Purav Mody

Hospital Patterns of Use of Positive Inotropic Agents in Patients with Heart Failure

OBJECTIVES This study sought to determine hospital variation in the use of positive inotropic agents in patients with heart failure. BACKGROUND Clinical guidelines recommend targeted use of positive inotropic agents in highly selected patients, but data are limited and the recommendations are not specific. METHODS We analyzed data from 376 hospitals including 189,948 hospitalizations for heart failure from 2009 through 2010. We used hierarchical logistic regression models to estimate hospital-level risk-standardized rates of inotrope use and risk-standardized in-hospital mortality rates. RESULTS The risk-standardized rates of inotrope use ranged across hospitals from 0.9% to 44.6% (median: 6.3%, interquartile range: 4.3% to 9.2%). We identified various hospital patterns based on the type of agents: dobutamine-predominant (29% of hospitals), dopamine-predominant (25%), milrinone-predominant (1%), mixed dobutamine and dopamine pattern (32%), and mixed pattern including all 3 agents (13%). When studying the factors associated with interhospital variation, the best model performance was with the hierarchical generalized linear models that adjusted for patient case mix and an individual hospital effect (receiver operating characteristic curves from 0.77 to 0.88). The intraclass correlation coefficients of the hierarchical generalized linear models (0.113 for any inotrope) indicated that a noteworthy proportion of the observed variation was related to an individual institutional effect. Hospital rates or patterns of use were not associated with differences in length of stay or risk-standardized mortality rates. CONCLUSIONS We found marked differences in the use of inotropic agents for heart failure patients among a diverse group of hospitals. This variability, occurring in the context of little clinical evidence, indicates an urgent need to define the appropriate use of these medications.

Trends in Aortic Dissection Hospitalizations, Interventions, and Outcomes Among Medicare Beneficiaries in the United States, 2000–2011

Background—The epidemiology of aortic dissection (AD) has not been well described among older persons in the United States. It is not known whether advancements in AD care over the last decade have been accompanied by changes in outcomes. Methods and Results—The Inpatient Medicare data from 2000 to 2011 were used to determine trends in hospitalization rates for AD. Mortality rates were ascertained through corresponding vital status files. A total of 32 057 initial AD hospitalizations were identified. The overall hospitalization rate for AD remained unchanged at 10 per 100 000 person-years. For 30-day and 1-year mortality associated with AD, the observed rate decreased from 31.8% to 25.4% (difference, 6.4%; 95% confidence interval [CI], 6.2–6.5; adjusted, 6.4%; 95% CI, 5.7–6.9) and from 42.6% to 37.4% (difference, 5.2%; 95% CI, 5.1–5.2; adjusted, 6.2%; 95% CI, 5.3–6.7), respectively. For patients undergoing surgical repair for type A dissections, the observed 30-day mortality decreased from 30.7% to 21.4% (difference, 9.3%; 95% CI, 8.3–10.2; adjusted, 7.3%; 95% CI, 5.8–7.8) and the observed 1-year mortality decreased from 39.9% to 31.6% (difference, 8.3%; 95% CI, 7.5–9.1%; adjusted, 8.2%; 95% CI, 6.7–9.1). The 30-day mortality decreased from 24.9% to 21% (difference, 3.9%; 95% CI, 3.5–4.2; adjusted, 2.9%; 95% CI, 0.7–4.4) and 1-year decreased from 36.4% to 32.5% (difference, 3.9%; 95% CI, 3.3–4.3; adjusted, 3.9%; 95% CI, 2.5–6.3) for surgical repair of type B dissection. Conclusions—Although AD hospitalization rates remained stable, improvement in mortality was noted, particularly in patients undergoing surgical repair.

Most Important Articles on Cardiovascular Disease Among Racial and Ethnic Minorities

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease among racial and ethnic minorities.

Development of a Hospital Outcome Measure Intended for Use With Electronic Health Records: 30-Day Risk-standardized Mortality After Acute Myocardial Infarction.

Background:Electronic health records (EHRs) offer the opportunity to transform quality improvement by using clinical data for comparing hospital performance without the burden of chart abstraction. However, current performance measures using EHRs are lacking. Methods:With support from the Centers for Medicare & Medicaid Services (CMS), we developed an outcome measure of hospital risk-standardized 30-day mortality rates for patients with acute myocardial infarction for use with EHR data. As no appropriate source of EHR data are currently available, we merged clinical registry data from the Action Registry—Get With The Guidelines with claims data from CMS to develop the risk model (2009 data for development, 2010 data for validation). We selected candidate variables that could be feasibly extracted from current EHRs and do not require changes to standard clinical practice or data collection. We used logistic regression with stepwise selection and bootstrapping simulation for model development. Results:The final risk model included 5 variables available on presentation: age, heart rate, systolic blood pressure, troponin ratio, and creatinine level. The area under the receiver operating characteristic curve was 0.78. Hospital risk-standardized mortality rates ranged from 9.6% to 13.1%, with a median of 10.7%. The odds of mortality for a high-mortality hospital (+1 SD) were 1.37 times those for a low-mortality hospital (−1 SD). Conclusions:This measure represents the first outcome measure endorsed by the National Quality Forum for public reporting of hospital quality based on clinical data in the EHR. By being compatible with current clinical practice and existing EHR systems, this measure is a model for future quality improvement measures.

Most Important Outcomes Research Papers on Anticoagulation for Cardiovascular Disease

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of anticoagulation for cardiovascular disease.

Most Important Outcomes Research Papers on Variation in Cardiovascular Disease

The topic of variation in health care has garnered significant attention since Wennberg and Gittelsohn in 19731 identified up to 10-fold variation in use of tonsillectomy and other surgical procedures in small towns within Maine and Vermont. Wennberg and others further described large differences in the propensity to hospitalize patients in Boston and New Haven that were unrelated to case-fatality but highly related to bed supply.2 These findings suggested that regional treatment variation is in part driven by differences in physician preferences and heath resource capacity rather than the health status of patients. These observations of extensive geographic variation in treatment were most extensively formalized in the Dartmouth Atlas of Health Care, a massive undertaking that used Medicare claims data to describe differences in cost and utilization across more than 300 hospital referral regions (HRRs) that were built from zip codes and hospital service areas. The Dartmouth Atlas has been published by Wennberg and colleagues since 1996. More recently, greater attention has been directed to variation in treatment and outcomes at the hospital level. Health care payers including the Centers for Medicare and Medicaid Services have motivated the creation of performance measures that describe hospital variation in longitudinal outcomes such as rehospitalization and death.3–7 These measures have been endorsed by the National Quality Forum and are currently being used to direct financial penalties to hospitals with higher-than-expected rates of adverse outcomes for common conditions such as heart failure, acute myocardial infarction, and pneumonia. In the future, Medicare will likely assess hospital variation in outcomes for specific cardiovascular treatments including percutaneous coronary intervention and percutaneous valve replacement. Given the increased focus on treatment and outcomes variation at both regional and hospital levels, we have dedicated the reviews in this issue of Circulation: Cardiovascular Quality and Outcomes …

Most Important Outcomes Research Papers on Treatment of Stable Coronary Artery Disease

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research related to treatment of stable coronary artery disease (CAD).

Most Important Outcomes Research Papers in Cardiovascular Disease in the Elderly

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease in the elderly.

A Case of Respiratory Syncytial Virus Infection in an HIV-Positive Adult.

Respiratory syncytial virus (RSV) is commonly known to cause an influenza-like illness. However, it can also cause more severe disease in young children and older adults comprising of organ transplant patients with immunocompromised status. Till date, only four cases of RSV infections have been reported in HIV-positive adults. We describe here a case of HIV-positive female with relatively preserved immune function who presented with RSV infection requiring ventilation and showed improvement after prompt treatment with intravenous immunoglobulin.

An unusual cause of shortness of breath

A 65-year-old man with a history of esophagitis, presented with low grade fever, poor appetite and a fall at home. Admission vitals were stable with temperature 37.9 C (100.1 F). He was found to be dehydrated, and a urinalysis was compatible with urinary tract infection. An admission chest X-ray study was unremarkable. He was admitted for intravenous hydration and antibiotics. He was doing well after admission, when overnight he complained of new onset shortness of breath and epigastric pain. He reported that he had vomited approximately 150 mL of ‘brownish material’ 30 min prior, and his symptoms had started after that. The physical examination was notable for tachycardia (heart rate 104 beats/min), tachypnea (respiratory rate 22 breaths/min), decreased breath sounds at bilateral lung bases, hypoxia (oxygen saturation 86 % on 2 L nasal cannula), and epigastric tenderness. A chest X-ray study demonstrated pneumomediastinum and bilateral pleural effusions. A CT scan of the chest confirmed the presence of bilateral pnemuothoraces, pneumomediastinum and bilateral pleural effusions (Fig. 1). Given the onset of symptoms after a bout of vomiting, the diagnosis of esophageal rupture was considered. Bilateral chest tubes were urgently placed. Primary open surgical repair was deferred. Upper gastrointestinal endoscopy showed necrotic tissue and a full thickness tear in the esophagus around a hiatal hernia. An esophageal stent was successfully placed, and broad spectrum antibiotics initiated with continued placement of bilateral chest tubes. Biopsy of the necrotic tissue showed chronic inflammation without evidence of malignancy. The stent was removed after 4 weeks at which time repeat upper gastrointestinal endoscopy revealed a healed tear. At this time, the patient was tolerating oral feeds, and he was discharged. The esophagus lacks a serosal layer containing collagen and elastic fibers, making the wall weaker and more likely to rupture at lower pressures than the rest of the gastrointestinal tract [1]. Most cases of esophageal rupture are iatrogenic, and the term ‘Boerhaave syndrome’ is reserved for those induced spontaneously by uncoordinated vomiting [2]. The syndrome is characterized by full thickness tear, usually involving the posterolateral wall of distal esophagus, due to barogenic trauma induced by uncoordinated vomiting. This causes an acute rise in intraluminal pressure with esophageal disruption and forceful expulsion of gastric contents into the mediastinum or pleura with consequent chemical and bacterial mediastinitis. Mackler’s classic triad of vomiting, chest pain and subcutaneous emphysema is seen in only 50 % of cases. The physical examination reveals few specific signs. Subcutaneous emphysema, dullness to percussion (secondary to a pleural effusion), decreased breath sounds (due to pneumothorax), Hamman’s sign (a crunch like noise over the precordium due to mediastinal air) are seen in 20–30 % of patients. A chest X-ray study may show pneumomediastinum, subcutaneous emphysema, pleural effusions, pneumothorax, mediastinal widening, or hydropneumothorax. In patients with a suggestive clinical presentation, chest radiography, CT scan or esophagogram should be promptly obtained. A CT scan allows rapid detection of minute amounts of air, and an esophagogram can pinpoint the lesion more & Arjun Gupta sujata.bhushan@va.gov