Cost-effectiveness of coronary stenting in acute myocardial infarction: results from the stent primary angioplasty in myocardial infarction (stent-PAMI) trial.

BACKGROUND: Although several randomized trials have demonstrated that coronary stenting improves angiographic and clinical outcomes for patients with acute myocardial infarction (AMI), the cost-effectiveness of this practice is unknown. The objective of the present study was to evaluate the long-term costs and cost-effectiveness (C/E) of coronary stenting compared with primary balloon angioplasty as treatment for AMI. Methods and Results- Between December 1996 and November 1997, 900 patients with AMI were randomized to undergo balloon angioplasty (PTCA, n=448) or coronary stenting (n=452). Detailed resource utilization and cost data were collected for each patient's initial hospitalization and for 1 year after randomization. Compared with conventional PTCA, stenting increased procedural costs by approximately $2000 per patient ($6538+/-1778 versus $4561+/-1598, P<0.001). During the 1-year follow-up period, stenting was associated with significant reductions in the need for repeat revascularization and rehospitalization. Although follow-up costs were significantly lower with stenting ($3613+/-7743 versus $4592+/-8198, P=0.03), overall 1-year costs remained approximately $1000/patient higher with stenting than with PTCA ($20 571+/-10 693 versus 19 595+/-10 990, P=0.02). The C/E ratio for stenting compared with PTCA was $10 550 per repeat revascularization avoided. In analyses that incorporated recent changes in stent technology and pricing, the 1-year cost differential fell to <$350/patient, and the C/E ratio improved to $3753 per repeat revascularization avoided. The cost-utility ratio for primary stenting was <$50 000 per quality-adjusted life year gained only if stenting did not increase 1-year mortality by >0.2% compared with PTCA. CONCLUSIONS: As performed in Stent-PAMI, primary stenting for AMI increased 1-year medical care costs compared with primary PTCA. The overall cost-effectiveness of primary stenting depends on the societal value attributed to avoidance of symptomatic restenosis, as well as on the relative mortality rates of primary PTCA and stenting.

Correlating physical and mental health status with satisfaction in a health plan.

Managed care organizations strive to prevent illness where possible and improve patient outcomes for enrollees. The objective of this study was to examine how data from the Medical Outcomes Study Short Form-12 from more than 45,000 health plan enrollees can be used to: compare enrollee health status with national norms, examine the relationship between health status and member characteristics, and determine the extent to which health status is related to member satisfaction. The member survey measured physical and mental health and the following aspects of satisfaction: access, communication, and medical services. The researchers found that physical and mental health status were significantly associated with age, education, and ethnicity, whereas satisfaction was positively correlated with mental health status. Monitoring the health status of enrollees through the administration of a short, well-validated questionnaire can provide useful information in comparison with national norms as well as important insights regarding potential areas to target for quality improvement initiatives.

Influenza vaccination, hospitalizations, and costs among members of a Medicare managed care plan.

OBJECTIVE: To evaluate the effectiveness and possible cost savings of influenza vaccination. SUBJECTS: Members age 65 and older in a Medicare managed care plan during the 1994-1995, 1995-1996, and 1996-1997 influenza seasons. RESEARCH DESIGN: The study examined administrative data on influenza vaccination and subsequent hospitalizations. Outcomes included hospitalization with pneumonia or influenza, with any respiratory condition, and with congestive heart failure (CHF). RESULTS: Vaccinated subjects experienced fewer hospitalizations with respiratory conditions or CHF than had unvaccinated subjects (OR=0.8 (95% CI, 0.7, 0.9) in analyses adjusted for age, sex, pneumococcal vaccination, health utilization, and morbidity). Analyses adjusted in addition for ethnicity obtained similar results among the subgroup of members whose ethnicity was known. Subjects without major disease in the previous 12 months had lower odds ratios for vaccination than subjects with major disease (OR values of 0.5 [95% CI, 0.4, 0.7] and 0.9 [95% CI, 0.8, 1.1], respectively). Subjects ages 65 to 79 had lower odds ratios for vaccination than subjects ages 80 and older (OR values of 0.7 [95% CI, 0.6, 0.9] and 0.9 [95% CI, 0.8, 1.1], respectively). Estimated cost savings averaged about $80 per vaccinated subject. CONCLUSIONS: Subjects ages 65 to 79 who had received influenza vaccination experienced fewer hospitalizations and had lower costs than had unvaccinated subjects. Associations were weaker for subjects age 80 and older. The results, consistent with recommendations for the use of influenza vaccine, suggest that people ages 65 to 79 should be heavily targeted for vaccination.

Ethnic disparities in care following acute coronary syndromes among Asian Americans and Pacific Islanders during the initial hospitalization.

Despite the fact that Asian Americans and Pacific Islanders are the fastest growing minority population in the United States, little is known about their treatment patterns and outcomes, particularly for Asian American and Pacific Islander sub-groups. Multivariable logistic regression was used to compare differences in revascularization and mortality rates following acute coronary syndromes among Asian American and Pacific Islander sub-groups [Japanese (n = 1342), Chinese (n = 249), Filipino (n = 314), Native Hawaiian (n = 361)) and Caucasians (n = 569)] during the initial hospitalization using administrative (claims) data from 1997 to 1999. Analyses were stratified by gender and controlled for age, diabetes mellitus, congestive heart failure, acute myocardial infarction, ACG morbidity level and system of care. We found that the type of procedures received during the initial hospitalization differed according to patient ethnicity for male patients but not for female ones. Compared to Caucasians, male Asian Amercian and Pacific Islanders patients were less likely to undergo percutaneous coronary interventions and more likely to undergo coronary artery bypass graft surgery. In the future, a more comprehensive outcomes study is needed, to examine the impact of any interethnic differences in revascularization rates on intermediate and long-term mortality, patient satisfaction, and self-reported functioning and well-being. The trend toward higher mortality following acute coronary syndromes among Asian Americans and Pacific Islander males emphasizes the importance of such a study.

Do patient assessments of primary care differ by patient ethnicity?

OBJECTIVE: To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity. DATA SOURCES/STUDY DESIGN: A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design. PRINCIPAL FINDINGS: Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites. CONCLUSIONS: We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed.

Impact of smoking on health-related quality of life after percutaneous coronary revascularization.

BACKGROUND: PTCA is performed primarily to improve health-related quality of life (HRQOL) in patients with symptomatic coronary artery disease. In patients undergoing PTCA, smoking has been shown to increase risks of late myocardial infarction and death. Whether smoking also affects HRQOL after PTCA is currently unknown. METHODS AND RESULTS: We examined the relation between smoking status and HRQOL among 1432 patients who underwent PTCA as part of 2 multicenter clinical trials. HRQOL was assessed with the use of the Medical Outcomes Study SF-36 questionnaire. Patients were classified as smokers (n=301), quitters (n=141), or nonsmokers (n=990) on the basis of their smoking status at the time of their index procedure and during the first year of follow-up. For the overall population, HRQOL improved significantly after PTCA for all scales except general health perception, with improvements ranging from 5.5 points for mental health to 23.2 points for role-physical functioning. After adjustment for baseline characteristics and initial HRQOL, nonsmokers had gains at 6 months that were larger than those of smokers for all health domains: physical function (15.4 versus 10.4 points), role-physical (24.5 versus 13.9), pain (18.4 versus 13.3), general health perception (1.7 versus -4.5), vitality (11.0 versus 4. 7), social function (12.8 versus 3.5), role-emotional (13.5 versus 6. 7), and mental health (6.8 versus 0.8; P:<0.02 for all comparisons). Quitters had 6-month HRQOL improvements that were greater than those in smokers for all domains as well. Findings were similar at 1 year. CONCLUSIONS: Quality-of-life benefits of PTCA are diminished by continued smoking. Efforts to promote smoking cessation at the time of PTCA may substantially improve the health outcomes of these procedures.

Percutaneous coronary revascularization in elderly patients: impact on functional status and quality of life.

BACKGROUND: Percutaneous coronary intervention (PCI) is frequently performed in elderly patients, but little is known about its impact on overall health and quality of life. OBJECTIVE: To examine changes in health-related quality of life among elderly patients after PCI. DESIGN: Observational study. SETTING: 75 U.S. hospitals. PATIENTS: Participants in two clinical trials of PCI. MEASUREMENTS: Health-related quality of life was assessed by using the Medical Outcomes Study Short Form (SF-36) survey and the Seattle Angina Questionnaire at baseline, 6 months, and 1 year. RESULTS: Serial data on health-related quality of life were available for 295 elderly (> or =70 years) and 1150 nonelderly (<70 years) patients. At 6 months, physical health had improved in 51% of elderly patients and mental health had improved in 29%. Cardiovascular-specific health status had improved in 58% to 75% of elderly patients. Improvement did not significantly differ between elderly and non-elderly patients at 6 months or 1 year. CONCLUSIONS: Elderly patients selected for participation in a trial of PCI had substantial improvements in health-related quality of life after PCI that were similar to those in younger patients.

Physicians' recommendations to patients for use of antibiotic prophylaxis to prevent endocarditis.

CONTEXT: The American Heart Association recommendations for infectious endocarditis (IE) prophylaxis, published in June 1997, sought to improve patient and physician compliance by simplifying the dosing regimen and clarifying endocarditis risk. Adherence to these updated recommendations in patients with echocardiographic verification of their endocarditis risk profile is unknown. OBJECTIVE: To determine the recommended and actual use of IE prophylaxis as reported by patients undergoing echocardiography. DESIGN, SETTING, AND PARTICIPANTS: All patients who underwent outpatient transthoracic echocardiography at a university-based tertiary hospital in Boston, Mass, during December 1997 were contacted 6 to 9 months later to respond to a survey, completed by 218 (80%) eligible subjects. MAIN OUTCOME MEASURE: Patients' report of their physicians' instructions on actual use of IE prophylaxis in accordance with patient risk category, determined by echocardiographic data. RESULTS: One hundred eight patients (49.5%) had clinical or echocardiographic findings for which prophylaxis was indicated. Of these 108 patients, 71 (65.7%) reported that they were instructed to take IE prophylaxis. Sixteen high-risk patients (88. 9%) but only 55 moderate-risk patients (61.1%) reported that they were instructed to take prophylaxis. Among the 110 negligible-risk patients, 29 (26.4%) reported that they had been instructed to take IE prophylaxis. Overall, 100 patients (45.9%) reported that they received physician instructions to take IE prophylaxis. Of those who subsequently underwent a procedure for which IE prophylaxis was indicated (n=68), 9 (13.2%) elected not to follow their physician's advice to take prophylaxis. CONCLUSIONS: We found that although most patients reported receiving instructions for IE prophylaxis use consistent with American Heart Association guidelines, IE prophylaxis overuse among negligible-risk patients and underuse among moderate-risk patients was common. Continued physician and patient education may lead to improved adherence to the current American Heart Association recommendations. JAMA. 2000;284:68-71

Organizational and financial characteristics of health plans: are they related to primary care performance?

BACKGROUND: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data. OBJECTIVE: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences. METHODS: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians. RESULTS: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05). CONCLUSIONS: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.

Cardioversion in patients with atrial fibrillation and left atrial thrombi on initial transesophageal echocardiography: should transesophageal echocardiography be repeated before elective cardioversion? A cost-effectiveness analysis.

BACKGROUND: Transesophageal echocardiography (TEE) is used to expedite early cardioversion for patients with atrial fibrillation in whom TEE excludes the presence of atrial thrombi. However, the management of patients with atrial thrombi on initial TEE is controversial. Some advocate cardioversion after 3 to 4 weeks of anticoagulant therapy, whereas others perform a follow-up TEE to document thrombus resolution. We performed a cost-effectiveness analysis to compare the two strategies. METHODS AND RESULTS: A computer-based decision analysis model was used to compared 2 strategies: No Follow-up TEE-patients with thrombi on initial TEE complete 4 weeks of anticoagulation and undergo elective cardioversion. Follow-up TEE-patients undergo a follow-up TEE after 4 weeks of anticoagulant therapy. If a thrombus is detected, cardioversion is not performed and patients remain in atrial fibrillation; patients without a thrombus undergo cardioversion. Under our baseline estimates, the Follow-up TEE strategy is less costly and slightly more effective than the No Follow-up TEE strategy. The results are most sensitive to changes in the risk of postcardioversion stroke for patients with atrial thrombi on initial TEE who have completed 4 weeks of anticoagulation and to the probability of residual thrombi on follow-up TEE. CONCLUSIONS: In this cost-effectiveness analysis for patients with atrial fibrillation and left atrial thrombi detected on initial TEE, a Follow-up TEE strategy may be more cost-effective than the No Follow-up TEE strategy. However, the decision is particularly dependent on the risk of postcardioversion stroke in patients with undetected residual left atrial thrombi.

Linking primary care performance to outcomes of care.

BACKGROUND: Substantial research links many of the defining characteristics of primary care to important outcomes; yet little is known about the relative importance of each characteristic, and several characteristics have not been examined. These analyses evaluate the relationship between seven defining elements of primary care (accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment, and trust) and three outcomes (adherence to physician's advice, patient satisfaction, and improved health status). METHODS: Data were derived from a cross-sectional observational study of adults employed by the Commonwealth of Massachusetts (N = 7204). All patients completed a validated questionnaire, the Primary Care Assessment Survey. Regression methods were used to examine the association between each primary care characteristic (11 summary scales measuring 7 elements of care) and each outcome. RESULTS: Physicians' comprehensive ("whole person") knowledge of patients and patients' trust in their physician were the variables most strongly associated with adherence, and trust was the variable most strongly associated with patients' satisfaction with their physician. With other factors equal, adherence rates were 2.6 times higher among patients with whole-person knowledge scores in the 95th percentile compared with the 5th percentile (44.0% adherence vs 16.8% adherence, P < .001). The likelihood of complete satisfaction was 87.5% for those with 95th percentile trust scores compared with 0.4% for patients with 5th percentile trust scores (P < .001). The leading correlates of self-reported health improvements were integration of care, thoroughness of physical examinations, communication, comprehensive knowledge of patients, and trust (P < .001). CONCLUSIONS: Patients' trust in their physician and physicians' knowledge of patients are leading correlates of three important outcomes of care. The results are noteworthy in the context of pervasive changes in our nation's health care system that are widely viewed as threatening to the quality of physician-patient relationships.

The relationship between patient income and physician discussion of health risk behaviors.

CONTEXT: The US Preventive Services Task Force recommends that physicians assess patients' health risk behaviors, addressing those needing modification. OBJECTIVE: To examine the relationship between patient income, health risk behaviors, the prevalence of physician discussion of these behaviors, and the receptiveness of patients to their physicians' advice. DESIGN: Employee survey. PARTICIPANTS: A random sample of 6549 Massachusetts state employees in 12 health plans. MAIN OUTCOME MEASURES: Data were obtained using a patient-completed mail survey. Trend tests were used to discern differences in the prevalence of health risk behaviors, physician discussion of these behaviors, and patient receptiveness to discussions by patient income. RESULTS: Although unhealthy behaviors were common among all income groups, physician discussion of health risk behaviors fell far short of the universal risk assessment recommended by the US Preventive Services Task Force. Low-income patients were more likely to be obese and smoke than high-income patients and were less likely to wear seat belts and exercise. In contrast, stress and alcohol consumption increased with income, while the proportion of heavy drinkers did not vary significantly. Physicians were more likely to discuss diet and exercise with high-income patients in need of these discussions than with low-income patients, but were more likely to discuss smoking with low-income patients who smoked than with high-income patients who smoked. Among patients with whom discussions occurred, low-income patients were much more likely to report attempting to change their behavior based on physician advice. CONCLUSIONS: Physician counseling of patients regarding health risk behaviors should be greatly improved if the US Preventive Services Task Force recommendations are to be fulfilled. Improvement is especially needed in regard to alcohol consumption, safe sex, and seat belt use. Physicians also need to be more vigilant in properly identifying and counseling low-income patients at risk in regard to diet and exercise and high-income patients who smoke.

Asian-American patient ratings of physician primary care performance.

OBJECTIVE: To examine how Asian-American patients' ratings of primary care performance differ from those of whites. Latinos, and African-Americans. DESIGN: Retrospective analyses of data collected in a cross-sectional study using patient questionnaires. SETTING: University hospital primary care group practice. PARTICIPANTS: In phase 1, successive patients who visited the study site for appointments were asked to complete the survey. In phase 2, successive patients were selected who had most recently visited each physician, going back as far as necessary to obtain 20 patients for each physician. In total, 502 patients were surveyed, 5% of whom were Asian-American. MAIN RESULTS: After adjusting for potential confounders, Asian-Americans rated overall satisfaction and 10 of 11 scales assessing primary care significantly lower than whites did. Dimensions of primary care that were assessed include access, comprehensiveness of care, integration, continuity, clinical quality, interpersonal treatment, and trust. There were no differences for the scale of longitudinal continuity. On average, the rating scale scores of Asian-Americans were 12 points lower than those of whites (on 100-point scales). CONCLUSIONS: We conclude that Asian-American patients rate physicians primary care performance lower than do whites, African-Americans, and Latinos. Future research needs to focus on Asian-Americans to determine the generalizability of these findings and the extent to which they reflect differences in survey response tendencies or actual quality differences.

Cost-effectiveness of transesophageal echocardiographic-guided cardioversion: a decision analytic model for patients admitted to the hospital with atrial fibrillation.

OBJECTIVES: Using a decision-analytic model, we sought to examine the cost-effectiveness of three strategies for cardioversion of patients admitted to the hospital with atrial fibrillation. BACKGROUND: Transesophageal echocardiographic (TEE)-guided cardioversion has been proposed as a method for early cardioversion of patients with atrial fibrillation. The cost-effectiveness of this approach, relative to conventional therapy, has not been studied. METHODS: We ascertained the cost per quality-adjusted life-year (QALY) of three strategies: 1) conventional therapy--transthoracic echocardiography (TTE) and warfarin therapy for 1 month before cardioversion; 2) initial TTE, followed by TEE and early cardioversion if no thrombus is detected; 3) initial TEE, with early cardioversion if no thrombus is detected. With strategies 2 and 3, if a thrombus is seen, follow-up TEE is performed. If no thrombus is seen, cardioversion is then performed. All strategies utilized anticoagulation before and extending for 1 month after cardioversion. Life expectancy, utilities (quality-of-life weights) and event probabilities were ascertained from published reports. Cost estimates were based on published data and hospital accounting information. RESULTS: Transesophageal echocardiographic-guided early cardioversion (strategy 3: cost $2,774, QALY 8.49) dominates TTE/TEE-guided cardioversion (strategy 2: cost $3,106, QALY 8.48) and conventional therapy (strategy 1: cost $3,070, QALY 8.48) because it is the least costly with similar effectiveness. Sensitivity analyses demonstrated that TEE-guided cardioversion (strategy 3) dominates conventional therapy if the risk of stroke after TEE negative for atrial thrombus is slightly less than that after conventional therapy (baseline estimate 0.8%). The results also depend on the risk of major hemorrhage but are less sensitive to baseline estimates of morbidity from TEE, cost of TTE, cost of hospital admission for cardioversion and utilities for health states. CONCLUSIONS: On the basis of a decision-analytic model, TEE-guided early cardioversion, without TTE, is a reasonable cost-saving alternative to conventional therapy for patients admitted to the hospital with atrial fibrillation. Such a strategy appears particularly beneficial for patients with an increased risk of hemorrhagic complications. Future clinical studies examining the TEE strategy should consider eliminating initial TTE and carefully assess both the thromboembolic and hemorrhagic risk.

Effect of physician gender on the prescription of estrogen replacement therapy.

OBJECTIVE: To determine if women cared for by female physicians are more likely to receive postmenopausal estrogen replacement therapy than women cared for by male physicians. DESIGN: Case-control study with follow-up telephone survey. SETTING: An outpatient practice at an urban teaching hospital in Boston, Massachusetts. PARTICIPANTS: Subjects were women begun on estrogen replacement therapy during an 18-month period; controls were matched on age and month of visit. Seventy-one cases (mean age 60 years, 41% nonwhite) and 142 controls (mean age 60 years, 48% nonwhite) were identified. Fifty-two (82%) of 64 eligible case patients and 89 (80%) of 111 eligible control patients completed a follow-up telephone interview assessing their preferences for female physicians and interest in estrogen replacement therapy. MAIN RESULTS: After adjusting for potential confounders using conditional logistic regression, patients with female physicians were more likely to begin estrogen replacement therapy than those seen by male physicians (odds ratio [OR] 5.4; 95% confidence interval [CI] 1.8, 15.3). Case patients selected their primary care physician more often than control patients and were more interested in estrogen replacement therapy. After adjusting for potential confounders including patients' preferences to select their physician and their interest in estrogen replacement therapy, patients with female physicians were still more likely to begin estrogen replacement therapy than those seen by male physicians (OR 11.4, 95% CI 1.1, 113.6). CONCLUSIONS: We conclude that female patients are more likely to be prescribed estrogen replacement therapy if they are cared for by female physicians rather than male physicians even after accounting for patient preferences. Further research is required to determine whether these differences reflect differences in physicians' knowledge or attitudes regarding estrogen replacement therapy or reflect gender differences in how physicians discuss estrogen replacement therapy with their patients.