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Background: Little is known about regional patterns of intraaortic balloon pump (IABP) use in coronary artery bypass graft (CABG) operations. Our objectives were (1) to identify clinical variables associated with IABP use, and (2) to examine risk-adjusted rates of IABP use for 12 Massachusetts hospitals performing CABG operations., Methods: We used hospital discharge data to identify 6944 CABG surgical cases. Logistic regression was used to identify clinical variables associated with IABP use, and the resulting multivariate model was then used to risk adjust hospital rates of IABP use., Results: The IABP was used in 13.4% of the CABG surgical cases. The clinical variables independently associated with IABP use were cardiogenic shock, same admission angioplasty, prior CABG operation, cardiac arrest, congestive heart failure, recent myocardial infarction, and urgent admission status. Risk-adjusted rates of IABP use varied widely across hospitals from 7.8% to 20.8% (p < 0.0001)., Conclusions: Hospital rates of IABP use vary considerably in Massachusetts. This practice variation may be related to the persistent uncertainty regarding the precise clinical indications for the IABP in this patient population.

Our objectives were (1) to determine if studying hospital complication rates after coronary artery bypass graft (CABG) surgery provides information not available when only mortality is studied, and (2) to reexplore the utility of ICD-9-CM administrative data for CABG outcomes assessment. Using data from Massachusetts, we identified CABG cohorts from 1990 and 1992 to respectively develop and validate multivariate risk adjustment models predicting in-hospital mortality and complications. The resulting models had good discrimination and calibration. In 1992, adjusted hospital complication rates ranged widely from 13.0% to 57.6%, while mortality rates ranged from 1.4% to 6.1%. Hospitals with high complication rates tended to have high mortality (r = 0.74, p = 0.006), but 2 of the 12 hospitals studied ranked quite differently when judged by complications rather than mortality. We conclude that (1) complications after CABG occur frequently and may provide information about hospital quality beyond that obtained from hospital mortality rates, and that (2) administrative data continue to be a promising resource for outcomes research.

Objectives: The purpose of this research was to determine the influence of patient and physician characteristics on physicians' level of variability and certainty in breast cancer care., Methods: One hundred twenty-eight physicians viewed a videotape of a simulated physician-patient interaction in which the patient has an "atypical" breast lump. Six patient characteristics (age, race, socioeconomic status, physical mobility, comorbidity, presentation style) were manipulated experimentally, resulting in a balanced set of 32 different "patients." Physician subjects were recruited to fill four equal strata defined by specialty (surgeons versus nonsurgeons) and experience (< or = 15 or > 15 years since graduation from medical school)., Results: More than half of the physicians offered a diagnosis of benign breast disease, a third offered a diagnosis of breast cancer, and the rest believed that the patient had a normal breast or something "other." Results also indicated that physicians' level of certainty and test ordering behavior varied with the diagnosis that was offered. Of the six patient characteristics, only socioeconomic status influenced physician certainty; physicians were more certain of their diagnosis when the patient was of a higher socioeconomic status. Surgeons were found to be more certain of their diagnosis compared with nonsurgeons. However, surgeons were less likely to order radiologic tests or a tissue sample for metastatic evaluation than were nonsurgeons., Conclusions: Overall, physicians displayed considerable variability and uncertainty when diagnosing and managing possible breast cancer.

Background: There is controversy regarding the role of alcoholism as a prognostic factor in hospitalized patients with pneumonia., Objective: To assess the impact of alcohol abuse on hospitalization charges, length of hospital stay, intensive care unit use, and in-hospital mortality., Methods: We studied a cohort of all adults hospitalized in 1992 in Massachusetts with a principal diagnosis of pneumonia, and all Massachusetts residents hospitalized for pneumonia in 6 bordering states., Results: For the 23,198 pneumonia cases the mean total hospitalization charges were $9925, mean length of hospital stay was 9.6 days, 12% of the cases had intensive care unit stays, and 10% of the cases died during the hospitalization. In bivariate analyses, pneumonia cases with alcohol-related diagnoses had higher charges (mean, $11,232 vs $9877, P = .07), had shorter length of hospital stay (9.2 vs 9.6 days, P = .02), were more likely to experience an intensive care unit stay (19% vs 12%, P < .001), and had lower in-hospital mortality (6.0% vs 10.2%, P < .001). Multivariable analyses adjusting for comorbidity, pneumonia etiology, and demographics revealed that for pneumonia cases with alcohol-related diagnoses, risk-adjusted hospital charges were $1293 higher (adjusted mean, $11,179 vs $9888, P < .001), length of hospital stay was 0.6 days longer (10.1 vs 9.5 days, P = .001), intensive care unit use was higher (18% vs 12%; adjusted odds ratio, 1.63; 95% confidence interval, 1.33-1.98), and mortality was no different (10% with or without an alcohol-related diagnosis)., Conclusions: Having an alcohol-related diagnosis is associated with more use of intensive care, longer inpatient stays, and higher hospital charges. To understand resource utilization in cases of pneumonia, alcohol abuse is a comorbid factor that must be considered.

We identified 6,791 coronary artery bypass grafting (CABG) cases using the Massachusetts hospital discharge data to quantify the contribution of complications to the cost of a hospitalization for CABG. After adjusting for in-hospital mortality and baseline clinical severity as other contributors to cost, the additional costs associated with complications were substantial.

Background: Recent reports from New York and northern New England claim that statewide quality improvement initiatives and outcome reporting are leading to decreased mortality following coronary artery bypass graft (CABG) surgery., Objective: To compare trends in mortality after CABG surgery in Massachusetts (a state that has not instituted statewide outcome reporting) with the decreases reported from New York and northern New England., Design: Surgical cohorts from 1990, 1992, and 1994 were used to evaluate the risk-adjusted mortality trend for Massachusetts. We present this trend along with the published trends from New York and northern New England. For comparison, we also present unadjusted Medicare mortality trends from Massachusetts, New York, northern New England, and the entire United States., Setting: All 12 Massachusetts hospitals performing cardiac surgery (excluding a Veterans Affairs hospital). PATIENTS AND DATA SETS: Massachusetts administrative data were used to identify all patients undergoing isolated CABG surgery in 1990, 1992, and 1994., Main Outcome Measures: Observed and risk-adjusted in-hospital mortality., Results: Observed mortality rates in Massachusetts decreased from 4.7% in 1990 to 3.5% in 1992 and to 3.3% in 1994. The corresponding risk-adjusted mortality reductions for 1992 and 1994 (relative to 1990) were 35% and 42%, respectively. The mortality reduction seen in Massachusetts is comparable to the reductions seen in New York and northern New England over similar periods. Unadjusted Medicare mortality trends were generally similar in the states under study, and in the United States as a whole., Conclusions: In-hospital mortality after CABG surgery has decreased in Massachusetts despite the absence of statewide outcome reporting. Direct program evaluations are needed to better characterize the efficacy of the ongoing statewide outcome studies in New York and northern New England.

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

Testing asymptomatic women for chlamydial infection is advocated for high-risk populations, but testing criteria in low-risk settings are less clear. To determine whether findings from Papanicolaou (Pap) smears could identify women at risk for Chlamydia, we studied 512 women, 18 to 50 years of age, seeking routine gynecologic care. The prevalence of positive cultures for Chlamydia was 4.7%. Three cytologic findings were independently associated with Chlamydia on logistic regression: transformed lymphocytes, polymorphonuclear leukocytes, and squamous metaplasia. The sensitivity and the specificity of the presence of any two of these three findings were 75% and 73.6%, respectively. The prevalence of Chlamydia if two findings were present was 12.2%, nearly three times the population prevalence. Certain findings on cervical cytology may be useful as an adjunct in preventive care for chlamydial cervicitis.

To assess the effect of postmenopausal use of estrogens on the subsequent risk of hip fracture, we performed a retrospective cohort study of 2873 women in the Framingham Heart Study. Information obtained at routine biennial examinations about the use of estrogens, body weight, age at menopause, smoking, and alcohol consumption was used to evaluate the risk of hip fracture among postmenopausal women who received estrogens. Hip fractures occurred in 179 postmenopausal women, at a rate that increased exponentially after the age of 50. The risk of fracture was inversely related to weight at all ages. The relative risk of hip fracture in subjects who had taken estrogens at any time was 0.65 after adjustment for age and weight (95 percent confidence interval, 0.44 to 0.98). The adjusted relative risk in women who had taken estrogens within the previous two years was further reduced, to 0.34 (95 percent confidence interval, 0.12 to 0.98). Taking estrogens within four years of menopause also protected against fracture. The number of women in each age group who took estrogens was insufficient for a definitive evaluation of risk, but recent use of estrogens appeared to be protective in women under the age of 65 (no fractures among those who took estrogens) and those 65 to 74. We cannot exclude some degree of selection bias among the women who received estrogen-replacement therapy. Nevertheless, this large cohort study supports the hypothesis that postmenopausal use of estrogens protects against subsequent hip fracture in women.

Concerns about the insensitivity of Medicare's diagnosis-related groups (DRGs) to illness severity heightened interest in the potential of alternative patient classification systems to improve the fairness of hospital reimbursement. This article examines the ability of admission MedisGroups score to explain the costs of hospital stays. The database contained 54,112 patients 65 years or older discharged in 28 high-frequency DRGs from 1984 to the middle of 1986 from 24 hospitals across the country. Admission MedisGroups score alone explained 3% of costs using trimmed data. Addition of admission MedisGroups score to DRGs modestly improved ability to predict differences in cost: for trimmed data, DRGs alone explained 52% of the variation in costs, compared with 55% when admission MedisGroups score was added. Within individual DRGs, the explanatory power of admission MedisGroups score ranged from 0% to 21%. The level of explanatory power was not related to the spread of cases across admission MedisGroups scores within DRG. No consistent clinical pattern explained these differences across DRGs.