The effect of peer review on mortality rates.

OBJECTIVE: Lowering of mortality rates in hospitals with mortality rates higher than accepted reference values for acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia, stroke, mechanical ventilation (MV) and colorectal surgery by using an external peer review process that identifies areas requiring rectification and implements protocols directed at improving these areas. DESIGN: Retrospective, observational, quality management study using administrative data to compare in-hospital mortality rates (pre and post an external peer review process that included adoption of improvement protocols) with reference values. SETTING: German general hospitals of a large, private group. PARTICIPANTS: Hospitals with mortality rates higher than reference values. INTERVENTIONS: Peer review of medical records by experienced, outside physicians triggered by in-hospital mortality rates higher than expected. Inadequacies were identified, improvement protocols enforced and mortality rates subsequently re-examined. MAIN OUTCOME MEASURES: Mortality rates 1 year before and 1 year after peer review and protocol use. RESULTS: For AMI, CHF, pneumonia, stroke, MV and colorectal surgery, the mortality rates 1 year post-peer review were significantly decreased as compared to pre-peer review mortality rates. The standardized mortality ratio for all of the above diagnoses was 1.45, 1 year before peer review, and 0.97, 1 year after peer review. The absolute risk reduction of 7.3% translates into 710 deaths in this population which could have been prevented. CONCLUSIONS: Peer review triggered and conducted in the manner described here is associated with a significant lowering of in-hospital mortality rates in hospitals that previously had higher than expected mortality rates.

[10 years of Peer Reviewing: improving treatment by quality indicators from administrative data]. / 10 Jahre Peer Review - Verbesserung der medizinischen Behandlung durch Qualitätsindikatoren aus Routinedaten.

BACKGROUND AND OBJECTIVES: In-hospital mortality of myocardial infarction, heart failure and pneumonia within a private hospital chain were compared with the German average since 2000. METHODS: Increased in-hospital mortalities based on diagnosis coding with ICD-10 benchmarked with German average values induced peer reviews in concern hospitals. From 2000 until 2010, peer reviews as performed by at least 2 peers compared retrospectively case management and treatment with best care, classified the treatment and discussed it with responsible physicians. The classification consisted of category 1 for improvement potential, category 2 for miscoding and category 3 for sufficient treatment. Based on the improvement potential an operational plan of treatment improvement for the single hospital was produced which was to be realized by this hospital and supported by concern activities for knowledge improvement. RESULTS: In 2000, the indicators in-hospital mortality of myocardial infarction, heart failure and pneumonia of the hospital chain exceeded German average whereas in 2008 these values were lower (i. e. better) than German average. The peer reviews detected large improvement potentials in treatment processes and helped to improve them. CONCLUSION: Peer reviews as triggered by quality indicators supported improvement of treatment and likely outcomes.

Echocardiographic quantification of regional left ventricular wall motion with color kinesis.

Echocardiographic assessment of regional systolic left ventricular function is usually performed qualitatively and depends on investigator experience. In this study, we investigated a new method for quantifying regional systolic wall motion based on color kinesis. In this study, regional systolic wall motion velocity (Vsys) was determined by dividing end-systolic color width by systolic time. High regional wall motion velocity (Vhigh) was determined by dividing the width of the widest color by its duration of 40 ms. First, in vitro measurements with an acrylic glass model were obtained; these demonstrated a high correlation between echocardiographically determined and real "wall motion velocities" (R = 0.99, p<0.001, R2 = 0.99). Then, 17 healthy, young persons were examined, and normal values for each left ventricular wall segment (16-segment model) were determined. The mean Vsys and Vhigh of all 272 wall segments were 2.3+/-0.6 and 7.4+/-1.8 cm/s, respectively. Finally, in 12 patients with coronary artery disease and prior myocardial infarction, Vsys and Vhigh of each left ventricular wall segment were determined and compared with conventional echocardiographic wall motion analysis using the usual 4-grade score system. Analysis of data showed that quantitative color kinesis measurements demonstrated significantly lower velocity values in pathologic than in normal wall segments (Mann-Whitney U test, p<0.05). Measurements discriminated between pathologic and normal wall motion, with an accuracy of 89% for Vsys and 83% for Vhigh (chi-square test, p<0.05). To summarize, in this first study, measurements of regional wall motion velocities with color kinesis demonstrated reliable results for the quantification of regional left ventricular systolic function.

Dobutamine stress echocardiography.

Dobutamine is a synthetic catecholamine with predominant beta-stimulation. Its half-life is approximately 2 min. The positive chronotropic and inotropic effects of dobutamine induce myocardial ischaemia if significant coronary artery obstruction is present. Regional ischaemia produces regional wall motion abnormalities which can be detected by echocardiography. Most dobutamine stress protocols start at an infusion rate of 5 micrograms.kg-1.min-1 and increase to a peak dose of 40 or 50 micrograms.kg-1.min-1; to further increase heart rate, a bolus injection of 0.25-1.0 mg atropine is added. Test endpoints are the detection of new wall motion abnormalities, the occurrence of severe complications or achievement of the target heart rate. Viable myocardial regions have a positive inotropic reserve, which can be stimulated by dobutamine and detected by echocardiography. Indications for the use of dobutamine stress echocardiography are to prove stress-inducible myocardial ischaemia and to detect myocardial viability. The test should only be performed for the detection of stress-induced myocardial ischaemia if patients are unable to undergo exercise echocardiography, or if patients fail to reach their required test level in exercise echocardiography.

Arbutamine stress echocardiography.

Arbutamine, a new potent non-selective beta-adrenoceptor agonist with mild alpha 1-sympathomimetic activity, has been developed specifically for pharmacological stress testing. The drug acts like physical exercise, increasing both heart rate and myocardial contractility. Sensitivity, specificity and accuracy in detecting significant stenotic coronary artery disease are 76%, 96%, and 82%, respectively, again similar to those of exercise echocardiography. The drug is delivered by a computerized drug delivery and monitoring device (GenESA) which adjusts the infusion rate according to the patient's heart rate data feedback. The drug is generally well tolerated and has an acceptable safety profile. This article describes recent clinical experience with arbutamine and presents preliminary results of a multicentre multinational study which evaluates the clinical utility and safety of the GenESA system in diagnosing coronary artery disease.

Stress echocardiography: personnel and technical equipment.

In recent years, stress echocardiography has gained broad acceptance as a non-invasive method for the diagnosis of coronary artery disease. Facing different protocols, dosages and instrumentation, official guidelines for the performance, standardization and quality control of stress echocardiograms are needed; however, so far they are not available. This paper recommends the type of personnel and technical equipment needed for stress echocardiography laboratories, based on experience gained during more than 2000 stress echocardiographic procedures. To perform stress echocardiography, a cardiologist and a technical assistant--both well trained over a large number of tests--should be involved. The laboratory must have basic equipment such as a 12-lead ECG, blood pressure monitoring capacity, a treadmill or bicycle for ergometry, a precision intravenous delivery system for pharmacological stress testing as well as an adequate echo table; additionally, emergency equipment is mandatory. The ultrasound machine should contain transducers with high 2-D resolution; most important is a digital image acquisition system which facilitates performance and interpretation through side-by-side display of synchronized rest and stress images. Finally, there is a need for proper patient preparation and the obtaining of informed consent.

Detection of myocardial viability using stress echocardiography.

Asynergic myocardial regions in patients with coronary artery disease can be viable. They may have the ability to improve their function after restoring coronary blood flow. Asynergic but viable myocardial regions have a positive inotropic reserve which can be stimulated by catecholamines. Because echocardiography is an established method for evaluating regional left ventricular function, it has the potential to detect the inotropic response of asynergic myocardial regions. In the clinical setting, prediction of left ventricular functional improvement after revascularization is particularly important. Dobutamine stress echocardiography is the most frequently used stress echocardiographic test for detection of myocardial viability. Dobutamine is infused at low rates of 2.5 to 20 micrograms.kg-1.min-1 to detect myocardial viability. This paper reports on the sensitivity and specificity of the method for the detection of viability and its usefulness for prediction of left ventricular functional improvement after revascularization.

[Acute mitral insufficiency in osteogenesis imperfecta]. / Akute Mitralinsuffizienz bei Osteogenesis imperfecta.

A 56-year-old woman with known osteogenesis imperfecta tarda but no obvious sign of cardiac disease developed increasing dyspnoea, eventually even at rest, with blood-streaked sputum over a period of 10 days. The chest radiograph demonstrated intraalveolar pulmonary oedema. Transthoracic echocardiography revealed as the likely cause of these signs chordal rupture of the anterior leaflet of the mitral valve with mitral regurgitation. After treatment of the cardiac failure with frusemide (up to 500 mg daily intravenously), nitrates and captopril (25 mg daily by mouth) the diagnosis was confirmed by transoesophageal echocardiography. Elective replacement of the mitral and aortic valves was performed 6 months later. Acid mucopolysaccharides were demonstrated histologically in the valvar stroma, a finding consistent with osteogenesis imperfecta. Echocardiography should be performed routinely in connective-tissue disease to reveal any possible cardiovascular involvement.

Pharmacokinetics of thallium-201 in normal individuals after routine myocardial scintigraphy.

Data of pharmacokinetic distribution of and radiation dose from 201Tl chloride used in routine myocardial scintigraphy are based on animal studies or on small groups of humans not exercised. In order to obtain data under routine conditions pharmacokinetics of 201Tl were measured in 15 individuals who had undergone diagnostic myocardial scintigraphy and were classified as normal. Ventral and dorsal whole-body scans were acquired until 9 days after injection. Conjugate pixels were averaged geometrically. Percentage values of total administered dose were obtained for total body and 13 organs by using a calculation method that takes into account the differentiation of overlapping organs.