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Background: It is unclear whether patients understand that percutaneous coronary intervention (PCI) reduces only chronic stable angina and not myocardial infarction (MI) or associated mortality. Objective: To compare cardiologists' and patients' beliefs about PCI. Design: Survey. Setting: Academic center. Participants: 153 patients who consented to elective coronary catheterization and possible PCI, 10 interventional cardiologists, and 17 referring cardiologists. Measurements: Patients' and cardiologists' beliefs about benefits of PCI. All cardiologists reported beliefs about PCI for patients in hypothetical scenarios. Interventional cardiologists also reported beliefs for study patients who underwent PCI. Results: Of 153 patients, 68% had any angina, 42% had activity-limiting angina, 77% had a positive stress test result, and 29% had had previous MI. The 53 patients who underwent PCI were more likely than those who did not to have a positive stress test result, but angina was similar in both groups. Almost three quarters of patients thought that without PCI, they would probably have MI within 5 years, and 88% believed that PCI would reduce risk for MI. Patients were more likely than physicians to believe that PCI would prevent MI (prevalence ratio, 4.25 [95% CI, 2.31 to 7.79]) or fatal MI (prevalence ratio, 4.83 [CI, 2.23 to 10.46]). Patients were less likely than their physicians to report pre-PCI angina (prevalence ratio, 0.79 [CI, 0.67 to 0.92]). For the scenarios, 63% of cardiologists believed that the benefits of PCI were limited to symptom relief. Of cardiologists who identified no benefit of PCI in 2 scenarios, 43% indicated that they would still proceed with PCI in these cases. Limitation: The study was small and conducted at 1 center, and information about precatheterization counseling was limited. Conclusion: Cardiologists' beliefs about PCI reflect trial results, but patients' beliefs do not. Discussions with patients before PCI should better explain anticipated benefits. Primary Funding Source: None.

Background: Care from high-volume centers or surgeons has been associated with lower mortality rates in coronary artery bypass surgery, but how volume and quality of care relate to each other is not well understood. Objective: To determine how volume and differences in quality of care influence outcomes after coronary artery bypass surgery. Design: Observational cohort. Setting: 164 hospitals in the United States. Patients: 81 289 patients 18 years or older who had coronary artery bypass grafting from 1 October 2003 to 1 September 2005. Measurements: Hospital and surgeon case volumes were estimated by using a data set. Quality measures were defined by whether patients received specific medications and by counting the number of measures missed. Hierarchical models were used to estimate effects of volume and quality on death and readmission up to 30 days. Results: After adjustment for clinical factors, lowest surgeon volume and highest hospital volume were associated with higher mortality rates and lower readmission risk, respectively. Patients who did not receive aspirin (odds ratio, 1.89 [95% CI, 1.65 to 2.16) or [beta]-blockers (odds ratio, 1.29 [CI, 1.12 to 1.49]) had higher odds for death, after adjustment for clinical risk factors and case volume. Adjustment for individual quality measures did not alter associations between volume and readmission or death. However, if no quality measures were missed, mortality rates at the lowest-volume centers (adjusted mortality rate, 1.05% [CI, 0.81% to 1.29%]) and highest-volume centers (adjusted mortality rate, 0.98% [CI, 0.72% to 1.25%]) were similar. Limitation: Because administrative data were used, the quality measures may not replicate measures collected through chart abstraction. Conclusion: Maximizing adherence to quality measures is associated with improved mortality rates, independent of hospital or surgeon volume. Primary Funding Source: California HealthCare Foundation.

Background: After the acute coronary syndrome, adding warfarin to standard aspirin therapy decreases myocardial infarction and stroke but increases major bleeding. Purpose: To quantify the risks and benefits of warfarin therapy after the acute coronary syndrome. Data Sources: MEDLINE from 1990 to October 2004. Additional data were obtained from study authors. Clinical risk factors were used to classify hypothetical patients into cardiovascular and bleeding risk groups on the basis of published data. Study Selection: Randomized trials comparing intensive warfarin therapy (international normalized ratio > 2.0) plus aspirin with aspirin alone after the acute coronary syndrome. Data Extraction: Two reviewers independently selected studies and extracted data on study design; quality; and clinical outcomes, including myocardial infarction, stroke, revascularization, death, and major and minor bleeding. Rate ratios for outcomes were calculated and pooled by using the method of DerSimonian and Laird. Data Synthesis: Ten trials involving a total of 5938 patients (11 334 patient-years) met the study criteria. Compared with aspirin alone, warfarin plus aspirin was associated with a decrease in the annual rate of myocardial infarction (0.022 vs. 0.041; rate ratio, 0.56 [95% CI, 0.46 to 0.69]), ischemic stroke (0.004 vs. 0.008; rate ratio, 0.46 [CI, 0.27 to 0.77]), and revascularization (0.115 vs. 0.135; rate ratio, 0.80 [CI, 0.67 to 0.95]). Warfarin was associated with an increase in major bleeding (0.015 vs. 0.006; rate ratio, 2.5 [CI, 1.7 to 3.7]). Mortality did not differ. Limitations: Two large studies provided most of the data. Studies did not include coronary stenting, and results should not be applied to patients with stents. Relative risk reductions may not be consistent across risk groups. Conclusions: For patients with the acute coronary syndrome who are at low or intermediate risk for bleeding, the cardiovascular benefits of warfarin outweigh the bleeding risks.

Background: Although antiviral therapy is cost-effective in adults, its cost-effectiveness in older adults has not been studied. Objective: To determine the cost-effectiveness of influenza testing and treatment strategies for older adults. Design: Cost-utility decision model. Data Sources: Clinical trials of antiviral drugs and epidemiologic data. Target Population: Noninstitutionalized adults older than 65 years of age with influenza-like illness. Time Horizon: Lifetime. Perspective: Societal. Interventions: Rapid diagnostic testing or empirical therapy with antiviral drugs. Outcome Measures: Cost per quality-adjusted life-year (QALY) saved. Results of Base-Case Analysis: Compared with no intervention, empirically treating an unvaccinated 75-year-old patient with amantadine increased life expectancy by 0.0014 QALY at a cost of $1.57, a cost-effectiveness ratio of $1129 per QALY saved. Compared with amantadine, rapid diagnostic testing followed by treatment with oseltamivir cost $5025 per QALY saved and empirical treatment with oseltamivir cost $10 296 per QALY saved. Testing and treatment strategies were less cost-effective if the patient was vaccinated, ranging from $2483 per QALY saved with amantadine to $70 300 per QALY saved with oseltamivir. Results of Sensitivity Analysis: The decision was sensitive to the probability of influenza, the efficacy of oseltamivir in preventing hospitalizations, and hospitalization and case-fatality rates. The decision was not sensitive to the probability or severity of medication side effects, the quality of life for influenza illness or hospitalization, the efficacy of antiviral therapy in shortening influenza illness, or the rapid diagnostic test characteristics. Conclusions: For unvaccinated or high-risk vaccinated patients during the influenza season, empirical oseltamivir treatment is cost-effective. For other patients, rapid diagnostic testing followed by treatment with oseltamivir is cost-effective. Empirical amantadine treatment offers a low-cost alternative if patients cannot afford oseltamivir.