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The use of coronary catheterization and percutaneous coronary intervention (PCI) is increasing in China, but, to date, there are no nationally representative assessments of the quality of care and outcomes in patients undergoing these procedures.To assess the quality of care and outcomes of patients undergoing coronary catheterization and PCI in China.In a clinical observational study (China PEACE [Patient-Centered Evaluative Assessment of Cardiac Events]-Retrospective CathPCI Study), we used a 2-stage, random sampling strategy to create a nationally representative sample of 11 241 patients undergoing coronary catheterization and PCI at 55 urban Chinese hospitals in calendar years 2001, 2006, and 2011. Data analysis was performed from July 11, 2014, to November 20, 2015.Patient characteristics, treatment patterns, quality of care, and outcomes associated with these procedures and changes over time.Of the 11 241 patients included in the study, the samples included, for 2001, 285 women (weighted percentage, 28.6%); for 2006, 826 women (weighted percentage, 32.2%), and for 2011, 2588 women (weighted percentage, 35.7%). Mean (SD) ages were 58 (8), 60 (11), and 61 (11) years, respectively. Between 2001 and 2011, estimated national rates of hospitalizations for coronary catheterization increased from 26 570 to 452 784 and for PCI, from 9678 to 208 954 (17-fold and 21-fold), respectively. More than half of stable patients undergoing coronary catheterization had nonobstructive coronary artery disease; this amount did not change significantly over time (2001: 60.3% [95% CI, 56.1%-64.5%]; 2011: 57.5% [95% CI, 55.8%-59.3%], P = .05 for trend). The proportion of PCI procedures performed via radial approach increased from 3.5% (95% CI, 1.7%-5.3%) in 2001 to 79.0% (95% CI, 77.7%-80.3%) in 2011 (P . 001 for trend). The use of drug-eluting stents (DESs) increased from 18.0% (95% CI, 14.2%-21.7%) in 2001 to 97.3% (95% CI, 96.9%-97.7%) in 2011 (P .001 for trend) largely owing to increased use of domestic DESs. The median length of stay decreased from 14 days (interquartile range [IQR], 9-20) in 2001 to 10 days (IQR, 7-14) in 2011 (P .001 for trend). In-hospital mortality did not change significantly, but both adjusted risk of any bleeding (odds ratio [OR], 0.53 [95% CI, 0.36-0.79], P .001 for trend) and access bleeding (OR, 0.23 [95% CI, 0.12-0.43], P .001) were decreased between 2001 and 2011. The medical records lacked documentation needed to calculate commonly used process metrics including door to balloon times for primary PCI and the prescription of evidence-based medications at discharge.Although the use of catheterization and PCI in China has increased dramatically, we identified critical quality and documentation gaps that represent opportunities to improve care. Our findings can serve as a foundation to guide future quality improvement initiatives in China.

The NCDR ACTION Registry - GWTG (AR-G) uses an “all or none” composite quality score that encompasses key aspects of AMI care including timely provision of reperfusion, pharmacotherapy acutely and at discharge, as well as smoking cessation and cardiac rehabilitation referral. Little is known

BACKGROUND Because relative value unit (RVU)-based costs vary across hospitals, it is difficult to use them to compare hospital utilization. OBJECTIVE To compare estimates of hospital utilization using RVU-based costs and standardized costs. DESIGN Retrospective cohort. SETTING AND PATIENTS Years 2009 to 2010 heart failure hospitalizations in a large, detailed hospital billing database that contains an itemized log of costs incurred during hospitalization. INTERVENTION We assigned every item in the database with a standardized cost that was consistent for that item across all hospitals. MEASUREMENTS Standardized costs of hospitalization versus RVU-based costs of hospitalization. RESULTS We identified 234 hospitals with 165,647 heart failure hospitalizations. We observed variation in the RVU-based cost for a uniform “basket of goods” (10th percentile cost $1,552; 90th percentile cost of $3,967). The interquartile ratio (Q75/Q25) of the RVU-based costs of a hospitalization was 1.35 but fell to 1.26 after costs were standardized, suggesting that the use of standardized costs can reduce the “noise” due to differences in overhead and other fixed costs. Forty-six (20%) hospitals had reported costs of hospitalizations exceeding standardized costs (indicating that reported costs inflated apparent utilization); 42 hospitals (17%) had reported costs that were less than standardized costs (indicating that reported costs underestimated utilization). CONCLUSIONS Standardized costs are a novel method for comparing utilization across hospitals and reduce variation observed with RVU-based costs. They have the potential to help hospitals understand how they use resources compared to their peers and will facilitate research comparing the effectiveness of higher and lower utilization. Journal of Hospital Medicine 2013;8:373–379. © 2013 Society of Hospital Medicine

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Reviews. This series will summarize the most important manuscripts, as selected by the Editor, which have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes as well as general cardiology audience. The studies included in this article represent the most significant research in the area of valvular heart disease. ( Circ Cardiovasc Quality and Outcomes . 2012;5:-e103.) In recent years, no field of clinical cardiology has experienced a great influx of transformational therapeutic options as has the area of valvular heart disease. Treatment of severe aortic stenosis (AS) has been revolutionized by transcatheter aortic valve replacement (TAVR), which has been shown to improve life expectancy and functional outcomes in patients with inoperable AS1,2 and to have short-term outcomes comparable to surgical aortic valve replacement (AVR) in patients at high perioperative risk.3,4 Analogously, mitral valve disease has been amenable to percutaneous valve replacement,5,6 as well as clipping procedures7 that can substantively reduce severe mitral regurgitation (MR) and improve functional outcomes. Even right-sided heart disease involving valves in pulmonary8,9 and tricuspid10 positions has been treated successfully with endovascular techniques. Yet, even with this growing focus on percutaneous valvular interventions, open surgical techniques remain the dominant treatment strategies and standard of care for most advanced lesions. Surgical valve repair and replacement account for 10% to 20% of all cardiac surgical procedures,11–13 approximately two thirds of which are for AS.11–13 For patients undergoing surgery, there remains considerable debate about risk stratification,14 intraoperative technique,15 and postoperative …

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of anticoagulation for cardiovascular disease.

Background— The intensive practice style of hospitals with high procedure rates may result in higher costs of care for medically managed patients. We sought to determine how costs for patients with heart failure (HF) not receiving procedures compare between hospital groups defined by their overall use of procedures. Methods and Results— We identified all 2009 to 2010 adult HF hospitalizations in hospitals capable of performing invasive procedures that had at least 25 HF hospitalizations in the Perspective database from Premier, Inc. We divided hospitals into 2 groups by the proportion of patients with HF receiving invasive percutaneous or surgical procedures: low (>0%–10%) and high (≥10%). The standard costs of hospitalizations at each hospital were risk adjusted using patient demographics and comorbidities. We used the Wilcoxon rank sum test to assess cost, length of stay, and mortality outcome differences between the 2 groups. Median risk-standardized costs among low-procedural HF hospitalizations were $5259 (interquartile range, $4683–$6814) versus $6965 (interquartile range, $5981–$8235) for hospitals with high procedure use ( P P =0.009). We did not identify any single service area that explained the difference in costs between hospital groups, but these hospitals had higher costs for most service areas. Conclusion— Among patients who do not receive invasive procedures, the cost of HF hospitalization is higher in more procedure-intense hospitals compared with hospitals that perform fewer procedures.

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease in the elderly.

Background: Little is known about cost variation among heart failure (HF) patients across hospitals when controlling for invasive cardiovascular percutaneous and surgical procedures. Methods: We identified all adult HF hospitalizations in 2009-10 Premier, Inc. hospitals with >25 HF hospitalizations. Hospitals were divided into 3 groups by their percent of HF patients receiving invasive percutaneous or surgical procedures: none (0%), moderate (0-10%), and high (>10%) (see figure). The 10% mark was the median across hospitals. For each of the three groups, the median hospitalization cost was calculated for all non-procedural admissions in standard dollar costs (figure). Standard cost assigns each billed item its median cost across all hospitals. The Kruskal-Wallis test was used to assess cost, length of stay, and outcome differences among the 3 groups (p≤0.05). Frequencies of billing categories (e.g. pharmacy, lab, central supply) were calculated and compared across the 3 groups. Results: Median standard dollar costs among non-procedural HF hospitalizations were $5104 (IQR=$3421, $7968), $6108 ($4001, $9934) and $6585 ($4181, $11218) for hospitals with no, moderate and high procedure use, respectively (figure). Respective median lengths of stay were 3, 4, and 4 days, and risk-adjusted mortality was 4.8%, 4.9% and 4.7% (figure). Cost analysis by resource categories showed that the proportion of items billed did not appear to differ by hospital group. Conclusion: The cost of HF hospitalization is higher in more procedure-intense hospitals even among patients who do not receive invasive procedures. Length of stay may contribute to these differences. Despite higher costs, high procedure hospitals do not have materially improved risk-adjusted mortality rates.

Background: Patients hospitalized with heart failure (HF) are often treated for concomitant respiratory disease due to diagnostic uncertainty or coexisting conditions. Testing with natriuretic peptides, chest radiograph (CXR), and transthoracic echocardiogram (TTE) is common and may influence these treatment decisions. We examined hospital variation in diagnostic testing among inpatients with HF and how testing relates to additional treatment for coexisting respiratory conditions. Methods: We identified hospitalizations with a principal discharge diagnosis of HF from 2009-2010 Premier, Inc. hospitals and age>18y, known admission source, non-pediatric attending physician, receipt of HF treatment (loop diuretics, inotropes, or IV vasodilators), and >2 day hospital stay. We excluded hospitalizations with present-on-admission codes for infections besides pneumonia or inflammatory, allergic, or autoimmune conditions besides COPD. For hospital days 1-2, we calculated each hospital’s proportion of admissions receiving selected diagnostic tests (natriuretic peptides, CXR, TTE) and respiratory treatments (short-acting inhaled bronchodilators, antibiotics, high-dose steroids). Treatment categories were mutually exclusive. The proportion of admissions receiving diagnostic testing and respiratory treatments was calculated for each hospital, and summary statistics were reported across hospitals. Results: We identified 164,494 HF hospitalizations among 368 hospitals. Natriuretic peptide testing across hospitals was done in 81% to 92% (IQR; median 87%) of HF admissions, CXR testing was done in 87% to 94% (IQR; median 91%), and TTE testing was done in 39% to 56% (IQR; median 48%). The median proportion of hospitalizations receiving diagnostic testing at the hospital level was similar among patients treated only for HF and those also treated with at least one respiratory therapy (respectively, 88% vs. 90% for natriuretic peptides, 90% vs. 93% for CXR, and 51% vs. 49% for TTE). Detailed description of diagnostic testing among each treatment group at the hospital level is provided in the accompanying table. Conclusion: Hospital use of relatively inexpensive diagnostic tests among HF inpatients including natriuretic peptides and CXR is frequent with little inter-hospital variation. In contrast, more expensive testing with TTE is less common though more variable across hospitals. Although often ordered, natriuretic peptides, CXR, and TTE do not appear to influence physicians’ decisions to treat only for heart failure or also for potential coexisting respiratory conditions.

Background: Inpatients with heart failure (HF) may be treated for other acute conditions such as concomitant respiratory disease due to diagnostic uncertainty, coexisting illness, or other reasons. We investigated the frequency and mortality associated with respiratory treatments added to usual HF care. Methods: We included hospitalizations with a primary discharge diagnosis of HF from 2009-10 Premier, Inc. hospitals and age>18y, known admission source, non-pediatric attending physician, receipt of HF treatment (loop diuretics, inotropes, or IV vasodilators) and >2 day hospital stay. For hospital days 1-2 and 3-5, we noted receipt of potential respiratory treatments (short-acting inhaled bronchodilators, antibiotics, high-dose steroids). Hospitalizations with present-on-admission codes for infections besides pneumonia or inflammatory, allergic, or autoimmune conditions besides COPD were excluded. Hospitalizations were split into mutually exclusive and exhaustive groups based on treatments received in days 1-2 (table); odds of in-hospital mortality were determined for each after adjusting for age, sex, and Elixhauser comorbidities. Results: Among 164,494 HF hospitalizations, 54% (88,122) received treatment for acute respiratory conditions during hospital days 1-2 (table). At least 1 respiratory treatment was continued after day 2 in 60% (52,452) of patients who received initial treatment. Odds of in-hospital mortality increased with receipt of respiratory treatments in days 1-2 (table). Conclusions: HF inpatients are frequently treated for respiratory conditions. As these treatments are often given throughout hospitalization and identify patients at higher risk of death, coexisting comorbidities or a new cardiopulmonary syndrome may often be present, as may diagnostic uncertainty or overtreatment. Greater knowledge of patient complexity can improve treatment guidelines, patient outcomes, and risk-adjustment for performance measures.

Background: Although loop diuretics are frequently used for patients with heart failure (HF), little is known about the variation in patterns of diuretic therapy in US hospitals. We sought to describe such treatment patterns among a diverse group of hospitals. Methods: We studied HF hospitalizations occurring during 2009-10 in Premier Inc. hospitals participating in a collaborative project to pool administrative and charge data, which includes information about drug types, average daily dose, and duration of therapy. We excluded hospitals with less than 25 HF hospitalizations. For ease of comparison, all diuretic doses were converted to bioequivalent doses of intravenous (IV) furosemide: 40mg IV furosemide ∼ 80mg oral furosemide ∼ 20mg (oral or IV) torsemide ∼ 1mg (oral or IV) bumetanide. Summary statistics were calculated. Results: Among 366 studied hospitals (264,675 HF hospitalizations), use of any loop diuretic had an interquartile range (IQR) from 92% to 96% (median: 94%). At the hospital level, the average daily dose IQR varied from 45mg to 64 mg (median: 55 mg) and the median duration of therapy was 4 days (IQR: 4 to 4; median: 4), as was the median length of stay. The IQR for use of furosemide varied from 89% to 94% (median: 92%), and its median average daily dose had an IQR from 40mg to 60 mg (median: 53 mg). Hospital use of bumetanide had an IQR from 2% to 11%, and hospital use of torsemide had an IQR from 0% to 4% (medians of 5% and 1%, respectively). The variation in median average daily dose for bumetanide and torsemide was greater than for furosemide (bumetanide IQR: 79mg to 127 mg, with median of 89 mg; torsemide IQR: 53mg to 120 mg, with median of 80 mg). Use of IV diuretics on the last day before home discharge had an IQR from 16% to 33% (median: 24%) across hospitals. Conclusion: US hospitals administer loop diuretics, particularly furosemide, to the vast majority of HF inpatients. The duration and daily dosage of therapy was similar across most hospitals. In contrast, a minority of hospitals used bumetanide and torsemide for several patients. The daily dosage of these agents showed more marked variation. We observed a high rate of intravenous diuretic use on the last day of hospitalization, with considerable variation across hospitals.

Administration of Intravenous Fluids in Patients Hospitalized with Heart Failure Background: Administration of intravenous (IV) fluids to patients with acute decompensated heart failure (HF) may worsen pulmonary congestion or hemodynamic status. However, little is known about the use of IV fluids in clinical practice. We examined the frequency and volume with which commonly used IV fluid preparations are used among inpatients with HF as well as the association of these treatment patterns with diuretic use and length of stay (LOS). Methods: We identified all hospitalizations in 2009-2010 with a principal discharge diagnosis of heart failure from the Premier, Inc. hospitals. In order to capture inappropriate therapy with intravenous fluids, we limited our study period to the initial two days, a period during which most HF patients undergo diuresis for fluid overload. We excluded patients with a potential indication for fluid resuscitation (concomitant therapy with vasopressors or inotropes, undergoing invasive procedures, or having secondary diagnosis of bleeding, sepsis or anaphylaxis). We also excluded hospitalizations with age < 18 yrs, < 3 day LOS, transfer-ins, and hospitals with < 25 HF cases. We calculated the administration frequency and volume of commonly used IV fluids (normal saline, half normal saline, 5% dextrose, and Lactated Ringer’s), the percentage of patients receiving concomitant therapy with loop diuretics, and the average LOS associated with administration of each of the four fluids. Results: Among 195,652 hospitalizations, 25% (48,611) were administered at least one of the four IV fluids. Normal saline was the most commonly administered fluid (19.4% of hospitalizations), followed by 5% dextrose (6%), half normal saline (2.2%), and Lactated Ringer’s (0.2%). The median volume of fluid administration over the first two days was 1,000 ml (IQR: 250, 1250). Eighty-nine percent of patients receiving fluid therapy received concomitant loop diuretics. Increasing median LOS was noted with increasing fluid volumes across all four individual IV fluid categories (see Table). Conclusion: A substantial proportion of patients hospitalized with HF receive a considerable volume of intravenous fluid during their first 2 hospital days; normal saline was the most commonly administered formulation. Loop diuretic use was very common in those receiving IV fluids. Greater understanding of the concomitant use of intravenous fluids and diuretics and their relation to length of stay may provide an opportunity to improve quality of care.

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review . This series will summarize the most important manuscripts (as selected by the Editor) that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of health costs, cost-effectiveness, and resource utilization.

The amyloidoses are a group of hereditary or acquired disorders caused by the extracellular deposition of insoluble protein fibrils that impair tissue structure and function. All amyloidoses result from protein misfolding, a common mechanism for disorders in older persons, including Alzheimer's disease and Parkinson's disease. Abnormalities in the protein transthyretin (TTR), a serum transporter of thyroxine and retinol, is the most common cause of cardiac amyloidoses in elderly adults. Mutations in TTR can result in familial amyloidotic cardiomyopathy, and wild-type TTR can result in senile cardiac amyloidosis. These underdiagnosed disorders are much more common than previously thought. The resulting restrictive cardiomyopathy can cause congestive heart failure, arrhythmias, and advanced conduction system disease. Although historically difficult to make, the diagnosis of TTR cardiac amyloidosis has become easier in recent years with advances in cardiac imaging and more widespread use of genetic analysis. Although therapy has largely involved supportive medical care, avoidance of potentially toxic agents, and rarely organ transplantation, the near future brings the possibility of targeted pharmacotherapies designed to prevent TTR misfolding and amyloid deposition. Because these disease-modifying agents are designed to prevent disease progression, it has become increasingly important that older persons with TTR amyloidosis be expeditiously identified and considered for enrollment in clinical registries and trials.

Malnutrition is common in older adults in the community, nursing home, and hospital. Deficiencies in caloric and vitamin intake increase with age, functional impairment, and institutionalization, with resultant added risk of skin breakdown, illness, and death. Common contributory factors to undernutrition include polypharmacy, dementia, depression, oral health problems, and socioeconomic factors. Unintentional weight loss always warrants evaluation. Nutritional assessment includes a focused medical and social history, anthropometrics, selected biochemical and hematological parameters, and tools such as the Mini Nutritional Assessment and Simplified Nutritional Appetite Questionnaire. In addition to addressing the cause of malnutrition, management includes meeting patient food preferences, providing oral supplements, and rarely using orexigenic medications. Importantly, all interventions should respect patient preferences and treatment goals in the context of overall prognosis.

Water, potassium, sodium, and chloride play key roles in health. Each nutrient has a physiologic role, homeostatic balance, and relationship to disease when ingested in inappropriate amounts. Adequate intake of water helps maintain circulating volume and prevent impairments in cognition and exercise capacity due to dehydration. Potassium is needed to maintain electrochemical gradients across cellular membranes; adequate intake from dietary sources can reduce blood pressure, bone demineralization, and formation of kidney stones. Sodium and chloride also impact membrane potential as the principal extracellular ions. When taken in excess, sodium increases blood pressure and cardiovascular risk in salt-sensitive populations such as older persons and African Americans. Education and policy measures to promote appropriate intakes of water, potassium, and sodium can translate into population-wide health benefits.

The immediate period after hospital discharge is dangerous. Patients’ health, often marginal at best, frequently deteriorates, sending them to the emergency department,1 back to the hospital in-patient service,2 or into a period of functional decline.3,4 Among older patients hospitalized with heart failure, for example, death is even more common in the month following discharge than during the initial hospital stay.5,6 Vulnerabilities in this period are many, and patients are susceptible to deterioration in health from a broad spectrum of conditions, not just the initial illness that triggered hospitalization.7 This period has been labeled post-hospital syndrome, as it appears that patients have an acquired, transient period of generalized risk to a wide range of medical problems.8 As recognition of these risks has increased, the goal of improved short-term outcomes after hospitalization has become a focus for providers, payers, and policymakers.9 In this issue of the Journal, McAlister and colleagues ask whether short-term vulnerability after hospitalization is related to weekend versus weekday discharge. After examining almost 8,000 patients discharged from the general medical wards of 7 teaching hospitals in Alberta, Canada, the authors found that only 1 in 7 were discharged on weekends, defined as Saturday or Sunday. Patients discharged on the weekend were younger, had fewer chronic health conditions, and shorter average lengths of stay. In analyses adjusted for patient demographics and a measure of short-term risk after hospitalization (LACE score), weekend discharge was not associated with higher rates of unplanned readmission or death at 30 days. Most strikingly, only the healthiest patients were discharged on weekends. These results are similar to findings from the authors’ previous work on patients hospitalized with heart failure.10 Yet the implications for discharge planning are much less clear, as the few analyses of discharge day from the authors10 and others11 do not account for the range of factors that may influence risk after hospitalization such as patients’ clinical characteristics, the quality of both hospital and transitional care, and the post-hospital environments to which patients are discharged. Not surprisingly, different methodologic approaches have shown weekend discharge to be associated with a range of outcomes including lower,11 identical,12 and higher10 rates of unplanned readmission and death. Moreover, the influence of discharge timing itself is likely to involve further complexities including patients’ readiness for discharge,13 the specific days of the week on which both admission and discharge occur,14 and the outpatient resources made available to patients by specific health insurance carriers.14 These studies illustrate a fundamental issue with our efforts to reduce short-term readmission, namely, that we do not understand which factors most influence risk.15 Prediction models have generally focused on traditional markers of risk including patients’ demographic characteristics, their physical examination findings, and laboratory test results. While models based on these variables are often excellent at discriminating between patients who are likely to die soon after hospitalization, their ability to identify specific patients who will be rehospitalized has been mediocre.16,17 This difficulty with prediction suggests that readmission has far more complex determinants than death in the short-term period after hospitalization. Unfortunately, we have yet to identify and model the factors that matter most. Where should we look to find these additional sources of vulnerability after hospitalization? Previous research has made clear that we are unlikely to find single markers of risk that adequately predict the future. Rather, we will need to develop more complete understandings of patients including their dynamics of recovery, the role of the hospital environment in prolonging or instigating further vulnerability, the manners by which organizational context and implementation strategies impact transitional care, and the ways in which social and environmental factors hasten or retard recovery. For each of these categories, there are multiple specific questions to address. The following are illustrative examples

All patients deserve high quality hospital care and the best possible outcome Research describing variation in hospital treatment and outcomes has improved care for patients with acute myocardial infarction. Studies, particularly from the United States, have shown significant differences in hospitals’ use of evidence based tests and treatments for acute myocardial infarction including aspirin, β blockers, and angiotensin converting enzyme inhibitors.1 In response, major US organizations developed a set of core process measures for treatments considered to be standard of care.2 Hospitals’ performance on these measures were publicly reported and used to guide reimbursement.3 Subsequently, research identified significant variation in hospitals’ outcomes for acute myocardial infarction, including rates of 30 day readmission and mortality.4 The federal government has used hospitals’ performance on these metrics to exact financial penalties on institutions with worse than expected 30 day outcomes.5 It is with this focus on quality of healthcare that Chung and colleagues in the linked paper (doi:10.1136/bmj.h3913) describe variation in guideline recommended treatments and outcomes for patients admitted with acute myocardial infarction in the United Kingdom and Sweden.6 The authors examined nationwide registry data from all hospitals providing care for acute myocardial infarction in both countries between 2004 and 2010. They found that variation in …

Hospital acquired conditions must be reduced throughout the week, not just at weekends In the United States, efforts to improve patient safety have focused, in part, on reducing hospital acquired conditions, or HACs. Hospital acquired conditions include healthcare associated infections, iatrogenic complications, and other adverse events occurring during treatment for another condition. Historically, the additional costs incurred by these adverse events led to greater payments by the government.1 To encourage a reduction in these potentially preventable conditions, the US Centers for Medicare and Medicaid Services (CMS) in 2008 decided not to pay for the higher costs of care resulting from 14 specific hospital acquired conditions.2 Starting this year, the CMS’s HAC Reduction Program will levy considerable financial penalties on hospitals scoring poorly on a composite measure of performance regarding hospital acquired conditions, which is derived from a review of administrative claims and medical record data.3 4 In a linked paper, Attenello and colleagues (doi:10.1136/bmj.h1460) determined whether weekend admission is associated with a greater likelihood of developing these adverse events,5 as weekend admission has been associated with worse outcomes for a large number of life threatening conditions, such as myocardial infarction,6 pulmonary embolism,7 and intracerebral haemorrhage.8 …

To the Editor: Diuretics are a mainstay of treatment in both chronic and acute decompensated heart failure (HF). Studies during the 1990s and early 2000s show that roughly 90% of HF patients receive at least 1 class of diuretics, particularly a loop diuretic, for management of chronic ([1,2][1]) or

IMPORTANCE Current guidelines allow substantial discretion in use of noninvasive cardiac imaging for patients without acute myocardial infarction (AMI) who are being evaluated for ischemia. Imaging use may affect downstream testing and outcomes. OBJECTIVE To characterize hospital variation in use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of hospitals using 2010 administrative data from Premier, Inc, including patients with suspected ischemia on initial evaluation who were seen in the emergency department, observation unit, or inpatient ward; received at least 1 cardiac biomarker test on day 0 or 1; and had a principal discharge diagnosis for a common cause of chest discomfort, a sign or symptom of cardiac ischemia, and/or a comorbidity associated with coronary disease. We excluded patients with AMI. MAIN OUTCOMES AND MEASURES At each hospital, the proportion of patients who received noninvasive imaging to identify cardiac ischemia and the subsequent rates of admission, coronary angiography, and revascularization procedures. RESULTS We identified 549,078 patients at 224 hospitals. The median (interquartile range) hospital noninvasive imaging rate was 19.8% (10.9%-27.7%); range, 0.2% to 55.7%. Median hospital imaging rates by quartile were Q1, 6.0%; Q2, 15.9%; Q3, 23.5%; Q4, 34.8%. Compared with Q1, Q4 hospitals had higher rates of admission (Q1, 32.1% vs Q4, 40.0%), downstream coronary angiogram (Q1, 1.2% vs Q4, 4.9%), and revascularization procedures (Q1, 0.5% vs Q4, 1.9%). Hospitals in Q4 had a lower yield of revascularization for noninvasive imaging (Q1, 7.6% vs Q4, 5.4%) and for angiograms (Q1, 41.2% vs Q4, 38.8%). P.001 for all comparisons. Readmission rates to the same hospital for AMI within 2 months were not different by quartiles (P = .51). Approximately 23% of variation in imaging use was attributable to the behavior of individual hospitals. CONCLUSIONS AND RELEVANCE Hospitals vary in their use of noninvasive cardiac imaging in patients with suspected ischemia who do not have AMI. Hospitals with higher imaging rates did not have substantially different rates of therapeutic interventions or lower readmission rates for AMI but were more likely to admit patients and perform angiography.

Introduction During the past decade, the volume of percutaneous coronary intervention (PCI) in China has risen by more than 20-fold. Yet little is known about patterns of care and outcomes across hospitals, regions and time during this period of rising cardiovascular disease and dynamic change in the Chinese healthcare system. Methods and analysis Using the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) research network, the Retrospective Study of Coronary Catheterisation and Percutaneous Coronary Intervention (China PEACE-Retrospective CathPCI Study) will examine a nationally representative sample of 11 900 patients who underwent coronary catheterisation or PCI at 55 Chinese hospitals during 2001, 2006 and 2011. We selected patients and study sites using a two-stage cluster sampling design with simple random sampling stratified within economical-geographical strata. A central coordinating centre will monitor data quality at the stages of case ascertainment, medical record abstraction and data management. We will examine patient characteristics, diagnostic testing patterns, procedural treatments and in-hospital outcomes, including death, complications of treatment and costs of hospitalisation. We will additionally characterise variation in treatments and outcomes by patient characteristics, hospital, region and study year. Ethics and dissemination The China PEACE collaboration is designed to translate research into improved care for patients. The study protocol was approved by the central ethics committee at the China National Center for Cardiovascular Diseases (NCCD) and collaborating hospitals. Findings will be shared with participating hospitals, policymakers and the academic community to promote quality monitoring, quality improvement and the efficient allocation and use of coronary catheterisation and PCI in China. Registration details http://www.clinicaltrials.gov (NCT01624896).

Objectives To determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions. Design Retrospective cohort study. Setting Medicare beneficiaries in the United States. Participants Patients aged 65 and older who were readmitted within 30 days after hospital admission for heart failure, acute myocardial infarction, or pneumonia in 2007-09. Main outcome measures Readmission diagnoses were classified with a modified version of the Centers for Medicare and Medicaid Services’ condition categories, and readmission timing was classified by day (0-30) after hospital discharge. Hospital 30 day risk standardized readmission rates over the three years of study were calculated with public reporting methods of the US federal government, and hospitals were categorized with bootstrap analysis as having high, average, or low readmission performance for each index condition. High and low performing hospitals had ≥95% probability of having an interval estimate respectively less than or greater than the national 30 day readmission rate over the three year period of study. All remaining hospitals were considered average performers. Results For readmissions in the 30 days after the index admission, there were 320 003 after 1 291 211 admissions for heart failure (4041 hospitals), 102 536 after 517 827 admissions for acute myocardial infarction (2378 hospitals), and 208 438 after 1 135 932 admissions for pneumonia (4283 hospitals). The distribution of readmissions by diagnosis was similar across categories of hospital performance for all three conditions. High performing hospitals had fewer readmissions for all common diagnoses. Median time to readmission was similar by hospital performance for heart failure and acute myocardial infarction, though was 1.4 days longer among high versus low performing hospitals for pneumonia (P

Background Heart failure as recognized and treated in typical practice may represent a complex condition that defies discrete categorizations. To illuminate this complexity, we examined treatment strategies for patients hospitalized and treated for decompensated heart failure. We focused on the receipt of medications appropriate for other acute conditions associated with shortness of breath including acute asthma, pneumonia, and exacerbated chronic obstructive pulmonary disease. Methods and Results Using Premier Perspective®, we studied adults hospitalized with a principal discharge diagnosis of heart failure and evidence of acute heart failure treatment from 2009-2010 at 370 US hospitals. We determined treatment with acute respiratory therapies during the initial 2 days of hospitalization and daily during hospital days 3-5. We also calculated adjusted odds of in-hospital death, admission to the intensive care unit, and late intubation (intubation after hospital day 2). Among 164,494 heart failure hospitalizations, 53% received acute respiratory therapies during the first 2 hospital days: 37% received short-acting inhaled bronchodilators, 33% received antibiotics, and 10% received high-dose corticosteroids. Of these 87,319 hospitalizations, over 60% continued receiving respiratory therapies after hospital day 2. Respiratory treatment was more frequent among the 60,690 hospitalizations with chronic lung disease. Treatment with acute respiratory therapy during the first 2 hospital days was associated with higher adjusted odds of all adverse outcomes. Conclusions Acute respiratory therapy is administered to more than half of patients hospitalized with and treated for decompensated heart failure. Heart failure is therefore regularly treated as a broader cardiopulmonary syndrome rather than as a singular cardiac condition.

Noninvasive positive pressure ventilation (NIPPV) has been used in acute heart failure (AHF) for 20 years with no consensus as to its role. Little is known about hospital practice patterns of NIPPV use in AHF, including the timing and setting of therapy, and the relationship between hospital NIPPV

The objective of the study is a comparative evaluation of flavone isolated from Mucuna pruriens and coumarin isolated from Ionidium suffruticosum was assessed for the hypolipidemic activity in rats fed with high fat diet. The acute toxicity study was found that flavone (M.pruriens) and coumarin (I.suffruticosum) are safe up to 100mg/kg, so one tenth of this dose (10mg/kg) was consider as a evaluation dose. High fat diet group of rats showed significant (pM. pruriens) and coumarin isolated from (I.suffruticosum) at the dose of 10mg/kg b.wt/day along with high fat diet significantly (pI.suffruticosum) had showed more cardio protective effect against hyperlipidemia than that of flavone (M.pruriens).

Concern about rising cost has focused attention on altering hospital practices to reduce expenses. We examined variation in use of the ICU, a high cost setting, for heart failure (HF) admissions. We identified 188,216 HF discharges from 341 hospitals in the 2009-10 Premier Perspective database. We