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Background —Trends in risk-severity and operative mortality (OM) were examined in 3330 consecutive patients aged 70 years and older who underwent isolated coronary artery bypass graft surgery (CABG) between 1982 and 1996. Methods and Results —The proportion of elderly patients rose significantly over time ( P P =.001) from 16.2% in 1982 to 1986 to 19.5% in 1987 to 1991 and 26.9% in 1992 to 1996. OM in high-risk patients fell significantly ( P =.044) from 17.2% in 1982 to 1986 to 9.1% in 1987 to 1991 and was 8.9% in 1992 to 1996. Contemporary independent predictors of OM among elderly patients were poor ventricular function (LV grade 2 to 3, odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3 to 5.2; and LV grade 4, OR, 10.7; 95% CI, 4.4 to 26); previous CABG (OR, 3.7; 95% CI, 2.0 to 7.0), female sex (OR, 1.8; 95% CI, 1.1 to 2.8), peripheral vascular disease (OR, 1.8; 95% CI, 1.1 to 2.8), and diabetes (OR, 1.7; 95% CI, 1.1 to 2.7). Previous angioplasty was protective (OR, 0.3; 95% CI, 0.1 to 0.9). Conclusions —OM in elderly patients has declined significantly in recent years despite an increase in the prevalence and severity of their risk factors. A careful weighing of risk, rather than advanced age alone, should determine who is offered surgical revascularization. In this regard, poor ventricular function and repeat CABG continue to have the greatest impact on OM in elderly patients.

Background This study was conducted to assess the overall mortality rate and the amount of interhospital variation in risk-adjusted mortality rates after coronary artery bypass graft (CABG) surgery in Ontario, Canada. CABG outcomes data are not publicly disseminated in Ontario. Methods and Results Clinical risk factors and surgical outcomes were collected on 15 608 patients undergoing isolated CABG surgery between April 1, 1991, and March 31, 1994, at the nine hospitals performing adult cardiac surgery in Ontario. The data were analyzed on the basis of a fiscal year. The overall mortality rate was 3.01%, and the risk-adjusted mortality rate declined from 3.17% in 1991 to 2.93% in 1993. In 1991, one of the nine hospitals had a risk-adjusted mortality rate significantly lower than the provincial average. Otherwise, the hospitals all had risk-adjusted mortality rates within the expected range during the time period of the study. All hospitals performed >300 CABG procedures in 1992 and 1993, and only 2 of 42 cardiac surgeons performed Conclusions The in-hospital mortality rate after CABG surgery in Ontario is low, and the amount of interhospital variation in risk-adjusted mortality rates is no greater than that expected by chance alone. These outcomes are probably attributable to regionalization of CABG surgery and a very low prevalence of low-volume cardiac surgeons in Ontario.

To assess the match between multifactorial risk of coronary heart disease (CHD) and treatment intensity under the National Cholesterol Education Program (NCEP) guidelines for primary prevention of CHD.The multiple logistic regression equation from the Framingham Study was used to derive predicted risks for development of CHD over eight years of follow-up for different age-gender groupings, with serum total cholesterol (TC) values chosen in light of the NCEP cutoff points for both TC and low-density-lipoprotein cholesterol levels. Additional risk factors--hypertension, glucose intolerance, and smoking--were considered in combination for each of these values.Controlling for the effects of age and gender, there is little difference in the ranges of absolute CHD risks for persons who would receive interventions of differing intensities (i.e., general dietary advice, dietary treatment, or drug therapy). Those who are candidates for drug treatment because of serum lipids alone are often at low levels of risk for the development of CHD when compared with those of the same age with lower TC values who have other risk factors. Discrepancies in CHD risk are wider still when age is also allowed to vary. Furthermore, in every age grouping, women with high TC levels (e.g., 6.9 mmol/L) and two other risk factors are eligible for drug treatment but have a CHD risk that is no higher, and often much lower, than that of males with one other risk factor and TC levels of 4.8 mmol/L or 5.7 mmol/L who are candidates for dietary advice or dietary therapy, respectively.Inconsistencies exist in the NCEP guidelines such that persons at low risk for the development of CHD are offered more intensive interventions than are other who actually are at much higher risks, and vice versa. Women in particular tend to be overtreated, relative to men. These findings point out the difficulties of promulgating guidelines that will appropriately match risk to preventive interventions in a complex multifactorial disease.

In virtually all industrialized nations, the past decade has brought unprecedented scrutiny of the processes and outcomes of medical care, even as private and public payers press for further cost containment. An old management-consulting adage reads: “Good, fast, cheap: pick any two.” In health care, the contemporary equivalent seems to be: “Quality, accessibility, affordability: have all three.” This management revolution in medicine has gained legitimacy from countless studies showing inexplicable variations in what physicians do and how effectively or efficiently they do it. However, the Achilles' heel of managed care is mounting public and professional concern that quality has been . . .

OBJECTIVE To determine whether physician willingness to prescribe drugs for primary prevention of cardiovascular disease is influenced by information about the resultant life-expectancy gains (presented in one of two formats) and about drug costs. MATERIALS AND METHODS Mailed survey (four versions randomly allocated) asking physicians to assess hypothetical preventive interventions with outcomes expressed either as averaged or as stratified gains in life expectancy (e.g., average gain of 15 weeks, versus 5% of treated patients gain 2 to 6 years, 10% gain up to 2 years, and 85% remain unchanged). Both costs and gains were varied to high and low values. The subjects rated their willingness to prescribe treatments on an 11-point scale from "strongly oppose" to "strongly favor." PARTICIPANTS Internists randomly selected from two Canadian academic centers (n = 330). RESULTS 231 usable responses were received (76% of the deliverable questionnaires). For low-yield scenarios typical of very effective primary prevention strategies, the physicians gave significantly higher ratings in response to stratified life-expectancy data than to equivalent averaged data (p < 0.0001). The same trend was not observed for high-yield scenarios (p = NS). The ratings were strongly influenced by cost: 34% of the physicians reversed their treatment decisions in response to a tenfold price increase. Despite this, the rankings of the treatments differed from those expected on the basis of cost-effectiveness criteria (p < 0.0001). CONCLUSIONS Physician enthusiasm for a therapy designed to prolong life expectancy may be influenced by the format in which that life-expectancy gain is presented. Knowledge of drug cost also affects physicians' choices, but their greater focus on treatment effects causes their rankings to depart from those expected with cost-effectiveness criteria.

EDITOR–An editorial on meta-analysis that one of us wrote1 noted in passing two difficulties with a paper by Le Lorier et al that showed apparent discrepancies between results of meta-analyses and of individual trials.2 Le Lorier and Gregoire have written to counter those criticisms,3 but we think that they have missed the salient methodological issues. Le Lorier et al defined a negative trial as “one in which the treatment resulted in an equal or worse …

Overthe last 25 years the randomized clinical trial and the science of clinical epidemiology have begun to reshape the way medicine is practiced and taught, replacing anecdote and tradition with concrete quantitative data. During the same period, cognitive psychologists have demonstrated that the interpretation of quantitative data may be substantially influenced by the manner in which the data are presented.1,2Early work by McNeil et al3suggested that physicians' interpretations of treatment outcomes are not immune to such cognitive biases. That the results of properly conducted trials of medical interventions should have an impact on the application of those interventions in clinical practice is indeed encouraging. But, that the magnitude and even the direction of that impact should depend on the numeric presentation of the results is cause for concern. A number of recent studies4-12have convincingly demonstrated that both physicians and patients are susceptible to

America's cardiovascular establishment has strongly supported the National Cholesterol Education Program (NCEP) and its clinical guidelines for detection and management of dyslipidemias. 1 In this issue of JAMA , Hulley et al 2 trenchantly criticize the NCEP guidelines for young adults—men under 35 years of age and premenopausal women. They conclude that routine testing of all such persons every 5 years is of unproven effectiveness for prolonging life, very inefficient from an economic and clinical standpoint, and perhaps unethical given that primary preventive maneuvers alter the lives of otherwise well persons. See also p 1416. Underpinning their criticisms is a simple observation. In isolation, an elevated total cholesterol (TC) or low-density lipoprotein cholesterol (LDL) level is a mediocre marker for short-term and even longer-term risk of coronary events. 3,4 This is especially so for young men and premenopausal women where coronary heart disease (CHD) is a rare cause of death. There

In North America, gestational diabetes mellitus (GDM) is diagnosed from a 100-g oral glucose tolerance test (OGTT) with criteria proposed by the National Diabetes Data Group (NDDG). These criteria were derived in the 1950s from an unrepresentative sample of women tested predominantly in the latter stages of pregnancy. The original studies did not check for reproducibility of OGTT results. Measurements were made with the Somogyi-Nelson whole-blood glucose technique, and test translation errors are present in the threshold values proposed for modern plasma glucose oxidase methods. Whereas GDM is now diagnosed with a view to adverse m ternal-fetal outcomes, the criteria were chosen to reflect maternal risk of developing glucose intolerance as shown by a 75-g OGTT in the nonpregnant state over the ensuing 8 yr. For that outcome, the positive predictive value of the criteria was only 36.1%, and this is a marked overestimate, because the study cohort was a highly selected group with an increased incidence of glucose intolerance both during and after pregnancy. The criteria are also conceptually flawed in that they impose a dichotomous definition of normal and abnormal on gestational glucose tolerance, when the risk of adverse maternal-fetal outcomes and later diabetes mellitus should logically be graded upward with higher values on the gestational OGTT and with the degree of fasting hyperglycemia. Although NDDG criteria merit continued use for lack of a better alternative, new diagnostic criteria for GDM should be derived and validated.

Health services in the Republic of South Africa (RSA) are provided by a mixture of public and private providers and institutions. Estimates of total health-related expenditure for 1985 range between 5.3% and 5.9% of gross national product (GNP), divided on approximately a 55:45 basis between public and private sectors. Basic preventive and curative services are provided by a hospital- and clinic-based public system. The public system does not adequately serve the rural areas and African tribal bantustans, and racial discrimination and/or segregation are obvious in its organisation and funding. The public sector's strength is the provision of state-subsidised care to many citizens who are unable to afford private medicine. The vast majority of hospitals are operated on a non-profit basis by government, industries, and voluntary agencies. Excluding hospitals that receive state subsidies, private investor-owned hospitals control about 10% of all hospital beds in the RSA. One-third of these investor-owned beds are held by state-dependent contractors providing long-term care. Two-thirds are wholly independent. Growth has been rapid in the independent hospital sector, and major corporations have entered the market. In 1985, over 85% of the white population was privately insured by a variety of prepayment programmes, including those organised through parastatal corporations and government departments. Despite major enrollment growth in the preceding decade, only 8% of blacks held private insurance by 1985; their coverage also tended to be less comprehensive. Faced with deficit financing, a sluggish economy, complaints from its white constituency about taxation levels, and pressure from private sector interest groups, the Nationalist government has endorsed the concept of privatisation of health care. Exponents of privatisation claim that it will permit differentiation by income to supplant discrimination by race. However, the direct links between disposable income and race, the rapidly rising costs of private insurance, and the still-limited extent of private coverage among the black majority, indicate that privatisation is likely to co-opt a comparatively small proportion of the total black population. It may exacerbate the urban-rural imbalance in health status and health services, promote growth of hospital-intensive curative services rather than needed expansion of community-centred preventive and primary care, and create financial barriers to access for low-income patients.(ABSTRACT TRUNCATED AT 400 WORDS)