16,854 research outputs found

    Payments For Acute Myocardial Infarction Episodes Of Care By Hospital Interventional Capability

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    It is not known whether hospitals with percutaneous coronary intervention (PCI) capability provide more costly care than hospitals without PCI capability for patients admitted for acute myocardial infarction (AMI). The growing number of PCI-capable hospitals and higher rate of PCI use at technologically advanced hospitals may result in higher costs for episodes of care initiated at PCI hospitals. However, higher rates of transfers and post-acute care procedures may result in higher costs for episodes of care initiated at non-PCI hospitals. We identified all AMI admissions in 2008 among Medicare fee-for-service beneficiaries and classified hospitals as PCI- or non-PCI-capable based on hospitals\u27 2007 PCI performance. We added all payments from the time of admission through 30 days post-admission, including payments to hospitals other than the admitting hospital. We calculated and compared risk- standardized payment for PCI and non-PCI hospitals using 2-level hierarchical generalized linear models that adjust for patient demographics and clinical characteristics. PCI hospitals had a slightly higher mean 30-day risk-standardized payment than non-PCI hospitals (20,340v.20,340 v. 19,713, P\u3c0.001). Patients presenting to PCI hospitals had higher PCI rates (39.2% v. 13.2%, P\u3c0.001) and higher coronary artery bypass graft (CABG) rates (9.5% v. 4.4%, P\u3c0.001) during index AMI admissions, lower transfer rates (2.2% v. 25.4%, P\u3c0.001), and lower revascularization rates within 30 days (0.15% v. 0.27%, P\u3c0.0001) than those presenting to non- PCI hospitals. Despite higher PCI and CABG rates for patients who began their 30-day episode of care at PCI hospitals, PCI hospitals were only $627 more costly than non-PCI hospitals for the treatment of patients with AMI

    Hospital revascularisation capability and quality of care after an acute coronary syndrome in Switzerland.

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    BACKGROUND: Patients with acute coronary syndrome (ACS) transferred to regional nonacademic hospitals after percutaneous coronary intervention (PCI) may receive fewer preventive interventions than patients who remain in university hospitals. We aimed at comparing hospitals with and without PCI facilities regarding guidelines-recommended secondary prevention interventions after an ACS. METHODS: We studied patients with ACS admitted to a university hospital with PCI facilities in Switzerland, and either transferred within 48 hours to regional nonacademic hospitals without PCI facilities or directly discharged from the university hospital. We measured prescription rates of evidence-based recommended therapies after ACS including reasons for nonprescription of aspirin, statins, β-blockers, angiotensin converting-enzyme inhibitors (ACEI) / angiotensin II receptor blockers (ARB), along with cardiac rehabilitation attendance and delivery of a smoking cessation intervention. RESULTS: Overall, 720 patients with ACS were enrolled; 541 (75.1%) were discharged from the hospital with PCI facilities, 179 (24.9%) were transferred to hospitals without PCI facilities. Concomitant prescription of aspirin, β-blockers, ACEI/ARB and statins at discharge was similar in hospitals with and without PCI facilities, reaching 83.9% and 85.5%, respectively (p = 0.62). Attendance at cardiac rehabilitation reached 55.5% for the hospital with PCI facilities and 65.7% for hospitals without PCI facilities (p = 0.02). In-hospital smoking cessation interventions were delivered to 70.8% patients exclusively at the hospital with PCI facilities. CONCLUSION: Quality of care for patients with ACS discharged from hospitals without PCI facilities was similar to that of patients directly discharged from the hospital with PCI facilities, except for in-hospital smoking cessation counselling and cardiac rehabilitation attendance

    The cost-effectiveness of the Kentucky pilot project of allowing primary PCI at hospitals without onsite CABG capabilities.

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    A myocardial infarction (MI) occurs when blood supply to the heart is cut off by a blockage in one of the coronary arteries. Most hospitals treat a patient with thrombolysis or a percutaneous coronary intervention (PC I). The latter has been established as the preferred revascularization method. However, the American College of Cardiologists and the American Heart Association strongly recommend that a hospital performing PCI must also have coronary artery bypass graft capabilities (CABG). By following these recommendations, the state of Kentucky has limited the number of hospitals allowed to perform PCI and thereby limiting access to such a life-saving procedure. Recently, the state of Kentucky has begun evaluating if hospitals without such capabilities should be allowed to perform primary PCI, and data from this evaluation allowed the establishment of the medical soundness of allowing such hospitals to perform primary PCI. To have the most comprehensive understanding of the effects of allowing hospitals without surgical-backup performing primary PCI, the effects and costs must be evaluated simultaneously. The current study aims to study the financial feasibility of allowing these hospitals to do emergency PCI in addition to hospitals with onsite open-heart surgery capabilities. The estimates have been derived from a systematic literature review of national studies based on PCI registries as well as our earlier study - KENTUCKY PILOT PROJECT FOR PRIMARY PCI WITHOUT ONSITE CABG. Costs estimates were derived from the National Inpatient Sample, which approximates a twenty percent sample of the U.S. community hospitals. In determining costs, the sample was extracted by filtering using ICD-9 codes. A deterministic model was developed so that more uncertainty would not be introduced. The economic evaluation focused on estimating the incremental cost effectiveness ratio (ICER) of allowing regional hospitals to perform primary PCI from a payer\u27s perspective. Uncertainty about the model parameters was investigated through employing sensitivity analysis techniques. The study found that there were no statistically significant differences in outcomes between hospitals with and without CABG capabilities. The only characteristic, which was significantly different between these two groups, was total charges. The alternative to allow Regional Hospitals as well to perform primary PCI dominated the other alternative of Only Allowing Hospitals with Onsite CABG to perform PCI. That is, allowing regional hospitals to perform primary PCI both incur fewer costs while also averting more deaths. However, sensitivity to the cost of PC I at regional hospitals was observed in the model. The study suggests that by allowing primary PCI to be performed at selected facilities without onsite CABG, the state of Kentucky can expand access to PCI and reduce geographical health disparities, one of its main healthcare initiatives

    Volume-based referral for cardiovascular procedures in the United States: a cross-sectional regression analysis

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    BACKGROUND: We sought to estimate the numbers of patients affected and deaths avoided by adopting the Leapfrog Group's recommended hospital procedure volume minimums for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). In addition to hospital risk-adjusted mortality standards, the Leapfrog Group recommends annual hospital procedure minimums of 450 for CABG and 400 for PCI to reduce procedure-associated mortality. METHODS: We conducted a retrospective analysis of a national hospital discharge database to evaluate in-hospital mortality among patients who underwent PCI (n = 2,500,796) or CABG (n = 1,496,937) between 1998 and 2001. We calculated the number of patients treated at low volume hospitals and simulated the number of deaths potentially averted by moving all patients to high volume hospitals under best-case conditions (i.e., assuming the full volume-associated reduction in mortality and the capacity to move all patients to high volume hospitals with no related harms). RESULTS: Multivariate adjusted odds of in-hospital mortality were higher for patients treated in low volume hospitals compared with high volume hospitals for CABG (OR 1.16, 95% CI 1.10–1.24) and PCI (OR 1.12, 95% CI 1.05–1.20). A policy of hospital volume minimums would have required moving 143,687 patients for CABG and 87,661 patients for PCI from low volume to high volume hospitals annually and prevented an estimated 619 CABG deaths and 109 PCI deaths. Thus, preventing a single death would have required moving 232 CABG patients or 805 PCI patients from low volume to high volume hospitals. CONCLUSION: Recommended hospital CABG and PCI volume minimums would prevent 728 deaths annually in the United States, fewer than previously estimated. It is unclear whether a policy requiring the movement of large numbers of patients to avoid relatively few deaths is feasible or effective

    Management of patients with acute ST-segment elevation myocardial infarction in Russian hospitals adheres to international guidelines

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    Objective - Russia has one of the highest cardiovascular mortality rates. Modernisation of the Russian health system has been accompanied by a substantial increase in uptake of percutaneous coronary intervention (PCI), which substantially reduces the risk of mortality in patients with acute ST-elevation myocardial infarction (STEMI). This paper aims to describe contemporary Hospital treatment of acute STEMI among patients in a range of hospitals in the Russian Federation. Methods - This study used data from a prospective observational cohort of 1128 suspected patients with myocardial infarction recruited in both PCI and non-PCI hospitals across 13 regions and multiple levels of the health system in Russia. The primary objective was to examine the use of reperfusion strategies in patients with STEMI. Results - Among patients reaching PCI centres within 12 hours of symptom onset, the vast majority received angiography and PCI, regardless of age, sex and comorbidity, in line with current European Society of Cardiology guidelines. Conclusion- Patients reaching Russian hospitals are very likely to receive appropriate treatment, although performance varies. The best hospitals can serve as beacons of good practice as PCI facilities continue to expand across Russia where geography allows

    The chasm in percutaneous coronary intervention and in-hospital mortality rates among acute myocardial infarction patients in rural and urban hospitals in China: A mediation analysis

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    Objectives: To determine to what extent the inequality in the ability to provide percutaneous coronary intervention (PCI) translates into outcomes for AMI patients in China. Methods: We identified 82,677 patients who had primary diagnoses of AMI and were hospitalized in Shanxi Province, China, between 2013 and 2017. We applied logistic regressions with inverse probability weighting based on propensity scores and mediation analyses to examine the association of hospital rurality with in-hospital mortality and the potential mediating effects of PCI. Results: In multivariate models where PCI was not adjusted for, rural hospitals were associated with a significantly higher risk of in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.03–1.37). However, this association was nullified (OR: 0.94, 95% CI: 0.81–1.08) when PCI was included as a covariate. Mediation analyses revealed that PCI significantly mediated 132.3% (95% CI: 104.1–256.6%) of the effect of hospital rurality on in-hospital mortality. The direct effect of hospital rurality on in-hospital mortality was insignificant. Conclusion: The results highlight the need to improve rural hospitals’ infrastructure and address the inequalities of treatments and outcomes in rural and urban hospitals

    Elective and primary angioplasty at hospitals without on-site surgery versus with on-site surgery: results from a national registry

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    INTRODUCTION: Current European clinical guidelines do not restrict interventional cardiology at centers without on-site surgical backup, but disagreement still exists whether hospitals with cardiac catheterization laboratories, but without on-site cardiac surgery, should develop percutaneous coronary intervention (PCI) programs. Technical improvements in equipment and pharmacologic adjunctive therapy have increased the safety margins of diagnostic and therapeutic cardiac catheterization and more than half of the patients treated by PCI in Portugal are treated at hospitals without on-site cardiac surgery. OBJECTIVES: We set out to compare clinical outcomes of elective and primary PCI for ST-segment elevation myocardial infarction at centers without on-site cardiac surgery with those at centers with on-site cardiac surgery. METHODS: Based on the Portuguese Registry of Interventional Cardiology, we retrospectively reviewed a total of 13,235 PCI procedures performed from January 2002 to June 2006 and compared the results for 7,112 patients treated at hospitals without on-site cardiac surgery with 6,123 patients treated at hospitals with on-site cardiac surgery. RESULTS: Demographic data were similar, with a mean age of 64 (55-72) vs. 63 (54-71) years, 75% vs. 76% male and 25.0% vs. 24.2% with diabetes respectively at centers without and with on-site surgical backup. Hospital mortality at centers without and with on-site surgical backup respectively was: chronic angina: 0.3% vs. 0.3% (NS); acute coronary syndromes: 1.5% vs. 1.0% (NS); acute myocardial infarction with ST elevation and without cardiogenic shock: 4.0% vs. 5.0% (NS); cardiogenic shock: 50.9% vs. 53.4% (NS). CONCLUSIONS: Similar clinical outcomes for interventional cardiology were achieved at hospitals without on-site cardiac surgery and those with on-site cardiac surgery. In the era of coronary stents, adjunctive therapy and experienced operators, elective and primary PCI can safely be performed without on-site surgical backup

    Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention

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    17 USC 105 interim-entered record; under review.The article of record as published may be found at http://dx.doi.org/10.1111/acem.14195Background. Patients with ST-elevation myocardial infarction (STEMI) require timely reperfusion, and percutaneous coronary intervention (PCI) decreases morbidity and mortality. Regionalization of STEMI care has increased timeliness and use of PCI, but it is unknown whether benefits to regionalization depend on a community's distance from its nearest PCI center. We sought to determine whether STEMI regionalization benefits, measured by access to PCI centers, timeliness of treatment (same-day or in-hospital PCI), and mortality, differ by baseline distance to nearest PCI center. Methods. Using a difference-in-difference-in-differences model, we examined access to PCI-capable hospitals, receipt of PCI either on the day of admission or during the care episode, and health outcomes for patients hospitalized from January 1, 2006, to September 30, 2015. Results. Of 139,408 patients (2006 to 2015), 51% could reach the nearest PCI center in <30 minutes, and 49% required ≥30 minutes driving time. For communities with baseline access ≥30 minutes, regionalization increased the probability of admission to a PCI-capable hospital by 9.4% and also increased the likelihood of receiving same-day PCI (by 11.2%) and PCI during the hospitalization (by 7.4%). Patients living within 30 minutes did not accrue significant benefits (measured by admission to a PCI-capable hospital or receipt of PCI) from regionalization initiatives. Regionalization more than halved access disparities and completely eliminated treatment disparities between communities ≥30 minutes and communities <30 minutes from the nearest PCI hospital. Conclusions. Measured by likelihood of admission to a PCI-capable facility and receipt of PCI, benefits of STEMI regionalization in California accrued only to patients whose nearest PCI center was ≥30 minutes away. We found no mortality benefits of regionalization based on distance from PCI center. Our results suggest that policymakers focus STEMI regionalization efforts in communities that are not already well serviced by PCI-capable hospitals

    Prescriptions for Excellence in Health Care Spring 2010 Dowload Full PDF

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    Hospital Treatment Rates and Spill-Over Effects: Does Ownership Matter?

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    This paper studies the effect of hospital ownership on treatment rates allowing for spatial correlation among hospitals. Competition among hospitals and knowledge spillovers generate significant externalities which we try to capture using the spatial Durbin model. Using a panel of 2342 hospitals in the 48 continental states observed over the period 2005 to 2008, we find significant spatial correlation of medical service treatment rates among hospitals. The paper also shows mixed results on the effect of hospital ownership on treatment rates that depends upon the market structure where the hospital is located and which varies by treatment type
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