The association between processes, structures and outcomes of secondary prevention care among VA ischemic heart disease patients

BACKGROUND: Hyperlipidemia and hypertension are well-established risk factors for recurrent cardiovascular events among patients with ischemic heart disease (IHD). Despite national recommendations, concordance with guidelines for LDL cholesterol and blood pressure remains inadequate. The objectives of this study were to 1) determine concordance rates with LDL cholesterol and BP recommendations; and 2) identify patient factors, processes and structures of care associated with guideline concordance among VA IHD patients. METHODS: This was a cross sectional study of veterans with IHD from 8 VA hospitals. Outcomes were concordance with LDL guideline recommendations (LDL<100 mg/dl), and BP recommendations (<140/90 mm Hg). Cumulative logit and hierarchical logistic regression analyses were performed to identify patient factors, processes, and structures of care independently associated with guideline concordance. RESULTS: Of 14,114 veterans with IHD, 55.7% had hypertension, 71.5% had hyperlipidemia, and 41.6% had both conditions. Guideline concordance for LDL and BP were 38.9% and 53.4%, respectively. However, only 21.9% of the patients achieved both LDL <100 mg/dl and BP <140/90 mm Hg. In multivariable analyses, patient factors including older age and the presence of vascular disease were associated with worse guideline concordance. In contrast, diabetes was associated with better guideline concordance. Several process of care variables, including higher number of outpatient visits, higher number of prescribed medications, and a recent cardiac hospitalization were associated with better guideline concordance. Among structures of care, having on-site cardiology was associated with a trend towards better guideline concordance. CONCLUSION: Guideline concordance with secondary prevention measures among IHD patients remains suboptimal. It is hoped that the findings of this study can serve as an impetus for quality improvement efforts to improve upon secondary prevention measures and reduce the morbidity and mortality of patients with known IHD

Financial impact of reducing door-to-balloon time in ST-elevation myocardial infarction: a single hospital experience

<p>Abstract</p> <p>Background</p> <p>The impact of reducing door-to-balloon time on hospital revenues, costs, and net income is unknown.</p> <p>Methods</p> <p>We prospectively determined the impact on hospital finances of (1) emergency department physician activation of the catheterization lab and (2) immediate transfer of the patient to an immediately available catheterization lab by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected financial data for 52 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention from October 1, 2004–August 31, 2005 and compared this group to 80 consecutive ST-elevation myocardial infarction patients from September 1, 2005–June 26, 2006 after protocol implementation.</p> <p>Results</p> <p>Per hospital admission, insurance payments (hospital revenue) decreased ($35,043 ±$36,670 vs. $25,329 ±$16,185, P = 0.039) along with total hospital costs ($28,082 ±$31,453 vs. $18,195 ±$9,242, P = 0.009). Hospital net income per admission was unchanged ($6962 vs.$7134, P = 0.95) as the drop in hospital revenue equaled the drop in costs. For every $1000 reduction in total hospital costs, insurance payments (hospital revenue) dropped$1077 for private payers and $1199 for Medicare/Medicaid. A decrease in hospital charges ($70,430 ± $74,033 vs.$53,514 ± $23,378, P = 0.059), diagnosis related group relative weight (3.7479 ± 2.6731 vs. 2.9729 ± 0.8545, P = 0.017) and outlier payments with hospital revenue>$100,000 (7.7% vs. 0%, P = 0.022) all contributed to decreasing ST-elevation myocardial infarction hospitalization revenue. One-year post-discharge financial follow-up revealed similar results: Insurance payments: $49,959 ±$53,741 vs. $35,937 ±$23,125, P = 0.044; Total hospital costs: $39,974 ±$37,434 vs. $26,778 ±$15,561, P = 0.007; Net Income: $9984 vs.$9159, P = 0.855.</p> <p>Conclusion</p> <p>All of the financial benefits of reducing door-to-balloon time in ST-elevation myocardial infarction go to payers both during initial hospitalization and after one-year follow-up.</p> <p>Trial Registration</p> <p><b>ClinicalTrials.gov ID</b>: NCT00800163</p