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Background. High-deductible health plans (HDHPs) are of high interest to employers, policy makers, and insurers because of potential benefits and risks of this fundamentally new coverage model. Objective. To investigate the impact of HDHPs on health care utilization and costs in a heterogeneous group of enrollees from a variety of individual and employer-based health plans. Data. Claims and member data from a major insurer and zip code-level census data. Study Design. Retrospective difference-in-differences analyses were used to examine the impact of HDHP plans. This analytical approach compared changes in utilization and expenditures over time (2007 versus 2005) across the two comparison groups (HDHP switchers versus matched PPO controls). Results. In two-part models, HDHP enrollment was associated with reduced emergency room use, increases in prescription medication use, and no change in overall outpatient expenditures. The impact of HDHPs on utilization differed by subgroup. Chronicallyill enrollees and those whoclearlyhad a choice ofplans were more likelyto increase utilization in specific categories after switching to an HDHP plan. Conclusions. Whether HDHPs are associated with lower costs is far from settled. Various subgroups of enrollees may choose HDHPs for different reasons and react differently to plan incentives.

In 1994, Tennessee converted its Medicaid program to a managed care system--TennCare. Graduate medical education (GME) funding by TennCare was linked to several workforce goals that included increasing the number of residents training in primary care and increasing the number of primary care physicians practicing in underserved areas of Tennessee.To determine the effects of the TennCare GME plan on GME and the physician workforce of Tennessee.Bureau of TennCare GME data from 1996-2004 and American Medical Association Physician Masterfile data through 2003.Changes in filled residency positions and number of stipend supplements awarded after implementation of the TennCare GME plan. Changes in physician workforce characteristics between a 5-year period before and after implementation of TennCare.Filled primary care residency positions increased from 839 (45.2%) in 1996 to 906 (47.9%) in 2000, but declined to 862 (43.5%) by 2004. Eleven of 133 available primary care stipend supplements were awarded through 2004. The percentage of physicians remaining in Tennessee after completion of residency decreased from 46.2% before TennCare to 42.4% (P = .087) after implementation of TennCare. U.S. medical graduates remaining in state declined by 5.8% (P = .019).The major goals of the TennCare GME plan have not been achieved. Overall, physician retention has decreased and the number of U.S. medical graduates remaining in state has declined. State policymakers should consider other methods to increase the number of residents training in primary care and ultimately practicing in underserved areas of Tennessee.

This statement provides a concise list of diagnostic terms for ECG interpretation that can be shared by students, teachers, and readers of electrocardiography. This effort was motivated by the existence of multiple automated diagnostic code sets containing imprecise and overlapping terms. An intended outcome of this statement list is greater uniformity of ECG diagnosis and a resultant improvement in patient care. The lexicon includes primary diagnostic statements, secondary diagnostic statements, modifiers, and statements for the comparison of ECGs. This diagnostic lexicon should be reviewed and updated periodically.

This statement examines the relation of the resting ECG to its technology. Its purpose is to foster understanding of how the modern ECG is derived and displayed and to establish standards that will improve the accuracy and usefulness of the ECG in practice. Derivation of representative waveforms and measurements based on global intervals are described. Special emphasis is placed on digital signal acquisition and computer-based signal processing, which provide automated measurements that lead to computer-generated diagnostic statements. Lead placement, recording methods, and waveform presentation are reviewed. Throughout the statement, recommendations for ECG standards are placed in context of the clinical implications of evolving ECG technology.

((Author: please insert an abstract. This should be 4 to 5% of the length of the article (but no more than Abstract 400 words) and highlight, in an informative manner, specific important points addressed in the main body of the text. Please do not just describe the general areas covered in the manuscript. The journal style is to not cite references in the abstract so as to provide a discrete synopsis of the article)) 1. The Economics of Prevention in a Post-Managed and technical infrastructure to deliver these services, and reducing

The electrocardiogram has been shown in epidemiologic studies to be an independent predictor of survival. These studies have adjusted for selected covariates simultaneously. This article assesses the value of the electrocardiogram as a predictor of survival when introduced at progressive stages of the common clinical encounter. Data collected from 4,518 patients ages of 60 to 96 years with isolated systolic hypertension who were followed-up for up to 6 years as part of the Systolic Hypertension in the Elderly Project were analyzed. Survival curves and 3- and 5-year survival rates (Cox regression methods) of groups with normal and abnormal resting electrocardiograms were compared. Blocks of covariates representing demographic information, risk factors for cardiovascular disease, clinical history, and physical examination findings were added to the survival models sequentially to mimic the sequence of the common clinical encounter, and the independent significance of the electrocardiogram as a predictor of survival was assessed at each step. An abnormal electrocardiogram was associated with reduced survival when no adjustment for covariates is made. Survival was also significantly (P

Research translation typically includes translation from basic science into clinical research and from clinical research into everyday clinical practice. In this essay, we propose a greater emphasis on applying research findings, both basic and clinical, into effective public policies that promote health. Research can have important influences on policy by providing a scholarly basis for action research, and translation science units within academic health centers are in powerful positions to build bridges between the research and policy making communities to promote the development of evidence based policy. The results will benefit the researcher and the decision maker, as well as the research itself.

Psychological burnout significantly and detrimentally affects individuals and the organizations for which they work. Leaders with burnout often display characteristics that are the opposite of those required to implement major organizational change. This study was undertaken to assess the level of psychological burnout of leaders of the Department of Veterans Affairs (VA) medical centers during a period of rapid change. The objective was to quantify trends in the level of burnout and associated measures of psychological stress. Surveys of medical center directors, associate medical center directors, and chiefs of staff of each VA medical center were conducted in 1989, 1992, and 1997 to evaluate burnout, role characteristics, and job satisfaction. Burnout was measured using the Maslach Burnout Inventory and scored using the phase model of burnout. Findings demonstrated higher prevalences of more advanced levels of burnout in the 1992 and 1997 surveys than in the 1989 survey. Role clarity, perceived adequacy of resources to complete assigned tasks, and several measures of job satisfaction were lower in the 1997 survey compared to the earlier survey data. Therefore, psychological burnout and other indicators of stress increased during the 1989 to 1997 study period. These findings suggest cause for concern as the largest integrated healthcare system in the United States undertakes major organizational change to meet present and future challenges.

A new and comprehensive National Health Insurance Law was implemented in Israel on January 1, 1995. This major health care reform initiative culminated an effort lasting several decades to assure broad universal health care coverage for the population as a matter of national law. Issues that affected the development of the reform package included 1) the formation of sick funds that provide care to over 96% of the population as part of other powerful sociopolitical organizations, 2) the historical development of parallel private July 16, 1995 and governmental health care systems before Israel became a state in 1948 and the post-state maintenance of multiple health care delivery systems, and 3) the close interactions of health care systems and the political processes and parties of the nation. This paper describes the effects of these forces on resisting changes that were widely accepted as being necessary to expand access, control rising health care costs, and improve the efficiency of the nation's health ...

The choice of a specialty by medical students is a complex one that has significant implications for the future supply of physician manpower. The study by Weissman et al. portrays this choice as reflecting the degree of congruence between a student's needs and values and his or her perception of the characteristics of the various specialties. The existing shortages in the supply of various specialists in Israel may be interpreted as signifying a lack of alignment of student needs and perceptions. This commentary will extend the implications of this work to include the connection between students' choices and the physician manpower needs of society, and will focus on primary care physician shortages in the United States as but one example of the implications of these relationships.

TennCare, the health care system reform plan implemented in Tennessee on January 1,1994, was developed with the dual objectives of controlling the rapidly rising cost of the state's Medicaid program and extending health insurance coverage to most Tennesseans without access to employer-sponsored or other government-sponsored health insurance. Beneficiaries enroll in competing, state-chartered managed care organizations that are responsible for providing broad preventive, inpatient, and outpatient services and are reimbursed by the state on a capitation basis at a rate based on a statewide global budget for health care. The program initially proposed to enroll up to 1 775 000 citizens and was projected to result in a cumulative cost savings to Tennessee and the federal government of $7.2 billion by the end of the 5-year demonstration period. However, major start-up problems encountered by the state and by managed care organizations and limitations imposed by the government have significantly constrained these expectations. At the end of its first year, more than 1.2 million citizens were enrolled, but the program incurred a $99 million deficit. Managed care organizations and hospitals have reported major financial problems, and constituency groups—especially those representing physicians—have attempted to block the program. Our objective is to describe the design and rationale of TennCare and discuss key issues the plan continues to face that may affect its long-term success. ( JAMA . 1995;274:1235-1241)

This study was designed to determine the impact of noncritical (less than 70% narrowing of the luminal diameter) coronary stenoses on the long-term survival rate of patients with coronary artery disease. The survival rate of 3,342 patients with normal coronary arteries (Group 1A) was compared with that of 2,184 patients with only noncritical stenoses (Group IB). Similarly, the survival rate of 1,128 patients with one or more critical lesions (Group 2A) was compared with that of 5,944 cases with noncritical plus critical lesions (Group 2B). Patients with noncritical lesions had significantly lower 10-year survival rates (85.8%) than did those with normal coronary arteries (90.1%). However, the difference in survival rate was attributable to older age, male sex, and higher prevalence of cigarette smoking, diabetes mellitus, and hypertension in Group IB than in Group 1A; presence of noncritical stenoses was not a statistically significant independent determinant of survival. Long-term survival rates of the patients with one or more critical lesions (Group 2A) were equivalent to that of patients with critical stenoses plus one or more noncritical lesions (Group 2B). Therefore, 1) patients with only noncritical stenoses have more risk factors for coronary artery disease than do those with normal coronary arteries; 2) these patients have a reduced long-term survival rate that reflects these risk factors rather than the presence of noncritical lesions; and 3) in patients with critical lesions, the presence of additional non-critical stenoses does not affect the long-term survival rate.

Study objective This study was undertaken to determine the effects of altered risk factors and treatment modalities on the short- and long-term survival of patients with documented coronary artery disease whose conditions were diagnosed from 1972 through 1982. Study design The study was a retrospective database analysis of clinical, angiographic, and follow-up information. Setting Data from all patients referred for cardiac catheterization at the Baptist Memorial Hospital, Memphis, Tenn, were studied. Patients Risk factors and survival of patients who underwent cardiac catheterization from 1972 through 1982 and who were followed up for at least 5 years were evaluated. Cohort A included 1,821 patients studied from 1972 through 1977; cohort B included 5,369 patients studied between 1977 and the end of 1982. Each cohort was subdivided based on type of therapy (medical or surgical) that the patients received. Measurements and results The 30-day (short-term) and 5-year (long-term) survival rates were compared by life table methods. Short-term survival improved significantly in both medical (from 94.9% to 97.5%, p Conclusions These results indicate that during the study period, a significant decline in short-term mortality occurred for patients with angiographically documented coronary artery disease. Long-term survival did not, however, improve possibly due to a complex interplay between factors that promote coronary artery disease, eg, cigarette abuse and hypercholesterolemia, and factors that determine survival, eg, increases in age and history of prior infarction and advances in medical and surgical therapy.

Objectives. Utilization rates for cardiac catheterization and cardiac surgery in the Department of Veterans Affairs (VA) health care system were studied to determine whether racial diierences existed in a delivery plan in which access is not determined by patient finances. Background. Prior studies have demonstrated significant differences in utilization of cardiac diagnostic and therapeutic resources by white and black patients. Reasons for the reduced utilization by black patients include socioeconomic, biologic and sociocultural effects. Methods. Computerized discharge records of 30,300 patients with coronary artery disease and 1,335 patients with valvular heart disease who were discharged from any of 172 VA Medical Centers between October 1, 1990 and September 30, 1991 were studied. Results. For patients with coronary artery disease, utilization rates of cardiac catheterization were significantly greater for white patients (503.4 procedures/1000 patients) than for black patients (433.2/1000 patients), with a relative odds ratio of 1.33, Rates for surgery (179.0 vs. 124.5/1,000 patients) were also greater for whites for blacks, with a relative odds ratio of 1.53. For the subset with valve disease, the catheterization rate was significantly greater for whites than for blacks (575.4 vs. 432.6 procedures/1,000 patients), with a relative odds ratio of 1.78. Surgical rates were not significantly different (423.8 vs. 354.6 operations/ 1,000 patients). Racial differences for both catheterization and surgery varied widely as a function of geographic region and the level of complexity of the local VA facility. Conclusions. Racial differences in resource utilization exist in a health care system in which economic influences are minimized. The pattern of these differences depends on numerous variables and suggests both biologic and sociocultural factors as underlying causes.

The detection and assessment of cardiac chamber hypertrophy has long been an important objective of clinical electrocardiography. Its importance has increased in recent years with the recognition that hypertrophy can be reversed with therapy, and that by doing so, adverse clinical outcomes can be

The safety and efficacy of a 10- to 15-mg/h continuous infusion of intravenous diltiazem were evaluated in 47 patients with atrial fibrillation or flutter who first responded to 20 mg or 20 mg followed by one or more 25-mg bolus doses of open label intravenous diltiazem. Of the 47 patients, 44 responded to the bolus injection and were randomized under double-blind conditions to receive either a continuous infusion of intravenous diltiazem (10 to 15 mg/h) (23 patients) or placebo (21 patients) for up to 24 h.Seventeen (74%) of the 23 patients receiving diltiazem infusion and none of the 21 with placebo infusion maintained a therapeutic response for 24 h (p < 0.001). Over 24 h, patients receiving diltiazem infusion lost response significantly more slowly than did those receiving placebo infusion (p < 0.001). Nonresponders to the double-blind infusion were given an additional bolus injection of open label intravenous diltiazem and administered an open label 24-h intravenous diltiazem infusion. The overall proportion of patients maintaining a response to a 24-h infusion of intravenous diltiazem under double-blind or open label conditions combined was 83% (34 of 41).Efficacy of the 24-h infusion of intravenous diltiazem was similar in elderly versus young patients, those who did versus those who did not receive digoxin and those weighing

This study was undertaken to quantify basic cardiac electrical field properties using the Karhounen-Loeve (K-L) numerical expansion technique after experimental myocardial infarction. Transmural anterior myocardial infarction was produced in seven dogs by injection of liquid latex into the anterior descending artery; posterior myocardial infarction was produced in five dogs by injection of the circumflex artery. Body surface potentials from 84 electrodes were recorded during sinus rhythm prior to and 1 week after infarction. Electrical field properties during the QRS, ST, and QRST intervals were computed by the K-L method based upon areas calculated for each lead. The ratio of the sum of magnitude of the first three eigenvectors to the sum of all computed eigenvectors expressed as a percentage was used as a measure analogous to field dipolarity. Values before infarction were high during the QRS (97.1% +/- 2.0%, mean +/- 1SD), ST (96.0% +/- 5.1%), and QRST (97.7% +/- 2.7%) intervals, with no significant difference between the three periods. After infarction, the ratio during QRS decreased significantly, with lower values after posterior (61.9% +/- 11.7%) than after anterior (91.1% +/- 6.0%) infarction (p less than 0.001). Values during ST and QRST intervals were not significantly changed by infarction. Spatial patterns of the first eigenvector indicated that the derived QRS area electric field is directed away from the myocardial lesion for both anterior and posterior infarcts. Thus, experimental myocardial infarction produces significant changes in cardiac electrical field properties as measured by the K-L technique.

Previous studies have documented a reduced survival time in patients with an electrocardiographic (ECG) ST-T wave abnormality. This study was designed to determine the clinical, hemodynamic and angiographic correlates of this observation. Data from 9,731 patients undergoing cardiac catheterization from 1976 through 1986 were analyzed; 5,531 had severe (greater than 70%) obstruction of at least one major coronary artery, 1,706 had mild (10 to 69%) obstruction and 2,494 had no obstruction. Of the patients with severe obstruction, 2,536 were treated medically and 2,995 were treated by surgical revascularization. Patients with an ST-T abnormality had more clinical risk factors (including older age and greater prevalence of diabetes mellitus, hypertension and prior myocardial infarction) and greater left ventricular dysfunction (including higher end-diastolic pressure and ventricular volume, reduced ejection fraction and greater prevalence of contraction abnormality) than did those without this ECG pattern. Survival time was significantly (p less than 0.01) reduced in subsets of patients with an ST-T abnormality and with severe or mild coronary artery disease; in those without coronary disease, ST-T changes did not correlate with reduced survival. Stepwise regression analysis was applied to each group to determine the independent predictors of 5-year survival. In patients with severe disease or no disease, an ST-T abnormality was not chosen as an independent predictor of 5-year survival; in the group with mild disease, ST-T changes were an independent predictor of reduced survival. Thus, the independent impact of an ST-T abnormality on survival is dependent on the severity of underlying coronary artery disease.

This study examined effects of race and insurance on the risk of potentially avoidable hospitalizations (PAHs) in Tennessee. Applying the current Agency for Healthcare Research and Quality definitions for ambulatory-care-sensitive conditions to inpatient discharge data, the study found hospitalized Black patients more likely than their White counterparts to have experienced a PAH for chronic conditions. In contrast, Black inpatients' risk was lower than that of White inpatients for acute conditions after controlling for covariates. The results also showed the strong influence of insurance coverage. Finally, an analysis of racial differences in the relative risks for PAHs using data grouped by insurance status showed that hospitalized Blacks within each subset had a greater risk of having a PAH than hospitalized Whites, although the risk varied with insurance type. The variations of PAH risks across racial and insurance categories, together with the extra risks associated with chronic conditions, deserve greater examination.

Benazepril HCl is an orally effective angiotensin converting enzyme (ACE) inhibitor previously shown to have significant acute hemodynamic benefits in patients with congestive heart failure. In this study, 21 patients with New York Heart Association Class III or IV congestive heart failure were treated with 2 to 15 mg of benazepril HCl as a single daily oral dose for 28 days to determine the clinical and hemodynamic value of chronic therapy. Each patient underwent clinical evaluation during the 28-day period, as well as invasive hemodynamic studies on the first two and last two days of the trial. Plasma ACE activity and aldosterone levels fell significantly and renin levels rose after therapy. Benazepril HCl produced significant (p less than 0.01) reductions in arterial pressure and systemic vascular resistance, with corresponding increases in cardiac output and decreases in pulmonary artery wedge pressure. Responses after 28 days of therapy were equivalent to those after the initial doses. Clinical effects included reduced rest, exertional and paroxysmal nocturnal dyspnea, as well as reduced peripheral edema. Only one patient developed symptomatic orthostatic hypotension. Thus, benazepril HCl, given once daily, is an effective and well tolerated oral agent for the chronic treatment of advanced congestive heart failure.

This statement examines the relation of the resting ECG to its technology. Its purpose is to foster understanding of how the modern ECG is derived and displayed and to establish standards that will improve the accuracy and usefulness of the ECG in practice. Derivation of representative waveforms and measurements based on global intervals are described. Special emphasis is placed on digital signal acquisition and computer-based signal processing, which provide automated measurements that lead to computer-generated diagnostic statements. Lead placement, recording methods, and waveform presentation are reviewed. Throughout the statement, recommendations for ECG standards are placed in context of the clinical implications of evolving ECG technology.

Rationale: To examine: (1) the rates of potentially avoidable hospitalization (AH) of patients insured under Tennessee's Medicaid managed care program (TennCare) and compare them to those who have other types of insurance (e.g., Medicare or commercial insurance) and with those who are uninsured, and (2) the role of race in influcing the variations in hospitalization rate among the different insurance types. Objectives: The purpose of this paper is to test the hypothesis that significant variation exists in the probability of having an AH across different health insurance types and to evaluate indirectly the relative effectiveness of providing primary care across insurance types. Methodology: Logistic regression estimation of a multi-year, patient level UB-92 hospital discharge dataset for 2002-04 Anticipated Outcomes: The most direct outcome of the study will be baseline population-based relative prevalence rates of potentially avoidable hospitalization among different racial and insurance groups. These rates will reveal how severely the prevalence rate of avoidable hospitalizations of one population group (e.g., African Americans) differs from that of another group (e.g., white Americans) in Tennessee. Another important outcome will be a predictive model that can be used to estimate and predict the likelihood of being admitted to a hospital for an avoidable hospitalization and how that likelihood may be influenced by an individual's race, ethnicity, and insurance coverage. These probability estimates will be produced for each of the underlying medical conditions, called ambulatory-care sensitive or ACS conditions that can give rise to avoidable hospitalizations and for different racial/ethnic and insurance subgroups. Also available will be similar rates for individual hospitals and for different geographic areas across Tennessee based on, for example, the Health Planning Areas established by Tennessee Department of Health. When completed, the results will assist practitioners and hospital administrative staff in targeting groups at risk for unnecssary hospitalizations in an effort to improve quality of care and reduce costs.

In this issue of the Journal ofElectrocardiology, Castini et al. report electrocardiographic (ECG) findings supporting the validity of the Brody effect (1). This effect, reported in 1956 by Dr. Daniel Brody, describes the theoretical relationship between the conductivity of the blood mass contained within the heart and the potentials recorded outside the heart (2). The net result, as summarized by Brody, was that "the relatively large conductivity of the intracavitary blood mass tends to short-circuit the tangential components, but augments the radial components of myocardial doublets" (2). Because transmural ventricular activation is predominantly radial, increasing the size or conductivity of the left ventricular chamber would be predicted to enlarge body surface R waves. Castini et al. reported lower R wave amplitudes in patients after reducing ventricu]ar volume by venous compression (1), a finding expected from the Brody effect. To understand these data fully, it is important to distinguish between two fundamental factors that determine the amplitude and pattern of ECG potentials on the body's surface, namely, physiologic and biophysical variables. It is the interaction of these two sets of factors that, in the final analysis, determines body surface ECG potentials. Physiologic factors affecting the ECG are well known. The myocardial cell is the fundamental biologic cardiac generator, which generates cardiac electrical potentials as a result of multiple, timedependent ionic currents that traverse the cell membrane. The electrical activity of these cells is synchronized by the interaction of the specialized

The ability of the Karhunen-Loeve (K-L) numerical expansion technique to detect the presence of myocardial infarction is assessed by combining pools of QRS area data collected from 12 canines. First, potentials during normal sinus rhythm are recorded from 84 body surface electrodes. This set of potentials serves as control (CTL) data. Next, the dogs are divided into two groups for gathering data from both anterior and posterior infarcts in the left ventricle. One group consists of seven dogs all with anterior infarcts and a second group of five dogs all with posterior infarcts. One week after the infarcts are induced, potentials are again recorded during sinus rhythm. These potentials serve as anterior infraction (AI) and posterior infarction (PI) data sets. From the potential data, the QRS area for each lead is calculated for all three experimental populations. The CTL, AI, and PI QRS area data are grouped together in different combinations to study the effects of data pooling in identifying myocardial infarction with the K-L numerical expansion technique. The results indicate that the calculation of percent dipolarity of the QRS waveforms depends on the combination of data present in a given data pool. >

The relationship among postmenopausal estrogen use, coronary stenosis, and survival was examined retrospectively in 2268 women undergoing coronary angiography. The patients were selected for study if their age was 55 years or older at the time of angiography or if they had previously undergone bilateral oophorectomy. Postmenopausal estrogen use in 1178 patients with coronary artery disease (greater than 70% stenosis) and 644 patients with mild to moderate coronary artery disease (5% to 69% stenosis) was compared with 446 control subjects (0% stenosis) using life-table analysis. Over 10 years of follow-up, there was no significant difference in survival among patients initially free of coronary lesions on arteriography who had either never used (377) or ever used (69) estrogens. Among patients with mild to moderate coronary stenosis, 10-year survival of those who had never used estrogens was 85.0% and it was 95.6% among 99 "ever users." Survival was 60.0% among those with more than 70% coronary stenosis who had never used estrogen and it was 97.0% among 70 ever users. The "never users" group were older (65 vs 59 years), had a lower proportion of cigarette smokers (40% vs 57.1%), a higher proportion of subjects with diabetes (21.7% vs 12.9%) and hyperlipidemia (58% vs 44%), and approximately equal numbers of hypertensives (56.0% vs 54.3%). Cox's proportional hazards model was used to estimate survival as a function of multiple covariables. Estrogen use was found to have a significant, independent effect on survival in women. We conclude that estrogen replacement after menopause prolongs survival when coronary artery disease is present, but it has less effect in the absence of coronary artery disease.

Background Considerable variability exists in the use of cardiac procedures for patients with heart disease. One cause for this variability is the availability of local facilities to perform these procedures. This study was initiated to identify health system features that are related to rates of catheterization, percutaneous coronary angioplasty, and coronary artery bypass graft surgery in the Veterans Affairs health care system in which structured referral systems are intended to compensate for variation in local resource availability. Methods Medical records of 30,901 patients admitted to a Veterans Affairs medical center with coronary artery disease were analyzed. Odds ratios (OR) and 95% confidence intervals (CI) for undergoing each procedure, based on clinical variables (age, sex, race, coronary artery disease type, and a computed comorbidity score), and local Veterans Affairs facility features (geographic region, primary service area size, and hospital complexity) were estimated by logistic regression. Results Regression models demonstrated significant associations between the odds of undergoing each procedure and medical center geographic and complexity features, after adjustment for clinical variables. Associations included the presence of a cardiac catheterization laboratory for undergoing catheterization (OR 1.86, CI 1.76 to 1.95) and the presence of a cardiac surgical program for angioplasty (OR 1.46, CI 1.36 to 1.57) and bypass grafting (OR 1.43, CI 1.34 to 1.53). Including health system variables in addition to clinical variables in the regression models improved the discriminating ability of the models by 44.2% to 51.4%. Conclusions Geographic location and the complexity of the local Veterans Affairs hospital are important determinants of the use of cardiac procedures in the Veterans Affairs health care system, even though referral networks are intended to correct for local differences in hospital complexity. (Am Heart J 1999;137:706-13.)

Previous studies have demonstrated that regionalization of resources for cardiac catheterization, percutaneous coronary artery angioplasty (PTCA), and coronary artery bypass graft surgery (CABG) reduces the rate of procedure use. It was hypothesized that the impact of regionalization would be greater for the elderly and for African-Americans than for other populations. Discharge medical records of 30,901 patients admitted to a Veterans Affairs (VA) medical center between October 1, 1993, and September 30, 1994, with a diagnosis of coronary artery disease were analyzed. The presence of a cardiac catheterization laboratory in the patients’ local VA facility significantly increased the likelihood of undergoing catheterization, PTCA, and CABG, as determined by odds ratios and associated confidence limits estimated by logistic regression techniques. The presence of a cardiac surgical facility also significantly increased the likelihood of having the procedures. The odds ratios estimating the effects of resource availability were significantly greater for the subgroup of patients aged ≥70 years than for the younger subgroup for catheterization, PTCA, and CABG and for African-Americans than for white patients for PTCA and CABG. Thus, within the VA health care system, regionalization of cardiac procedures has a significant impact on utilization rates of tertiary cardiac procedures. These differences are significantly greater for the elderly and for African-Americans than for the general population.

In Galvani’s exploration of the electrical properties of living tissues [1], he discovered that a muscle or nerve could be stimulated electrically by touching either with the ends of two rods of dissimilar metals bound together. To prove that animal tissue could generate electricity, he placed a nerve attached to a muscle across two points of another living muscle, one of which had been injured. The muscle of the former underwent contraction. It was the first demonstration of animal electricity and a gradient in potential between an injured and uninjured muscle tissue, the current of injury. The rheoscopic nerve-muscle preparation he used as the sensor could also be made to respond when the nerve was placed in contact with a beating heart, as shown subsequently by Kolliker and Muller [2]. It was the first direct lead used to record cardiac electricity [3] but was an electromechanical device, since the current generated by the heart yielded a measurable contraction of muscle rather than a graphic representation of the cardiac electromotive force itself.

To meet the goals of body surface electrocardiographic mapping, a series of devices and techniques have been developed. These include electrode systems, data acquisition procedures, display formats, and qualitative and quantitative data analysis routines. Each of these will be described and evaluated in this chapter.

Myocardial ischemia caused by inadequate coronary blood flow produces abnormalities of the S-T segment and T wave as well as alterations in the QRS complex. In this chapter, we shall explore the mechanisms as well as the patterns of these changes that occur in the absence of acute myocardial infarction. Specific attention will be given to the electrocardiographic abnormalities produced by exercise stress testing.

In the previous chapter, we described the effects of acute myocardial infarction on ventricular repolarization forces. We will now proceed to detail the electrophysiologic consequences of injury and infarction on ventricular activation. After developing the physiologic bases for changes in the QRS complex, resulting abnormalities in the body surface potential distribution will be described, and data documenting the diagnostic utility of electrocardiographic mapping will be presented.

We have now established the physiologic basis for body surface electrocardiographic mapping and have described the methods needed for data acquisition and analysis. In this chapter, we will build upon these foundations by detailing evidence that the goals of body surface mapping, as set forth in Chapter 3, are attainable.

Affiliations between Department of Veterans Affairs [VA] medical centers and colleges of medicine are important to both parties. Recently, the values and costs of these relations have come under increasing scrutiny. In this study, the authors attempted to determine the attitudes of local VA medical center leadership members toward these affiliations. A mail survey of directors, associate directors, and chiefs of staff of VA medical centers was undertaken. Respondents were asked to score their agreement or disagreement with each of eight statements defining various features and values of VA-medical school affiliations. Scores were reported on a Likert scale of 1 (strongly agree) to 7 (strongly disagree). Strongly positive general attitudes toward VA-university affiliations were found from the results. Mean scores averaged 2.02. However, responses to statements identifying specific concerns with these affiliations (eg, diversion of resources away from VA toward university goals and the lower status of VA-based faculty) were less positive. More positive general attitudes and less negativity about specific concerns were expressed by chiefs of staff than by medical center directors or associate medical center directors and by leaders of highly affiliated medical centers than by leaders of other types of centers. Therefore, local VA medical center leaders have very positive general attitudes toward university affiliations. However, specific problem areas do exist. These issues and attitudes are important for leaders of both the VA health-care system and academic medical centers to consider when developing and implementing local and national policies.

The practice of medicine has come under increasingly intense public examination during the past several years. Two reasons for this scrutiny are rapidly rising health care costs and the increasing proportion of the population with limited access to health care1. Health care expenditures in the United States exceed those in any other nation, and more than 37 million citizens are not covered by basic health insurance. The public scrutiny has been facilitated by other developments in health care. First, many nonmedical groups, including economists, political scientists, and sociologists, have begun to study health care from their own perspectives and . . .

The objective of this study was to quantify the features of intracavitary potential recordings before and after experimental myocardial infarction. Potentials were recorded within the left ventricular cavity in 10 dogs using a cylindrical [45mm × 10mm] probe with 40 evenly spaced unipolar recording electrodes on its surface, before and after acute occlusion of the left anterior descending coronary artery. Analysis of control and post-infarct waveforms was based on QRS and ST-T area, and maximum negative potential and maximum negative dV/dt during the QRS complex. Infarction resulted in significant [p

ST-segment depression is the characteristic electrocardiographic response to myocardial ischemia. A hypothesis is presented defining the structural and functional requirements for ischemic blood flow and ST-T wave potential gradients for ST-segment depression to occur. Both flow and potential gradients may be either transmural or transventricular. ST-segment depression results only when both are concordant (e.g., both transmural); however, ischemic ST-segment depression does not follow when flow and potential gradients are discordant (e.g., one transmural and one transventricular).

THE RELATIONSHIPS BETWEEN HEALTH AND ECOnomic conditions have been known for many years. Richer nations generally have better overall health conditions than do poorer nations and more affluent individuals within a country have, on average, better health than do poorer individuals. Also, less healthy individuals enter the labor market less often, work fewer hours, and earn lower wages, with direct financial consequences to themselves, their families, and the businesses for which they work. An expanded understanding of the relationship between health and macroeconomic performance is that “health is an economic engine.” This concept proposes that better population health leads to economic growth. The World Health Organization has supported this concept to encourage direct international investment in health-promoting services in developing nations as a means to advance economic growth. This concept of health as an economic engine also has important implications for US domestic health policy.

Clinical, hemodynamic and coronary angiographic data from 9,801 patients were evaluated to determine the correlates of ST-segment depression, with or without T-wave inversion, on the resting routine electrocardiogram. The relative risk (RR) of having a measured clinical or angiographic variable was computed whether or not ST-T-wave abnormalities were observed. ST-segment depression was seen significantly more often in subjects greater than 55 years of age (RR = 1.4) who were women (RR = 1.3) or nonwhite (RR = 1.5), were hypertensive (RR = 1.8), had diabetes mellitus (RR = 1.6) or who smoked cigarettes (RR = 1.5). Angiographic findings related to presence of ST-T-wave abnormalities included severe coronary obstruction (less than 70%), higher number of diseased vessels, and the presence of obstruction in the left anterior descending coronary artery. In a multivariate model, the most significant correlates of ST-T-wave abnormalities were presence of left ventricular contraction abnormality, followed by age, gender, presence of left anterior descending coronary artery disease, elevated end-systolic volume index, and a diagnosis of hypertension. Thus, electrocardiographic ST-T abnormalities has specific and significant clinical and pathophysiologic correlates.

More physicians are assuming salaried positions within large health care organizations. In this report, we discuss the influence of such organizational changes on physician behavior in one large health care system--the Department of Veterans Affairs (VA) system--which employs more than 14,000 physicians. Conflicting pressures on these physicians in VA facilities affiliated with academic medical centers include differences between professional and organizational needs plus differences between the roles of the VA hospital and of the affiliate academic medical center. An analysis of these issues, based on organizational theory, suggests that these clashes are consequences of fundamental differences between the parties involved. Because the outcome of the conflicts may be fatal to the organizations, they must be managed, not ignored. This involves recognizing the existence and the nature of the differences as well as actively sharing the responsibilities and the issues usually charged to one of the two conflicting groups to form a conjoint organization between the "two sides of the street."

The effect of age at the time of coronary artery bypass graft surgery on postoperative survival was studied in 2,507 patients with significant coronary artery disease. Patients were subdivided into five groups based on age at the time of surgery: 20 to 39, 40 to 49, 50 to 59, 60 to 69 and greater than or equal to 70 years. The observed death rate was compared with that expected for subjects from the general U.S. population matched for age, gender, race and calendar year. For patients less than or equal to 59 years of age, the ratio of observed to expected death rates was significantly greater than unity (observed/expected = 4.9 for ages 20 to 39, 1.9 for ages 40 to 49 and 1.3 for ages 50 to 59 years, p less than 0.01). The prevalence of risk factors, including diabetes mellitus, hypertension, hypercholesterolemia and cigarette smoking, was evaluated in the different age subgroups. When patients were subdivided on the basis of history of cigarette smoking, the decreased relative survival rate of younger (less than 60 years old) patients existed only in those who smoked (observed/expected = 6.0 for ages 20 to 39, 2.2 for ages 40 to 49 and 1.4 for ages 50 to 59 years). In nonsmokers, observed/expected ratios for every age group were not significantly different from unity. Thus, the reduced relative survival rate of younger patients after coronary artery bypass graft surgery may be attributed to the interactive harmful effects of cigarette smoking.