three of five indicators. The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP. Conclusion Attention to broader domains of social policy may be helpful in accomplishing improvements in health envisioned by advocates of healthcare reform.

Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat

Abstract Objective:To assess the effectiveness of tailored interventions to implement guidelines for urinary tract infections in women and sore throat Design:Unblinded, cluster randomised pretest-post-test trial Setting:142 general practices in Norway Participants:72 practices received interventions to implement guidelines for urinary tract infection and 70 practices received interventions to implement guidelines for sore throat, serving as controls for each other. 59 practices in the urinary tract infection group and 61 practices in the sore throat group completed the study. Outcomes were measured in 16 939 consultations for sore throat and 9887 consultations for urinary tract infection. Interventions:Interventions were developed to overcome identified barriers to implementing the guidelines. The main components of the tailored interventions were patient educational material, computer based decision support and reminders, an increase in the fee for telephone consultations, and interactive courses for general practitioners and practice assistants Main outcome measures:Changes in rates of use of antibiotics, laboratory tests, and telephone consultations Results:Patients in the sore throat group were 3% less likely to receive antibiotics after the intervention. Women with symptoms of urinary tract infection in the intervention group were 5.1% less likely to have a laboratory test ordered. No significant differences were found between the groups for the other outcomes. Large variation was found across the included practicesin the rates of antibiotic prescription, use of laboratory tests and telephone consultations, and in the extent of change for all three outcome measures Conclusions:Passively delivered, complex interventions targeted at identified barriers to change had little effect in changing practice

Effectiveness and Cost of a Transitional Care Program for Heart Failure: A Prospective Study With Concurrent Controls

BACKGROUND Randomized controlled trials have demonstrated the efficacy of nurse-led transitional care programs to reduce readmission rates for patients with heart failure; the effectiveness of these programs in real-world health care systems is less well understood. METHODS We performed a prospective study with concurrent controls to test an advanced practice nurse-led transitional care program for patients with heart failure who were 65 years or older and were discharged from Baylor Medical Center Garland (BMCG) from August 24, 2009, through April 30, 2010. We compared the effect of the program on 30-day (from discharge) all-cause readmission rate, length of stay, and 60-day (from admission) direct cost for BMCG with that of other hospitals within the Baylor Health Care System. We also performed a budget impact analysis using costs and reimbursement experience from the intervention. RESULTS The intervention significantly reduced adjusted 30-day readmission rates to BMCG by 48% during the postintervention period, which was better than the secular reductions seen at all other facilities in the system. The intervention had little effect on length of stay or total 60-day direct costs for BMCG. Under the current payment system, the intervention reduced the hospital financial contribution margin on average

Re: Proton vs Intensity-Modulated Radiotherapy for Prostate Cancer: Patterns of Care and Early Toxicity

227 for each Medicare patient with heart failure. CONCLUSIONS Preliminary results suggest that transitional care programs reduce 30-day readmission rates for patients with heart failure. This underscores the potential of the intervention to be effective in a real-world setting, but payment reform may be required for the intervention to be financially sustainable by hospitals.

Community Factors and Hospital Readmission Rates

Over the past decade, intensity modulated radiotherapy (IMRT) has become the standard form of radiotherapy for the treatment of prostate cancer, accounting for more than 80% of all radiotherapy (1). Even as IMRT has been widely adopted, other radiotherapy modalities have come to market, most notably proton radiotherapy (PRT). Although PRT predates IMRT, dissemination of PRT has been increasing rapidly in recent years. In part because of its high capital cost, Medicare is reported to reimburse PRT at a rate 1.4 to 2.5 times that of IMRT (2–4), despite many unexplored questions. First, there is a lack of data regarding national patterns of use and the true cost of PRT among Medicare beneficiaries. Currently, there are only nine PRT centers in operation in the United States (5), and this relatively low treatment capacity limits costs. However, eight other centers are in development (5), along with smaller and more affordable proton machines (6), conceivably opening the door to more widespread adoption of PRT across the country. Second, the Institute for Clinical and Economic Review concluded unanimously that the state of current knowledge of comparative clinical effectiveness was “insufficient” (7,8). Because differences in cancer cure rates and survival from prostate cancer treatment often take many years to become evident, it has been suggested that initial study of prostate cancer treatments should focus on treatment-related toxicity (8). Proponents of PRT argue that the physical properties of protons may decrease the most common side effects associated with prostate radiotherapy—gastrointestinal and genitourinary toxicity (9). Early outcomes from single-arm, prospective trials investigating PRT are forthcoming, indicating low levels of radiation-induced toxicity with early follow-up (10,11). However, IMRT itself has a robust literature describing excellent efficacy and low toxicity in the treatment of prostate cancer (12). Therefore, it is unclear that PRT offers a statistically significant benefit beyond IMRT. Prior studies investigating PRT in Medicare beneficiaries using the Surveillance, Epidemiology, and End Results–Medicare database have been single-institution studies (13,14) and, therefore, are not of the whole country. These studies (13,14) noted a statistically significant reduction of gastrointestinal toxicity for patients undergoing IMRT compared with PRT. A comprehensive comparison of PRT with IMRT requires examination of the entire country for the most recent years available. As more PRT centers become operational, it will be crucial for patients, providers, and policy makers to understand the cost and national pattern of adoption of PRT and the incidence of treatment-related toxicity compared with IMRT. Therefore, we used a national sample of Medicare beneficiaries with prostate cancer to investigate the patterns and cost of PRT delivery, as well as the early treatment-related toxicity associated with PRT compared with IMRT.

Relation Between Hospital Specialization With Primary Percutaneous Coronary Intervention and Clinical Outcomes in ST-Segment Elevation Myocardial Infarction National Registry of Myocardial Infarction-4 Analysis

OBJECTIVE To examine the relationship between community factors and hospital readmission rates. DATA SOURCES/STUDY SETTING We examined all hospitals with publicly reported 30-day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets. STUDY DESIGN We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30-day risk-standardized readmission rate. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS The study sample included 4,073 hospitals. Fifty-eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties. CONCLUSIONS Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates.