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Objective: The aim of this study was to examine the association between accessibility to cardiovascular emergency centers and cardiovascular mortality in Japan., Design: A semi-ecological study., Setting: Three databases were generated: accessibility to emergency cardiovascular centers, population records and death records., Main Outcome Measures: The standardized mortality ratio (SMR) for cardiovascular disease was adjusted by age and sex. Accessibility was represented by transfer time, number of cardiovascular emergency hospitals, and the proportion of habitable areas. Combinations of the three were divided into Categories 1-8 from the worst to the best, and the association with SMR was analyzed., Results: There were 1998 cardiovascular emergency hospitals. The median of crude mortality was 0.16%. The median SMR of the reference Category 8 (transfer time <30 min and habitable area ≥50% with cardiovascular emergency hospitals) was 0.96, but that of the low accessibility Category 1 (transfer time ≥30 min and habitable area <50% without cardiovascular emergency hospitals) was 1.10. The SMR of accessibility Category 1 : Category 8 was 1.18 (95% confidence interval: 1.14-1.21)., Conclusions: Decreased accessibility to cardiovascular emergency hospitals was associated with increased SMR. Areas with less accessibility and higher cardiovascular mortality were characterized by geographical variability in Japan., (© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Objective: The aim of this study was to examine the impact of a government-directed regional cardiovascular center (RCVC) project on the length of stay (LOS) and medical costs due to acute myocardial infarction (AMI)., Design: A retrospective claim data review., Setting: Forty hospitals including four RCVCs in Korea., Participants: A total of 1469 AMI patients who visited a RCVC in two regions between February 2009 and December 2011., Interventions: RCVC project has been fostering specialized center by region for management of cardiovascular disease. It has built a system that could receive intensive care quickly within 3 h when disease occurred., Main Outcome Measures: Changes in the LOS and cost were evaluated using the difference-in-differences (DIDs) method combined with propensity score matching (1:1) and multilevel analysis with adjustment for patient's and institutional factors., Results: The net effect of RCVC project implementation showed decline of LOS (-0.71 days) and total medical costs (-797 US dollars) by DID. After the RCVC project, the LOS for patients with AMI hospitalized in a RCVC was decreased by 8.9% (β = -0.094, P = 0.041) compared with patients hospitalized in a hospital not designed as a RCVC. Compared with costs before the RCVC project, they were decreased by 11.5% (β = -0.122, P = 0.004)., Conclusions: We provided evidence regarding the change in the societal burden due to AMI after regionalization. Although there was a reduction of LOS and direct medical costs reported in limited number of regionalized hospitals, in the long term we can anticipate an expanding impact in all regionalized hospitals., (© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Background: In 2010, guidelines published by the National Institute for Clinical Excellence (NICE) suggested a change in the way patients with stable chest pain of suspected cardiac origin were investigated. These guidelines removed exercise treadmill testing from routine use and introduced cardiac CT to regular use., Objective: To investigate whether these guidelines had improved our service provision by reducing the number of further investigations required to make a diagnosis, and to see if our costs had increased now that the less expensive exercise treadmill tests were not recommended., Methods: Clinic letters were used to assess patients pretest likelihood of coronary artery disease for two six-month cohorts of consecutive patients seen in the rapid access chest pain clinic (January-June 2010 and July-December 2011) using NICE published methodology, and to ascertain which investigations patients had. Using NICE modelled costs, we generated comparative hypothetical costs for each cohort and an average cost per patient., Results: In the January-June 2010 cohort, 435 patients with chest pain were seen, and in July-December 2011, 334 patients were seen. In the pre-NICE guidelines cohort, 23% of patients required two investigations as compared with 11.4% in the post-NICE guidelines cohort, with no patient requiring three investigations as compared with 3% in the original cohort. There was no significant increase in costs per patient in the post-NICE guidance group., Conclusions: Implementing NICE guidance reduced the number of investigations needed per patient, and did not prove more expensive for our department in the short term.

Objectives: National trends in cardiac surgery show a shift towards a higher preoperative risk profile and factors that might also be expected to increase the risk of postoperative infective complications. We document the changing patient demographics in the first 15 years of a new cardiac surgery unit and examine the impact of these and other changes in estate, staffing and clinical protocols, on the risks of common postoperative infections., Methods: Data recorded included patient age, sex and body mass index, type and number of operations, logistic EuroSCORE, mortality rate, urgency of operation, reoperation rate, requirement for intra-aortic balloon pump, incidence of diabetes and the incidence of common postoperative infections., Results: A total of 8449 cardiac operations were undertaken. The mean patient age increased from 62.71 to 65.82 years; procedural complexity increased with the proportion of isolated coronary artery bypass procedures falling from 72.8 to 54%; there were increases in the urgency of operation (11.3-26.9%), average patient body mass index (27.01-28.67), the incidence of diabetes (12.3-21.2%), logistic EuroSCORE (5.36-7.74) and intra-aortic balloon pump usage (6.4-15.6%). The incidence of superficial sternal infection reduced (3.9-1.4%); other wound infection rates were low and showed no overall trend with time. Urinary tract infection varied between 0 and 1.7%, but did show a significant increase over the last 3 years (P < 0.01)., Conclusions: This study demonstrates a change in the patient profile, yet despite an increase in infection risk factors, no increase in actual infection rates. The importance of non-patient factors in influencing the outcomes after cardiac surgery is discussed.

Background: Implementing the recently published National Institute for Health and Clinical Excellence (NICE) clinical guideline on chest pain (CG95) in rapid access chest pain clinics (RACPCs) could significantly impact on overall cost, while introducing new technology like cardiac computed tomography (CT) scanning. With the National Health Service (NHS) under pressure to make £20 billion savings, applying CG95 in RACPCs could be challenging. An audit enabled us to assess the cost implications., Methods: A retrospective audit was performed of 204 consecutive cases attending Croydon RACPC from 13 July to 21 September 2010, on risk factors, demographics and planned first-line investigations. CG95 and three alternative strategies were mapped on the sample, and the estimated cost and volume of first-line investigations were compared with actual RACPC activities and costs., Results: Application of CG95 resulted in significant increases in cost and volume of functional testing, cardiac CT scan angiography and invasive coronary angiography, with 42-43% overall cost increases. The application of three alternative strategies resulted in annual cost increases ranging from 0.1 to 33%. An alternative cost analysis showed annual savings of up to 24%., Conclusions: Implementing NICE CG95 can significantly increase the cost of RACPCs but alternative strategies could enable the introduction of new technology without significant cost increases and even significant savings.

Background: Provision of cardiac rehabilitation is inadequate in all countries in which it has been measured. This study assesses the provision in the United Kingdom and the changes between 1998 and 2004., Methods: All UK cardiac rehabilitation programmes were surveyed annually. Figures for each year were up-rated to account for missing data and compared with national data for acute myocardial infarction, coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The total numbers and percentage of eligible patients included were charted for 7 years., Results: For centres giving figures, the total number treated rose from 29,890 in 1998 to 37,129 in 2004. The up-rated figures show that the percentage of eligible patients enrolled rose from 25.0% in 1998 to 31.5% in 1999 and has changed little since, falling from 31.3% in 2002 to 28.5% in 2004. About 25% of myocardial infarction patients, 75% of CABG patients and 20% of PCI patients joined cardiac rehabilitation programmes., Conclusions: The National Service Framework for Coronary Heart Disease set a target for 85% of myocardial infarct and coronary revascularization patients to be enrolled in rehabilitation programmes. Only one-third of this number is currently being enrolled and the percentage is falling.

Objective: Demographic changes, associated with increased demands for open heart surgery in the elderly, place increased burden on financial resources. To evaluate perioperative risk factors affecting incidence of hospital events and estimation of hospital charges, 2577 patients > or = 65 years (range 65-91), operated on from January 1991 to December 1994, were compared with a concurrent cohort of 2642 younger patients., Methods: Statistical analysis, by surgical procedure, focused on hospital mortality, key postoperative complications affecting length of hospital stay and hospital charges., Results: Overall hospital mortality was 4.7%, 3.5% in younger patients versus 6.1% in the older group (P << 0.01). Mortality was significantly lower in patients less than 65 years undergoing coronary artery bypass grafting (3% versus 5%, P < 0.01) and valve replacement (4% versus 9%, P = 0.01). Significant risk factors for hospital death in the elderly: diabetes (P < 0.01), hypertension (P < 0.01), myocardial infarction (P < 0.01) and congestive heart failure (P < 0.01). Significant postoperative events, more common in older patients, included prolonged ventilation (P << 0.01), congestive heart failure (P << 0.01), infection (P << 0.01), cerebrovascular accident (P < 0.01), and intra aortic balloon pump (P < 0.01). Incremental risk factors for morbidity in the elderly were: higher New York Heart Association class, congestive heart failure, emergent operation, and female gender. Mean length of hospital stay for the < 65 group was 15.3 versus > 19.5 days for the > 65 group (P << 0.01). Length of stay over 18 days positively correlated with increased morbidity in both age groups. For patients > or = 65 years of age, the average hospital charge for open heart surgery was 172% higher for patients with a length of stay greater than 18 days compared with 165% for patients less than 65 years of age., Conclusions: Higher operative mortality and longer length of stay in elderly patients, resulting in increased health care costs, was associated with more co-morbidities. These results suggest interventions designed to reduce congestive heart failure and other co-morbidities may improve patient's recovery and reduce costs.