RESUMEN
BACKGROUND: The Joint Commission (JC) began certifying primary stroke centers (PSCs) in the United States in 2003. We assessed whether 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates differed between hospitals with and without JC-certified PSCs in 2006. METHODS: The study cohort included all fee-for-service Medicare beneficiaries ≥65 years old discharged with a primary diagnosis of ischemic stroke (International Classification of Diseases, ninth revision, Clinical Modification 433, 434, 436) in 2006. Hierarchical linear regression models calculated hospital-level RSMRs and RSRRs, adjusting for patient demographics, comorbid conditions, and hospital referral region. Hospitals were categorized as being higher than, no different from, or lower than the national average. RESULTS: There were 310,381 ischemic stroke discharges from 315 JC-certified PSC and 4,231 noncertified hospitals. Mean overall 30-day RSMR and RSRR were 10.9% ± 1.7% and 12.5% ± 1.4%, respectively. The RSMRs of hospitals with JC-certified PSCs were lower than in noncertified hospitals (10.7% ± 1.7% vs 11.0% ± 1.7%), but the RSRRs were comparable (12.5% ± 1.3% vs 12.4% ± 1.7%). Almost half of JC-certified PSC hospitals had RSMRs lower than the national average compared with 19% of noncertified hospitals, but 13% of JC-certified PSC hospitals had lower RSRRs vs 15% of noncertified hospitals. CONCLUSIONS: Hospitals with JC-certified PSCs had lower RSMRs compared with noncertified hospitals in 2006; however, differences were small. Readmission rates were similar between the 2 groups. PSC certification generally identified better-performing hospitals for mortality outcomes, but some hospitals with certified PSCs may have high RSMRs and RSRRs whereas some hospitals without PSCs have low rates. Unmeasured factors may contribute to this heterogeneity.
Asunto(s)
Isquemia Encefálica/terapia , Certificación/tendencias , Hospitales/normas , Unidades de Cuidados Intensivos/normas , Joint Commission on Accreditation of Healthcare Organizations/legislación & jurisprudencia , Calidad de la Atención de Salud/tendencias , Accidente Cerebrovascular/terapia , Anciano , Isquemia Encefálica/mortalidad , Certificación/normas , Estudios de Cohortes , Femenino , Hospitales/clasificación , Hospitales/tendencias , Humanos , Unidades de Cuidados Intensivos/tendencias , Masculino , Calidad de la Atención de Salud/normas , Accidente Cerebrovascular/mortalidad , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Younger, but not older, women have a higher mortality than men of similar age after a myocardial infarction (MI). We sought to determine whether this relationship is true for both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI). DESIGN: Retrospective cohort study. SETTING: 1057 USA hospitals participant in the National Registry of Myocardial Infarction between 2000 and 2006. PATIENTS: 126 172 STEMI and 235 257 NSTEMI patients. MAIN OUTCOME MEASURE: Hospital death. RESULTS: For both STEMI and NSTEMI, the younger the patient's age, the greater the excess mortality risk for women compared with men, while older women fared similarly (STEMI) or better (NSTEMI) than men (p<0.0001 for the age-sex interaction). In STEMI, the unadjusted women-to-men RR was 1.68 (95% CI 1.41 to 2.01), 1.78 (1.59 to 1.99), 1.45 (1.34 to 1.57), 1.08 (1.02 to 1.14) and 1.03 (0.98 to 1.07) for age <50 years, age 50-59, age 60-69, age 70-79 and age 80-89, respectively. For NSTEMI, corresponding unadjusted RRs were 1.56 (1.31 to 1.85), 1.42 (1.27 to 1.58), 1.17 (1.09 to 1.25), 0.92 (0.88 to 0.96) and 0.86 (0.83 to 0.89). After adjusting for risk status, the excess risk for younger women compared with men decreased to approximately 15-20%, while a better survival of older NSTEMI women compared with men persisted. CONCLUSIONS: Sex-related differences in short-term mortality are age-dependent in both STEMI and NSTEMI patients.
Asunto(s)
Infarto del Miocardio/mortalidad , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Métodos Epidemiológicos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Distribución por Sexo , Factores Sexuales , Estados Unidos/epidemiologíaRESUMEN
Little is known about patient awareness of nationally recommended blood pressure targets, especially among patients with cardiac disease. To examine this issue, we interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their systolic and diastolic blood pressure levels as well as corresponding national targets. We used bivariate and multivariate analyses to determine if any patient demographic or clinical characteristics were associated with blood pressure knowledge. Only 66.1% of patients could recall their own systolic and diastolic blood pressure levels. Only 48.9% of all patients could correctly name targets for these values. Knowledge of target blood pressure levels was particularly poor among patients who were female (odds ratio (OR) 0.69; 95% confidence interval (CI) 0.49-0.98), aged > or =60 years (OR 0.70, CI 0.51-0.97), without any college education (OR 0.48, CI 0.35-0.65), without a documented history of hypertension (OR 0.57, CI 0.39-0.84), and with known diabetes (OR 0.46, CI 0.33-0.66). Patients in the highest risk group, according to Joint National Committee guidelines stratification, were no more knowledgeable about their blood pressure levels and targets than lower risk patients. A significant proportion of patients hospitalized with coronary artery disease do not know their own blood pressure levels or targets. Current blood pressure education efforts appear inadequate, particularly for certain patient subgroups in which hypertension is an important modifiable risk factor.
Asunto(s)
Concienciación , Presión Sanguínea , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/psicología , Anciano , Diástole , Femenino , Objetivos , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Sístole , Estados UnidosRESUMEN
BACKGROUND AND PURPOSE: We sought to measure the overall rate of usage of tissue-type plasminogen activator (tPA) for ischemic stroke at academic medical centers, and to determine whether ethnicity was associated with usage. METHODS: Between June and December 1999, 42 academic medical centers in the United States each identified 30 consecutive ischemic stroke cases. Medical records were reviewed and information on demographics, medical history, and treatment were abstracted. Rates of tPA use were compared for African Americans and whites in univariate analysis and after adjustment for age, gender, stroke severity, and type of medical insurance with multivariable logistic regression. RESULTS: Complete information was available for 1195 ischemic stroke patients; 788 were whites and 285 were African Americans: Overall, 49 patients (4.1%) received tPA. In the subgroup of 189 patients without a documented contraindication to therapy, 39 (20.6%) received tPA. Ten (20%) of those receiving tPA had documented contraindication. African Americans were one fifth as likely to receive tPA as whites (1.1% African Americans versus 5.3%; P=0.001), and the difference persisted after adjustment (OR 0.21, 95% CI 0.06 to 0.68; P=0.01). When comparison was restricted to those without a documented contraindication to tPA, the difference remained significant (OR 0.24, 95% CI 0.06 to 0.93; P=0.04). Medical insurance type was independently associated with tPA treatment. After adjustment for ethnicity and other demographic characteristics, those with Medicaid or no insurance were one ninth as likely to receive tPA as those with private medical insurance (OR 0.11, 95% CI 0.02 to 0.17; P=0.003). CONCLUSIONS: tPA is used infrequently for ischemic stroke at US academic medical centers, even among qualifying candidates. African Americans are significantly less likely to receive tPA for ischemic stroke. Contraindications to treatment do not appear to account for the difference.
Asunto(s)
Centros Médicos Académicos/estadística & datos numéricos , Isquemia Encefálica/tratamiento farmacológico , Revisión de la Utilización de Medicamentos/estadística & datos numéricos , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Negro o Afroamericano/estadística & datos numéricos , Anciano , Isquemia Encefálica/complicaciones , Isquemia Encefálica/etnología , Estudios de Cohortes , Contraindicaciones , Bases de Datos Factuales , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/etnología , Terapia Trombolítica/estadística & datos numéricos , Estados Unidos , Población Blanca/estadística & datos numéricosRESUMEN
RATIONALE: Although clinical guidelines have become increasingly popular as a means to reduce variation in care, increase efficiency, and improve patient outcomes, little is known about their effectiveness when they are transported outside their original setting, or about the factors that influence their successful translation into clinical practice. This study assessed whether a clinical guideline for low-risk chest pain patients, implemented with a standardized protocol, could be effectively transported to five hospital settings. METHODS: In a prospective, interventional trial, a standardized protocol for low-risk chest pain was implemented at each site. A total of 553 consecutively hospitalized low-risk patients with chest pain were enrolled during a 3-month baseline period followed by a standardized 6-month intervention period. During the intervention period, each patient's physician was contacted about eligibility for discharge within the specified 2-day guideline period. Guideline adherence (discharged within 48 hours) and postdischarge patient outcomes were measured. Local guideline champions were interviewed about their implementation experience. RESULTS: Guideline adherence during the intervention period ranged from 61% to 100%, with only two sites achieving significant increases of > or = 10% from the baseline values. Guideline implementation did not affect clinical outcomes or patient satisfaction. Implementation factors such as preexisting hospital environment, implementation team staffing, and the rapid identification and resolution of barriers may influence the successful translation of guidelines into practice. CONCLUSIONS: Even with a standardized implementation protocol, consistent results across institutions were not obtained when a clinical guideline for chest pain was implemented beyond its original setting. These findings demonstrate the importance of understanding the local factors that influence guideline implementation.
Asunto(s)
Dolor en el Pecho/terapia , Hospitalización , Guías de Práctica Clínica como Asunto , Anciano , Connecticut , Estudios de Seguimiento , Encuestas de Atención de la Salud , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Nebraska , North Carolina , Evaluación de Resultado en la Atención de Salud , Alta del Paciente , Satisfacción del Paciente , Pennsylvania , Guías de Práctica Clínica como Asunto/normas , Estudios Prospectivos , South Carolina , Encuestas y CuestionariosRESUMEN
BACKGROUND AND PURPOSE: Intracranial hemorrhage is a serious complication of thrombolytic therapy for acute myocardial infarction, especially among the elderly, but little information exists on estimating risk. Better estimation of risk in individual patients may allow for withholding or using alternate therapies among those at highest risk. METHODS: To quantify the risk and identify predictors of intracranial hemorrhage associated with thrombolytic therapy, we performed a retrospective cohort study using data from medical charts. The study involved nearly all acute-care hospitals in the United States. All Medicare patients discharged with a principal diagnosis of acute myocardial infarction during a 9-month period in 1994 to 1995 were included. The main outcome measure was intracranial hemorrhage among those treated with thrombolytic therapy. RESULTS: The rate of intracranial hemorrhage was 1.43% (455 of 31 732). In a logistic model, age > or =75 years, female, black race, prior stroke, blood pressure > or =160 mm Hg, tissue plasminogen activator (versus other thrombolytic agent), excessive anticoagulation (international normalized ratio > or =4 or prothrombin time > or =24), and below median weight (< or =65 kg for women; < or =80 kg for men) were independent predictors. A risk stratification scale was developed on the basis of these factors: with none or 1 of the factors (n=6651), the rate of intracranial hemorrhage was 0.69%; with 2 factors (n=10 509), 1.02%; with 3 factors (n=9074), 1.63%; with 4 factors (n=4298), 2.49%; and with > or =5 factors (n=1071), 4. 11% (Mantel-Haenszel; P<0.001). CONCLUSIONS: The rate of intracranial hemorrhage in older patients after treatment with thrombolytic therapy exceeds 1%. Readily available factors can identify elderly patients with acute myocardial infarction at high and low risk for intracranial hemorrhage associated with thrombolytic therapy.
Asunto(s)
Fibrinolíticos/efectos adversos , Hemorragias Intracraneales/inducido químicamente , Infarto del Miocardio/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Factores de Edad , Anciano , Estudios de Cohortes , Femenino , Humanos , Incidencia , Hemorragias Intracraneales/epidemiología , Masculino , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
OBJECTIVE: To examine the relationship of depressive and disruptive disorders with patterns of mental health services utilization in a community sample of children and adolescents. METHOD: Data were from the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The sample consisted of 1,285 child (ages 9-17 years) and parent/guardian pairs. Data included child psychopathology (assessed by the Diagnostic Interview Schedule for Children), impairment, child need and use of mental health services, and family socioeconomic status. RESULTS: After adjusting for potential confounding factors, disruptive disorder was significantly associated with children's use of mental health services, but depressive disorder was not. For school-based services, no difference was found between the 2 types of disorders. Parents perceived greater need for mental health services for children with disruptive disorders than for those with depression. Conversely, depression was more related to children's perception of mental health service need than was disruptive disorder. CONCLUSIONS: The findings highlight the need for more effective ways to identify and refer depressed children to mental health professionals, the importance of improving school-based services to meet children's needs, and the necessity to better educate parents and teachers regarding the identification of psychiatric disorders, especially depression.
Asunto(s)
Servicios de Salud del Adolescente/estadística & datos numéricos , Déficit de la Atención y Trastornos de Conducta Disruptiva/terapia , Servicios de Salud del Niño/estadística & datos numéricos , Trastorno Depresivo/terapia , Servicios de Salud Mental/estadística & datos numéricos , Adolescente , Déficit de la Atención y Trastornos de Conducta Disruptiva/diagnóstico , Déficit de la Atención y Trastornos de Conducta Disruptiva/psicología , Niño , Trastorno Depresivo/diagnóstico , Trastorno Depresivo/psicología , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Análisis de Regresión , Factores de Riesgo , Servicios de Salud EscolarRESUMEN
OBJECTIVE: A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents. METHOD: Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization. RESULTS: More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend. CONCLUSIONS: These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.
Asunto(s)
Encuestas Epidemiológicas , Trastornos Mentales/epidemiología , Adolescente , Adulto , Niño , Estudios Transversales , Recolección de Datos , Femenino , Humanos , Incidencia , Masculino , Trastornos Mentales/clasificación , Trastornos Mentales/diagnóstico , National Institute of Mental Health (U.S.) , Determinación de la Personalidad , Proyectos de Investigación , Muestreo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To examine the criterion validity of the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, using a design that permitted several comparisons of DISC-generated diagnoses with diagnoses based on clinician symptom ratings. METHOD: Two hundred forty-seven youths were selected from the 1,285 parent-youth pairs that constituted the four-site MECA sample. Subjects who screened positive for any of the five diagnostic areas under investigation in the validity study (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, depressive disorder, and the major anxiety disorders) were recruited, as well as a comparable number of screen negatives. Clinicians reinterviewed separately both the youth and the primary caregiver using the DISC followed by a clinical-style interview, and then they rated the presence of symptoms and impairment. Computer algorithms combined this information into diagnoses using comparable rules for both DISC and clinical rating diagnoses. RESULTS: In general, the DISC showed moderate to good validity across a number of diagnoses. CONCLUSIONS: Results suggest some specific diagnostic areas in which further revision of the DISC is warranted. Three main sources of variability in DISC-clinician diagnostic agreement were evident over and above that due to the instrument itself, including (1) the informant used, (2) the algorithm applied in synthesizing symptom reports, and (3) the design of the validity comparison.