The cost of pneumonia after acute stroke.

OBJECTIVE: To determine the incremental costs of pneumonia occurring during hospitalization for stroke. METHODS: We reviewed hospital records of all Medicare patients admitted for ischemic or hemorrhagic stroke to 29 hospitals in a large metropolitan area, 1991 through 1997, excluding those who died or had do not resuscitate orders written within 3 days of admission. Hospital costs of patients with stroke were determined using Medicare Provider Analysis and Review data after adjustment for baseline factors affecting cost and propensity for pneumonia. Secondary analyses examined the risk-adjusted relationship of pneumonia to discharge disposition. RESULTS: Pneumonia occurred in 5.6% (635/11,286) of patients with stroke, and was more common among patients admitted from nursing homes and those with greater severity of illness (p < 0.001). Mean adjusted costs of hospitalization for patients with stroke with pneumonia were $21,043 (95% CI $19,698 to 22,387) and were $6,206 (95% CI $6,150 to 6,262) for patients without pneumonia, resulting in an incremental cost of $14,836 (95% CI $14,436 to 15,236). Patients with pneumonia were over 70% more likely to be discharged with requirements for extended care (adjusted OR 1.73, 95% CI 1.32 to 2.26). CONCLUSION: Extrapolated to the over 500,000 similar patients hospitalized for stroke in the United States, the annual cost of pneumonia as a complication after acute stroke is approximately $459 million.

The effect of pneumonia on mortality among patients hospitalized for acute stroke.

OBJECTIVE: To determine the effect of pneumonia on 30-day mortality in patients hospitalized for acute stroke. METHODS: Subjects in the initial cohort were 14,293 Medicare patients admitted for stroke to 29 greater Cleveland hospitals between 1991 and 1997. The relative risk (RR) of pneumonia for 30-day mortality was determined in a final cohort (n = 11,286) that excluded patients dying or having a do not resuscitate order within 3 days of admission. Clinical data were obtained from chart abstraction and were merged with Medicare Provider Analysis and Review files to obtain deaths within 30 days. A predicted-mortality model (c-statistic = 0.78) and propensity score for pneumonia (c-statistic = 0.83) were used for risk adjustment in logistic regression analyses. RESULTS: Pneumonia was identified in 6.9% (n = 985) of all patients and in 5.6% (n = 635) of the final cohort. The rates of pneumonia were higher in patients with greater stroke severity and features indicating general frailty. Unadjusted 30-day mortality rates were six times higher for patients with pneumonia than for those without (26.9% vs 4.4%, p < 0.001). After adjusting for admission severity and propensity for pneumonia, RR of pneumonia for 30-day death was 2.99 (95% CI 2.44 to 3.66), and population attributable risk was 10.0%. CONCLUSION: In this large community-wide study of stroke outcomes, pneumonia conferred a threefold increased risk of 30-day death, adding impetus to efforts to identify and reduce the risk of pneumonia in patients with stroke.

The association between hospital type and mortality and length of stay: a study of 16.9 million hospitalized Medicare beneficiaries.

OBJECTIVES: To examine the association between hospital type and mortality and length of stay using hospitalized Medicare beneficiaries for a 10-year period. METHODS: The retrospective cohort study included 16.9 million hospitalized Medicare beneficiaries > or = 65 years of age admitted for 10 common medical conditions and 10 common surgical procedures from 1984 to 1993. A total of 5,127 acute-care hospitals in the United States were grouped into 6 mutually exclusive hospital types based on teaching status and financial structure (for-profit [FP], not-for-profit [NFP], osteopathic [OSTEO], public [PUB], teaching not-for-profit [TNFP], and teaching public [TPUB]) as reported in the 1988 American Hospital Association database. Logistic and linear regression methods were used to examine risk-adjusted 30-day and 6-month mortality and length of stay. RESULTS: During the 10-year study period, 10.6 million patients were admitted with 1 of the 10 selected medical conditions, and 6.3 million patients were hospitalized for 1 of the 10 selected surgical procedures. Patients at TNFP hospitals had significantly lower risk-adjusted 30-day mortality rates than patients at other hospital types when all diagnoses or procedures were combined (combined diagnoses: RR(TNFP) = 1.00 [reference], RR(TPUB) = 1.40, RR(OSTEO) = 1.14, RR(PUB) = 1.07, RR(FP) = 1.03, RR(NFP) = 1.02; combined procedures: RR(TNFP) = 1.00 [reference], RR(OSTEO) = 1.36, RR(TPUB) = 1.30, RR(PUB) = 1.16, RR(FP) = 1.13, RR(NFP) = 1.08). The results were mostly consistent when diagnoses and procedures were examined separately. After adjustment for patient characteristics, patients at other hospital types had 10% to 20% shorter lengths of stay (LOS) than patients at TNFP hospitals for most diagnoses and procedures studied. CONCLUSION: As measured by the risk-adjusted 30-day mortality, TNFP hospitals had an overall better performance than other hospital types. However, patients at TNFP hospitals had relatively longer LOS than patients at other hospital types, perhaps reflecting the medical education and research activities found at teaching institutions. Future research should examine the empirical evidence to help elucidate the adequate LOS for a given condition or procedure while maintaining the quality of care.

Managed care for the Medicaid disabled: effect on utilization and costs.

The objective of this study was to describe the effect on health care utilization and costs of a program of managed care for the Medicaid disabled. The study was designed as a pre/post enrollment cohort comparison and was carried out in three Ohio counties. The subjects were disabled Medicaid-insured patients who voluntarily enrolled in a managed care program for at least 6 months between July 1, 1995 and December 31, 1997, and who had (1) at least one Medicaid claim in the 24-months pre-enrollment period and (2) overall satisfactory postenrollment encounter-level data. Ohio Medicaid provided claims and reimbursements (costs) for the pre-enrollment period and encounter-level data for the postenrollment period. Postenrollment costs were estimated by applying category-specific average pre-enrollment costs to postenrollment utilization data. We measured the following per patient-month: (1) trends in category-specific utilization and costs for up to 24 months before and after enrollment, (2) differences in overall and category-specific costs 1 year before and after enrollment, and (3) changes in the distribution of services 1 year before and after enrollment. Utilization categories included inpatient care, outpatient hospital (including emergency department) care, physician services, prescription medications, durable medical equipment and supplies, and home health care. We found that satisfactory encounter data were available in two of three counties. Of 1,179 enrollees, 592 met all inclusion criteria. Before enrollment, utilization and costs were increasing significantly in four of six categories and were unchanging in two. Postenrollment, decreasing utilization was observed for three categories, one remained unchanged, and two were increasing, but from a lower "baseline." Except for physician services and home health care, there were lower utilization and estimated costs in all categories in the year after enrollment. Estimated inpatient and total costs declined by $155/patient-month (44.9%) and $210/patient-month (37.1%), respectively. Findings were similar across sites. Inpatient care, outpatient hospital care, and prescription medications accounted for 97% of the reductions in estimated costs in the postenrollment period. Among patients voluntarily enrolled for at least 6 months, managed care for the Medicaid disabled was associated with striking decreases in health care utilization and estimated costs. The effect of managed care on these patients' satisfaction, access to specialized services, quality of care, and health outcomes are understood incompletely.

Comparison of risk-adjustment systems for the medicaid-eligible disabled population.

OBJECTIVE: The objective of this study was to compare 2 approaches for subjecting capitation rates for disabled Medicaid-eligible patients in managed care plans to risk adjustment, the Disability Payment System (DPS) and the Ohio Prior Expenditure System (OPES). DESIGN: This was a retrospective cohort. SETTING AND SUBJECTS: The subjects were 157,142 nonelderly disabled individuals eligible for > or =1 month during state fiscal year 1995 (SFY95) for a 3-county Ohio Medicaid managed care demonstration project. DATA SOURCE: Data were from the Ohio Medicaid eligibility and fee-for-service claims files. ANALYSIS: As per OPES policy, individuals were classified by the duration of their eligibility in SFY93 as "old" eligibles (> or =6 months) or "new" eligibles (<6 months). Published relative payment weights for each system were adjusted and used to predict SFY95 expenditures in a budget-neutral comparison. Measures were variance in SFY95 expenditures explained by predicted payments (R2) and predictive ratios (predicted payment/actual SFY95 expenditure). Individuals with HIV/AIDS and hematological conditions, who enrolled disproportionately across the demonstration counties, were analyzed separately. RESULTS: Of the 157,142 individuals, 56.4% were new eligibles; 40.1% of the old eligibles had no claims-documented chronic disease diagnosis in the baseline year. The overall R2 was 0.091 with OPES and 0.057 with DPS. Neither system predicted >1% of individual-level expenditures for new eligibles. OPES severely underpaid for eligibles in the top percentile of predicted expenditures; DPS had mixed results. DPS predicted SFY95 expenditures substantially better than OPES for the enrollment bias categories. CONCLUSIONS: Before Medicaid programs move to full-risk capitation for disabled populations, better risk-adjustment methods are needed, especially for eligible patients with little claims experience, high predicted expenditures, or enrollment-bias conditions.

Rapid growth of rehabilitation services in traditional community-based nursing homes.

OBJECTIVE: To describe the changes in rehabilitation therapy services in nursing homes based in the community during a period of rapid escalation of Medicare payments to nursing homes. SETTING: All Medicaid-certified nursing homes in Ohio. SUBJECTS: The 52,705 residents newly admitted to nursing homes in 1994 and 1995. DESIGN: Retrospective trend analysis of administrative data. MAIN OUTCOME MEASURES: For newly admitted residents receiving 90 or more minutes of rehabilitation therapy per week, the trends in percentage and in the amount and type of therapy received were determined for eight quarters. RESULTS: Of all newly admitted residents, 50.5% received 90 or more minutes of therapy. When they received such therapy it averaged 412 minutes per week (SD = 259). Those residents who received rehabilitation services increased by 2.2% each quarter (p<.001), and the amount of therapy they received increased by 6.4 minutes each quarter (p<.0001). All three types of rehabilitation therapy-physical, occupational, and speech-increased (p<.015) over the study period. CONCLUSIONS: The traditional nursing home is an important site for the provision of rehabilitation therapy services. Rehabilitation specialists should be aware of these trends as they plan for the future of rehabilitation. The effectiveness of this increased provision of therapy service in terms of measurable outcomes needs to be evaluated.

Patient satisfaction with time spent with their physician.

BACKGROUND: We examined the variables related to patient satisfaction with the time spent with their family physician during the office visit. METHODS: Research nurses directly observed consecutive patient visits to 138 family physicians in 84 practices. Analyses examined sequential models of the association of patient and physician characteristics, visit type and length, and time use during visits, with patients' satisfaction with the amount of time spent with their physician. RESULTS: Among 2315 visit by adult patients returning questionnaires, patient satisfaction with the time spent with their physician was high and strongly linked to longer visits (P < 001). After controlling for visit duration, greater patient satisfaction with time spent was associated with older patient age, white race, better perceived health status, visits for well care, and visits with a greater proportion of the visit spent chatting. The physician's discussion of test results or findings from the physical examination was associated with greater satisfaction with time spent for visits longer than 15 minutes, but with less satisfaction with time spent for shorter visits. CONCLUSIONS: Physicians can enhance patient satisfaction with the amount of time spent during an office visit by spending a small proportion of time chatting about nonmedical topics, and by allowing sufficient time for exchange with the patient is feedback is necessary.

Indications, outcomes, and provider volumes for carotid endarterectomy.

CONTEXT: While trials have demonstrated that carotid endarterectomy is superior to best medical therapy, most recently among asymptomatic patients, uses and outcomes of the procedure in more representative settings have not been established. OBJECTIVES: To profile the use and outcomes of carotid endarterectomy in a representative sample of Ohio's Medicare beneficiaries and to examine the relationships between provider-specific procedural volumes and patient outcomes. DESIGN: Retrospective cohort using Medicare Provider Analysis and Review files supplemented by detailed reviews of medical records on a random sample of patients. SETTING: Ohio hospitals performing carotid endarterectomy. PATIENTS: A random sample of 678 charts of the 4120 non-health maintenance organization Medicare beneficiaries who underwent carotid endarterectomy between July 1, 1993, and June 30, 1994. MAIN OUTCOME MEASURES: Nonfatal stroke or death within 30 days of surgery. RESULTS: The reviewed patients were similar to all eligible patients in sociodemographic characteristics and 30-day mortality rates. Among the 678 patients, indications for surgery were asymptomatic carotid stenosis in 167 (24.6%), transient ischemic attack in 294 (43.4%), completed stroke in 62 (9.1%), and nonspecific symptoms in 155 (22.9%). Thirty-two patients (4.7%) died or suffered nonfatal strokes by 30 days postoperatively. In univariate analyses, rates varied by hospital volume (P=.004) but not surgeons' volume (P=.47), although power to detect this difference was limited. Patients at higher- and lower-volume hospitals had similar indications and distributions of comorbidities. In analyses controlling for indications, comorbid conditions, and surgeon's volume, being operated on in a higher-volume hospital conferred a 71% reduction in risk for 30-day stroke or death (odds ratio, 0.29; 95% confidence interval, 0.12-0.69; P=.006). CONCLUSIONS: Almost half (47.5%) of the carotid endarterectomies among Ohio's Medicare population are performed on persons who are asymptomatic or who have nonspecific symptoms. These results highlight the importance of identifying patients and providers having the most favorable outcome profiles. The higher rate of adverse outcomes observed in lower-volume hospitals deserves further investigation, as it does not appear to be due to differences in patient selection.

Barriers to adequate delivery of hemodialysis.

Mortality rates among American hemodialysis patients are the highest in the industrialized world. Measures of delivered dialysis (Kt/V) correspond strongly with survival and are estimated to be inadequate in one third of patients. We sought to determine the importance of potential barriers to adequate dialysis, including patient-related and technical factors. Using a cross-sectional study design, we abstracted the charts of 721 randomly selected patients from all 22 chronic hemodialysis units in northeast Ohio. For each of 1,836 treatments provided to these patients, we assessed delivered dialysis (Kt/V) and patient-related factors (ie, hypotension, intradialytic symptoms, and treatment time missed due to noncompliance or transportation problems) and technical factors (ie, dialysis prescription, type of vascular access, clotting, and dialyzer reuse). We used hierarchical regression analysis to determine which potential barriers were independently related to delivered dialysis after adjustment for patient demographic and medical characteristics. Barriers independently related to dialysis delivery (all P values < 0.001) included patient noncompliance, present in 3% of treatments; low dialysis prescription, 14%; use of a catheter for vascular access, 11%; and clotting, 1%. The prevalence of identified barriers varied dramatically across facilities (eg, the prevalence of low dialysis prescription ranged from 0% to 37%, while the prevalence of catheter use ranged from 3% to 28%). In conclusion, patient noncompliance, low dialysis prescription, catheter use, and clotting are the most important barriers to dialysis delivery. Further work is needed to develop interventions to overcome these barriers and to determine the effect of such interventions on dialysis adequacy and patient survival.

Atrial fibrillation as a risk factor for stroke: a retrospective cohort study of hospitalized Medicare beneficiaries.

OBJECTIVES: This study examined the relationship between atrial fibrillation and (1) stroke and (2) all-cause mortality. METHODS: All eligible Medicare patients older than 65 years of age hospitalized in 1985 were followed up for 4 years. Kaplan-Meier and Cox proportional hazards models were used for assessment of risk of stroke and mortality. RESULTS: A total of 4,282,607 eligible Medicare patients were hospitalized in 1985. The mean age was 76.1 (+/- 7.7) years; 58.7% were female; 7.2% were Black; and 8.4% had a diagnosis of atrial fibrillation. During the follow-up period, 66,063 patients (32.6/1000 person-years) developed nonembolic stroke and 7285 (3.6/1000 person-years) developed embolic stroke. After adjustment for age, race, sex, and comorbid conditions, atrial fibrillation remained a significant risk factor for both nonembolic stroke (relative risk [RR] = 1.56) and embolic stroke (RR = 5.80) and for mortality (RR = 1.31). Approximately 4.5% of nonembolic and 28.7% of embolic strokes among hospitalized Medicare patients aged 65 years and older were attributable to atrial fibrillation. CONCLUSIONS: This study demonstrates that atrial fibrillation is associated with an appreciable increase in the risk of stroke (both embolic and nonembolic) and in the risk of mortality from all causes.

Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation.

OBJECTIVE: To determine how often warfarin was prescribed to patients with nonrheumatic atrial fibrillation in our community in 1992 when randomized trials had demonstrated that warfarin could prevent stroke with little increase in the rate of hemorrhage, and to determine whether warfarin was prescribed less frequently to older patients-the patients at highest risk of stroke but of most concern to physicians in terms of the safety of warfarin. DESIGN: Cross-sectional study. Appropriateness of warfarin was classified for each patient based on the independent judgments of three physicians applying relevant evidence and guidelines. SETTING: Two teaching hospitals and five community-based practices. PATIENTS: Consecutive patients with nonrheumatic atrial fibrillation (n = 189). MEASUREMENTS AND MAIN RESULTS: Warfarin was prescribed to 44 (23%) of the 189 patients. Warfarin was judged appropriate in 98 patients (52%), of whom 36 (37%) were prescribed warfarin. Warfarin was prescribed to 11 (14%) of 76 patients aged 75 years or older with hypertension, diabetes mellitus, or past stroke, the group at highest risk of stroke. In a multivariable logistic regression model controlling for appropriateness of warfarin and other patient characteristics, patients aged 75 years or older were less likely than younger patients to be treated with warfarin (odds ratio 0.25; 95% confidence interval 0.10, 0.65). CONCLUSIONS: Warfarin was prescribed infrequently to these patients with nonrheumatic atrial fibrillation, especially the older patients and even the patients for whom warfarin was judged appropriate. These findings indicate a substantial opportunity to prevent stroke.

Effect of a nurse case manager on postdischarge follow-up.

OBJECTIVE: To examine whether use of a nurse case manager to coordinate postdischarge care would improve rates of follow-up, emergency department utilization, and unexpected readmission for general medicine patients. DESIGN: Prospective cohort trial. SETTING: Publicly supported, tertiary-care teaching hospital. PATIENTS: Four hundred seventy-eight patients admitted to the general medicine service. INTERVENTIONS: Use of a nurse case manager to provide discharge planning before hospital discharge and to arrange for postdischarge outpatient follow-up. Patients in the control group had discharge planning in the traditional ("usual care") manner. MEASUREMENTS AND MAIN RESULTS: The proportion of patients with scheduled outpatient appointments in the medical clinic and the proportion making clinic visits, emergency department visits, or with readmission to the hospital within 30 days following discharge. A significantly greater proportion of patients assigned to the nurse case manager intervention had appointments scheduled at the time of hospital discharge (63% vs 46%, p < .001), and made scheduled visits in the outpatient clinic (32% vs 23%, p < .03). Intervention group patients were especially more likely than control group patients to have definite follow-up appointments if they were discharged on weekends. Intervention and control group patients did not differ, however, in the rates of emergency department utilization (p = .52) or unexpected readmissions within 30 days of discharge (p = .11). CONCLUSIONS: Use of a nurse case manager to coordinate outpatient follow-up prior to discharge improved the continuity of outpatient care for patients on a general medical service. The intervention had no effect on unexpected readmissions or emergency department utilization.

Atrial fibrillation: restoration and maintenance of sinus rhythm and indications for anticoagulation therapy.

PURPOSE: To review the efficacy and safety of electrical and pharmacologic conversion of atrial fibrillation, strategies for maintenance of sinus rhythm, and the importance of antithrombotic therapy. DATA SOURCES: English-language trials were identified from the MEDLINE database through 1995, bibliographic references, Current Contents, textbooks, and recent abstracts. STUDY SELECTION: Randomized trials (including abstracts) were selected. Cohort studies were used if randomized trials were not available. DATA EXTRACTION: Study design and data were extracted from clinical trials. Statistical analysis of combined data was not appropriate, given the marked variations in study designs and study populations. DATA SYNTHESIS: Cardioversion restores sinus rhythm in more than 80% of patients. In atrial fibrillation of recent onset, pharmacologic regiments have a success rate of 40% to 90%. Sinus rhythm at 1 year is maintained in 30% of patients without antiarrhythmic therapy but in 50% of patients with such therapy. The efficacy and safety of antiarrhythmic drugs relative to one another are not established because trials done to date have been small and cases vary. Successful cardioversion and maintenance of sinus rhythm are most predictable when the duration of atrial fibrillation is brief. Warfarin reduces the incidence of ischemic strokes and emboli in patients with nonvalvular atrial fibrillation from 4.5% to 1.4% per year. Aspirin (325 mg/d) appears to be equally effective in patients younger than 75 years of age who do not have hypertension or a history of thromboembolism or recent heart failure. Although warfarin is more effective than aspirin in preventing embolic strokes in patients older than 75 years of age, it may increase the incidence of hemorrhagic stroke and result in a similar rate of disabling stroke. CONCLUSION: Cardioversion remains the preferred method with which to re-establish sinus rhythm. Long-term antiarrhythmic therapy is warranted only if recurrences or initial clinical instability are seen; pro-arrhythmic concerns and potential side effects should guide drug selection. Antithrombotic therapy is indicated for all patients older than 60 years of age and in all patients younger than 60 years of age who have clinical evidence of a primary cardiac disorder.

A cost analysis of alternative treatments for duodenal ulcer.

OBJECTIVE: To compare the costs of alternative strategies for the treatment of duodenal ulcer. DESIGN: A cost comparison using decision analysis. METHODS: A decision model was used to compare the costs per cure of an endoscopically documented duodenal ulcer for three initial treatment strategies: 1) H2-receptor antagonist therapy for 8 weeks, 2) antibiotic therapy for Helicobacter pylori infection plus H2-receptor antagonist therapy, and 3) urease test-based treatment. For symptomatic recurrences, secondary treatment strategies included empiric retreatment with the same or other regimen, and treatment based on repeat endoscopy-guided urease test or biopsy, with an assumption of subsequent cure. The cohort modeled for this analysis consisted of patients at low risk for a malignant ulcer. Probability estimates were derived from published clinical trials, cohort studies, and expert opinion. Side effects from combination therapy with antibiotics and H2-receptor antagonists and resulting costs were included from the perspective of a group practice model health maintenance organization. RESULTS: For all secondary treatment strategies, initial therapy with antibiotics for H. pylori infection plus an H2-receptor antagonist resulted in the lowest average costs per symptomatic cure when the prevalence or likelihood of H. pylori infection exceeded 66% to 76%; the costs ranged from $284 for secondary (re)treatment with empiric antibiotic and H2-receptor antagonist therapy to $398 for endoscopy-guided secondary treatment. Initial treatment with an H2-receptor antagonist resulted in the highest costs, ranging from $372 for secondary treatment with empiric antibiotic and H2-receptor antagonist therapy to $679 for endoscopy-guided secondary treatment. The results were not sensitive to the rates of duodenal ulcer recurrence after either treatment, to the cost of either treatment, or to prevalence of H. pylori. CONCLUSIONS: This cost analysis indicates that, regardless of the secondary treatment used for ulcer recurrence, initial therapy with antibiotics for H. pylori infection plus an H2-receptor antagonist provides the lowest costs per symptomatic cure. These cost savings and the lower recurrence rates associated with this treatment favor eradication of H. pylori as part of the initial treatment of duodenal ulcer.

Improving compliance with breast cancer screening in older women. Results of a randomized controlled trial.

BACKGROUND: To compare three approaches for improving compliance with breast cancer screening in older women. METHODS: Randomized controlled trial using three parallel group practices at a public hospital. Subjects included women aged 65 years and older (n = 803) who were seen by residents (n = 66) attending the ambulatory clinic from October 1, 1989, through March 31, 1990. All provider groups received intensive education in breast cancer screening. The control group received no further intervention. Staff in the second group offered education to patients at their visit. In addition, flowsheets were used in the "Prevention Team" group and staff had their tasks redefined to facilitate compliance. RESULTS: Medical records were reviewed to determine documented offering/receipt of clinical breast examination and mammography. A subgroup of women without previous clinical breast examination (n = 540) and without previous mammography (n = 471) were analyzed to determine the effect of the intervention. During the intervention period, women without a previous clinical breast examination were offered an examination significantly more often in the Prevention Team group than in the control group, adjusting for age, race, and comorbidity and for physicians' gender and training level. The patients in the Prevention Team group were offered clinical breast examination (31.5%) more frequently than those in the patient education or control groups, but this was not significant after adjusting for the above covariates. Likewise, mammography was offered more frequently to patients in the Prevention Team and in the patient education group than to patients in the control group, after adjusting for the factors above using logistic regression. CONCLUSIONS: The results provide support for patient education and organizational changes that involve nonphysician personnel to enhance breast cancer screening among older women, particularly those without previous screening.

Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: an analysis of pooled trials.

Recent studies have proposed that the exclusion of an atrial thrombus by transesophageal echocardiography (TEE) would allow for the safe cardioversion from atrial fibrillation or flutter without the need of prophylactic anticoagulation. Because all of the TEE trials have been small and descriptive and have lacked randomized, conventionally treated control groups, the pooled risk of embolic events from TEE trials was compared with that of a control group pooled from the literature on cardioversion both with and without conventional anticoagulation. Studies were identified from a MEDLINE search, references in review articles, and recent cardiology abstracts and were included if there were > 10 patients and if atrial fibrillation or flutter was of > 48 hours' duration. Where > 1 study had been published by the same group only the largest study was used. Studies were not selected by cause of arrhythmia, by predisposing risk factors for atrial fibrillation and flutter, or by method of cardioversion. The only patients excluded from TEE reports were those with atrial thrombi diagnosed on the precardioversion TEE or those documented to have adequate standard precardioversion anticoagulation. Seven TEE and 18 control studies met the inclusion criteria. More patients in the control studies had rheumatic valvular disease. Embolic events were significantly more frequent in the TEE group than in the anticoagulated control group (1.34% vs 0.33%, respectively; p = 0.04), whereas there was no significant difference between the TEE group and the nonanticoagulated control group (2.00%; p = 0.26). Thus the use of TEE screening to exclude patients with atrial thrombi before cardioversion does not identify patients who can safely undergo this procedure without anticoagulation.

You can lead a horse to water--improving physicians' knowledge of probabilities may not affect their decisions.

OBJECTIVES: To determine whether improving physicians' judgments of the probability of streptococcal pharyngitis for patients with sore throats would affect their use of antibiotics and affect the variation in such use. DESIGN: Post-hoc retrospective analysis of data previously collected as part of a controlled trial. SETTINGS: University student health services in Pennsylvania and Nebraska. PATIENTS: Sequential patients with pharyngitis seen before and after the time clinicians received either an experimental educational intervention designed to improve probabilistic diagnostic judgments (at the Pennsylvania site) or a control intervention, a standard lecture (at the Nebraska site). The clinician-subjects were the primary case physicians practicing at either site. MEASUREMENTS: Clinical variables prospectively recorded by the clinicians, probability assessments, and treatment decisions. RESULTS: At the experimental site, despite marked decreases in clinicians' overestimations of disease probability after the intervention, the proportion of patients prescribed antibiotics showed a trend toward increasing: 100/290 (34.5%) pre-intervention, 90/225 (40%) post-intervention. The intervention did not decrease practice variation between individual doctors. Univariable and multivariable analyses showed no major change in the relationships between clinical variables and treatment decisions after the intervention. At the control site there was no major change in probability judgments or treatment decisions after the intervention. CONCLUSIONS: Teaching physicians to make better judgments of disease probability may not alter their treatment decisions.