Subject(s)
Cardiology , Cardiovascular System , Career Choice , Career Mobility , Humans , Retirement , Treatment OutcomeABSTRACT
OBJECTIVE: Clinicians need better approaches to evaluating women at midlife and beyond who present to primary care with chest pain and related symptoms. A previously validated blood-based test, which includes age, sex, and gene expression levels, showed a 96% negative predictive value for determining an individual's current likelihood of having obstructive coronary artery disease (CAD) in a combined population of men and women. We hypothesized that age/sex/gene expression score (ASGES) would be incorporated into medical decision-making and would influence the rate of further cardiac evaluation. METHODS: An aggregate analysis of female cohorts from the Investigation of a Molecular Personalized Coronary Gene Expression Test on Primary Care Practice Pattern (IMPACT-PCP; NCT01594411) and REGISTRY I (NCT01557855) studies was conducted. Data on 320 women presenting with stable symptoms suggestive of obstructive CAD and undergoing ASGES testing (from 16 primary care providers in geographically diverse sites) were pooled. The primary outcome of this analysis was the association between ASGES and referrals for further cardiac evaluation. RESULTS: The mean participant age was 57.8 years, and the mean ASGES (predefined as low [ASGES ≤15] or elevated [ASGES >15]) was 10.3. The referral rate for further cardiac evaluation was 4.0% (10 of 248) for women with low ASGES versus 83.3% (60 of 72) for women with elevated ASGES, with an overall follow-up major adverse cardiac event/revascularization rate of 1.2%. After adjustment for clinical covariates, women with low ASGES were significantly less likely to be referred for further cardiac evaluation (odds ratio, 0.013; Pâ<â0.0001). CONCLUSIONS: ASGES can be incorporated into medical decision-making to help primary care providers rule out obstructive CAD among symptomatic women who are unlikely to benefit from further cardiac testing.
Subject(s)
Algorithms , Ambulatory Care/methods , Clinical Decision-Making , Coronary Artery Disease/diagnosis , Primary Health Care/methods , Cohort Studies , Coronary Angiography/methods , Coronary Artery Disease/prevention & control , Female , Gene Expression Profiling/methods , Humans , Middle Aged , Predictive Value of Tests , Prospective Studies , Risk Assessment/methods , Women's HealthSubject(s)
Cardiac Catheterization/standards , Cardiology/standards , Certification/standards , Clinical Competence/standards , Health Facilities/standards , Heart Valve Diseases/therapy , Heart Valve Prosthesis Implantation/standards , Mitral Valve , Cardiac Catheterization/adverse effects , Heart Valve Diseases/diagnosis , Heart Valve Diseases/physiopathology , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/methods , Humans , Medical Staff Privileges/standards , Mitral Valve/physiopathology , Patient Care Team/standards , Policy Making , Program Development/standards , Treatment OutcomeSubject(s)
Aortic Valve Stenosis/surgery , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/standards , Hospitals/standards , Mitral Valve/surgery , Patient Care Team/standards , Cardiac Catheterization , Cardiac Surgical Procedures/methods , Cardiology/standards , Clinical Competence/standards , Humans , Treatment OutcomeSubject(s)
Cardiac Catheterization , Fractional Flow Reserve, Myocardial , Percutaneous Coronary Intervention , Terminology as Topic , Ultrasonography, Interventional , Cardiac Catheterization/classification , Clinical Competence , Curriculum , Education, Medical, Graduate , Humans , Learning Curve , Percutaneous Coronary Intervention/classification , Percutaneous Coronary Intervention/education , Predictive Value of Tests , Ultrasonography, Interventional/classificationSubject(s)
Acute Coronary Syndrome , Coronary Artery Disease , American Heart Association , Cardiology/standards , Female , Humans , Male , Societies, Medical , United StatesSubject(s)
Acute Coronary Syndrome/therapy , American Heart Association , Cardiology/standards , Coronary Artery Disease/therapy , Research Design/standards , Acute Coronary Syndrome/diagnosis , Acute Coronary Syndrome/epidemiology , Advisory Committees/standards , Coronary Artery Disease/diagnosis , Coronary Artery Disease/epidemiology , Disease Management , Foundations/standards , Humans , Research Report/standards , Treatment Outcome , United States/epidemiologySubject(s)
Aortic Valve Stenosis/therapy , Cardiac Catheterization/standards , Clinical Competence/standards , Heart Valve Prosthesis Implantation/standards , Hospitals/standards , Evidence-Based Medicine/standards , Heart Valve Prosthesis Implantation/methods , Humans , Knowledge Bases , Medical Staff Privileges/standards , Patient Care Team/standards , Quality of Health Care/standards , Treatment OutcomeABSTRACT
BACKGROUND: Risk-standardized all-cause 30-day readmission rates (RSRRs) after percutaneous coronary intervention (PCI) have been endorsed as a national measure of hospital quality. Little is known about variation in the performance of hospitals on this measure, and whether high hospital rates of readmission after PCI are due to modifiable deficiencies in quality of care has not been assessed. METHODS AND RESULTS: We estimated 30-day, all-cause RSRRs for all nonfederal PCI-performing hospitals in Massachusetts, adjusted for clinical and angiographic variables, between 2005 and 2008. We assessed if differences in race, insurance type, and PCI and post-PCI characteristics, including procedural complications and discharge characteristics, could explain variation between hospitals using nested hierarchical logistic regression models. Of 36 060 patients undergoing PCI at 24 hospitals and surviving to discharge, 4469 (12.4%) were readmitted within 30 days of discharge. Hospital RSRRs ranged from 9.5% to 17.9%, with 8 of 24 hospitals being identified as outliers (4 lower than expected and 4 higher than expected). Differences in race, insurance, PCI, and post-PCI factors accounted for 10.4% of the between-hospital variance in RSRRs. CONCLUSIONS: We observed wide variation in hospital 30-day all-cause RSRRs after PCI, most of which could not be explained by identifiable differences in procedural and postprocedural factors. A better understanding of etiologies of hospital variation is necessary to determine whether this measure is an actionable assessment of hospital quality, and, if so, how hospitals might improve their performance.