Michael W. Pozen

A Nurse Rehabilitator's Impact on Patients with Myocardial Infarction

A nurse rehabilitator, supplementing routine physician/nursing coronary care unit (CCU) care, was found to be effective in increasing the return to work rate (p < .05) and decreasing smoking (p < .05) in a randomized trial of 102 patients with acute myocardial infarction (MI). These outcomes were thought to be due to the nurse rehabilitators efforts in increasing patient knowledge of heart disease (p < .01) and individual counseling.

Effectiveness of a prehospital medical control system: an analysis of the interaction between emergency room physician and paramedic.

Medical control for paramedics by means of radio and ECG telemetry is costly, time consuming, and-of unproved value. We assessed the interaction between emergency room physicians and paramedics during ambulance transport of “seriously ill” cardiac patients (cardiac arrest, acute myocardial infarction, or new onset on crescendo angina pectoris) with paramedics in service. Thirty-five percent of all arrhythmias and 35% of potentially life-threatening arrhythmias were misclassified. Correct treatment was rendered in 74% of the cases, although only 65% were correctly diagnosed (p < 0.01). The principal predictive variable for misdiagnosing or incorrectly treating a patient was the presence of a potentially life-threatening arrhythmia, precisely the condition for which medical control and the paramedic system has the most to offer. Only 39% of patients with life-threatening arrhythmias were correctly diagnosed and correctly treated, whereas 64% of patients without life-threatening arrhythmias were correctly diagnosed and correctly treated (p < 0.001). Mortality reflected correct diagnosis and treatment. In-hospital and overall mortalities were 12% and 33%, respectively, for patients who were correctly diagnosed and treated (p < 0.06), compared with 20% and 43%, respectively, for patients who were incorrectly diagnosed or incorrectly treated (p < 0.04). More rigorous medical control is needed to improve the quality of patient care and outcome and to further integrate the advanced life support program into the health care system.

Optimal Identification of the Patient with Acute Myocardial Ischemia in the Emergency Room

Although angina pectoris was meticulously described more than 200 years ago by Heberden [1] and the presentation of myocardial infarction was first reported 50 years ago by Herrick [2], accurate identification of acute ischemic heart disease (AIHD) in the emergency room (ER) remains a task that challenges the skill of the most seasoned clinician. In the United States, for each coronary care unit (CCU) patient in whom AIHD is confirmed, two patients are admitted with this as an ER diagnosis. There are great costs to patients and to the medical reimbursement system resulting from the large number of false-positive AIHD diagnoses and the resulting CCU overuse. Since each year in this country more than 1.5 million patients with suspected AIHD are admitted to CCUs, even a modest improvement in admitting practices would yield substantial savings. Additionally, many patients would be spared the needless physical and psychological side effects resulting from unnecessary admission to intensive care units. This chapter reviews studies that have attempted to optimize AIHD diagnostic accuracy in the ER setting.

Cardiac nuclear imaging. Adoption of an evolving technology.

A national survey was conducted to examine the extent of adoption and use of nuclear imaging procedures in cardiology in hospitals by 1979 and to develop estimates for 1983. The data are based on the responses of 171 hospitals from a representative 200-hospital sample stratified for region, bed-size, and teaching status. Extrapolating the data, it is estimated that 2,106 hospitals nationally use cardiac nuclear imaging. In 1979, hospitals with at least 200 beds performed an estimated 396,000 cardiac nuclear imaging studies at a cost of

An analytic method for the evaluation of rural Emergency Medical Service development.

93 million. By 1983, it is estimated that 4,061 hospitals had the capability to perform cardiac nuclear imaging and that national expenditures would exceed

Implications of Alternative Sampling Strategies for Emergency Medical Service Evaluation

200 million (noninflated dollars). Although cardiac nuclear imaging procedures have been demonstrated to be valuable in detecting coronary artery disease or measuring ventricular function, these procedures were rapidly being adopted by the medical community at a time when only limited information about their effectiveness and efficiency are available.

Book Reviews : Cholesterol, Children and Heart Disease: An Analysis of Alternatives Donald M. Berwick, Shan Cretin, Emmett B. Keeler, 400 pp, illustrated, New York: Oxford Press, 1980.

An analytic method is presented for assessing the marginal impact of incremental changes in rural Emergency Medical Services (EMS) on cardiac mortality, morbidity, EMS system process and performance, and health care system utilization. The method incorporates a model of the EMS system. This model specifies five sets of interactive variables characterizing EMS system development and effectiveness. The analytic method quantifies the contribution of each of these sets of interactive variables on the outcome variables (cardiac mortality, morbidity, EMS process/performance, and health care system utilization) for three target populations: those who utilize the EMS system, all hospitalized patients with acute ischemic heart disease independent of EMS system use, and the population of all patients dying from acute ischemic heart disease on a communitywide basis. By including in the model those factors unique to rural areas, such as scarcity of fiscal and health care system resources, geographical constraints, and the skewed severity of case mix due to the clinical and socioeconomic conditions found among rural patients, the analytic method is able to quantify and help explain the impact of these factors on the EMS system and the limitations which they impose. The analytic method affords planners and administrators and rational basis for decisions regarding future rural EMS system development through its identification of those system characteristics amenable to change and worth pursuing from a health policy perspective.

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Evaluations of emergency medical service (EMS) programs have been ambiguous, due in part, to problems of sample definition. Four different sampling strategies were studied: 1) all patients in cardiac arrest; 2) patients with a final diagnosis of myocardial infarction (MI); 3) patients with an emergency room diagnosis of “rule out MI”; and 4) patients identified by the ambulance team as a possible MI. Using a regional data base of all ambulance runs, we created study samples based on each of these strategies and measured the error that may be introduced as a result of sample selection. Bias was measured along three parameters of EMS system performance: 1) observed incidence of MI in the ambulance system; 2) condition recognition—the ability of the ambulance team to correctly identify acute cardiac patients; and 3) emergency room and hospital mortality rates. The emergency room diagnosis strategy systematically excludes all false-positives, while samples based on the ambulance teams assessment omit all false-negatives. The final diagnosis strategy yields significant underestimates of cardiac mortality. Samples restricted to cardiac arrests result in biased estimates of both the incidence of MI and the number of deaths.

Book reviewOrganizational issues in health care management: by Alan Sheldon. Spectrum Publications, Inc., New York, 1975. 343 pp.

which for the most part are succinct presentations that avoid turgid medical, legal, and philosophic prose. While the book is appropriate for students, philosophers, and physicians, both the medical and philosophic background discussions are spartan, and the naive reader may need assistance from other sources. Medical decision analysts, who are often faced with difficult tradeoffs between competing values that tread on the thin ice of ethical conflict, should welcome this rigorous yet informal presentation of medical ethics.

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