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Objective. We present a Monte Carlo technique to evaluate if observed mortality rates differ from model-predicted rates for situations when the number of deaths is small. Data Sources. We used Medicare hospital claims and model-predicted mortality rates from the Health Care Financing Administration (HCFA) for the 169 acute care hospitals in Georgia. The HCFA data provided model-predicted mortality rates at 30 days postadmission for 17 conditions and procedures of interest. The model-predicted rates calculated by HCFA were adjusted for patient factors, including demographic characteristics, principal diagnosis, and comorbidities. Study Design. We test the hypothesis that model-predicted 30-day mortality rates at the 169 hospitals differ significantly from the observed 30-day mortality rates. Our approach uses a test statistic that resembles a chi-square statistic, and Monte Carlo simulations to estimate the distribution of the test statistic under the null hypothesis of no differences between the observed and predicted rates. We illustrate the method using two conceptually similar simulation models. We use results of the simulations to estimate p-values and compare these results with p-values associated with the nominal chi-square distribution. Data Extraction Methods. We extracted 30-day observed and predicted mortality rates for Medicare beneficiaries for federal fiscal year 1990 for 17 conditions and procedures of interest. Principal Findings. If the number of deaths in some hospitals is small, p-values calculated using the nominal chi-square distribution can be misleading, thus supporting the usefulness of our simulation method. Conclusions. The Monte Carlo simulation is an appropriate approach to the analysis of hospital mortality or small area analysis for situations in which the number of deaths is small., An important type of analysis, and one that the Health Care Financing Administration (HCFA) has directed state Peer Review Organizations to conduct, involves investigating mortality rates following hospital admission (Health [...]

In the current health care environment, innovative roles are emerging for acute care nurse practitioners to provide care to increasingly complex patients. The roles are characterized by the provision of unique care that is comprehensive, cost-effective, efficient, and accessible. In this article, the development of the role of the vascular nurse practitioner in the acute care setting is explored. Practice privileges, practice agreements, and a model for delivering care are discussed.

P wave morphology during atrial pacing along the atrioventricular (AV) ring was evaluated to develop electrocardiographic (ECG) criteria for identifying the site of origin of the atrial activation wave during reentrant supraventricular tachycardia. Because P wave morphology changes as the pattern of atrial activation changes, the P wave should show characteristic morphologies during reentrant supraventricular tachycardia with use of either accessory AV pathways or the AV node for retrograde atrial activation. In 14 patients, 12-lead ECGs were recorded during bipolar atrial pacing at sites in the coronary sinus vein (along the mitral annulus) and along the atrial endocardium of the tricuspid annulus. P wave morphology was graded for each lead at each site. Sensitivity, specificity, and predictive value of ECG criteria for left versus right and anterior versus posterior atrial pacing sites were evaluated. Data were obtained from 14 sites along the AV ring, including 71 recordings at 6 sites in the coronary sinus vein and 94 recordings at 8 sites along the tricuspid annulus. These recordings were further divided into 54 anterior sites and 80 posterior sites, as well as 62 recordings along the right free wall and 32 recordings along the right atrial septum. The predictive value of a positive P wave in lead I indicating right atrial site of origin was 98.9%, and that for a negative or isoelectric P wave in lead I indicating a left atrial site of origin was 94.6%. Negative P wave in leads II, III, and aVF indicated a posterior site of origin, with a predictive value of 91.2%. The predictive value of a negative or isoelectric P wave in lead V"1 indicating a right atrial free wall site was 87.5%. Thus, P wave morphology can be used to localize the site of origin of the atrial depolarization wave to a region along the AV ring.