Challenges in comparing risk-adjusted bypass surgery mortality results: results from the Cooperative Cardiovascular Project

OBJECTIVES

We sought to evaluate the predictive accuracy of four bypass surgery mortality clinical risk models and to examine the extent to which hospitals' risk-adjusted surgical outcomes vary depending on which risk-adjustment method is applied.

BACKGROUND

Cardiovascular "report cards" often compare risk-adjusted surgical outcomes; however, it is unclear to what extent the risk-adjustment process itself may affect these metrics.

METHODS

As part of the Cooperative Cardiovascular Project's Pilot Revascularization Study, we compared the predictive accuracy of four bypass clinical risk models among 3,654 Medicare patients undergoing surgery at 28 hospitals in Alabama and Iowa. We also compared the agreement in hospital-level risk-adjusted bypass outcome performance ratings depending on which of the four risk models was applied.

RESULTS

Although the four risk models had similar discriminatory abilities (C-index, 0.71 to 0.74), certain models tended to overpredict mortality in higher-risk patients. There was high correlation between a hospital's risk-adjusted mortality rates regardless of which of the four models was used (correlation between risk-adjusted rating, 0.93 to 0.97). In contrast, there was limited agreement in which hospitals were identified as "performance outliers" depending on which risk-adjustment model was used and how outlier status was defined.

CONCLUSIONS

A hospital's risk-adjusted bypass surgery mortality rating, relative to its peers, was consistent regardless of the risk-adjustment model applied, supporting their use as a means of provider performance feedback. Designation of performance outliers, however, can vary significantly depending on the benchmark and methods used for this determination.

Prophylactic value of preincision intra-aortic balloon pump: analysis of a statewide experience

OBJECTIVE

The objective of this study was to determine whether preincision use of an intra-aortic balloon pump improves survival and shortens postoperative length of stay in hemodynamically stable, high-risk patients undergoing coronary artery bypass grafting.

METHODS

A post hoc analysis of the Alabama CABG Cooperative Project database was performed by using propensity scores to model the likelihood of receiving a prophylactic preincision intra-aortic balloon pump. Every patient receiving a prophylactic preincision balloon pump was matched with another patient of similar propensity score who did not receive one. We then compared outcomes for matched pairs.

RESULTS

There were 7581 patients of whom 592 received a prophylactic preincision balloon pump. Patients with preoperative renal insufficiency, heart failure, or left main coronary artery disease, or who had undergone previous bypass grafting were significantly more likely to receive a prophylactic preincision balloon pump. By using propensity scores, we matched 550 patients who received a prophylactic preincision balloon pump with 550 who did not. Survival did not significantly differ by whether a prophylactic preincision balloon pump was used. However, surviving patients who received a preincision balloon pump had a significantly shorter postbypass length of stay (7 +/- 7.3 days) than did matched patients not receiving a balloon pump (8 +/- 6.2 days; P <.05).

CONCLUSIONS

No survival advantage was found for use of a prophylactic intra-aortic balloon pump in hemodynamically stable, high-risk patients undergoing bypass grafting, as opposed to placing a balloon pump on an "as needed" basis during or after the operation. However, the patients receiving the balloon pump had improved convalescence as shown by significantly shorter length of stay.

Is insurance a more important determinant of healthcare access than perceived health? Evidence from the Women's Health Initiative

Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Women's Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.

Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI

CONTEXT

Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate.

OBJECTIVE

To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI).

DESIGN, SETTING, AND PATIENTS

Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995.

MAIN OUTCOME MEASURES

Administration of reperfusion therapy on admission, aspirin during hospitalization, and beta-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission.

RESULTS

Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63. 7%, 60.0%, and 58.0% (P<.001); for beta-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P =.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy.

CONCLUSIONS

In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262

Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain

CONTEXT

Although chest pain is widely considered a key symptom in the diagnosis of myocardial infarction (MI), not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown.

OBJECTIVES

To determine the frequency with which patients with MI present without chest pain and to examine their subsequent management and outcome.

DESIGN

Prospective observational study.

SETTING AND PATIENTS

A total of 434,877 patients with confirmed MI enrolled June 1994 to March 1998 in the National Registry of Myocardial Infarction 2, which includes 1674 hospitals in the United States.

MAIN OUTCOME MEASURES

Prevalence of presentation without chest pain; clinical characteristics, treatment, and mortality among MI patients without chest pain vs those with chest pain.

RESULTS

Of all patients diagnosed as having MI, 142,445 (33%) did not have chest pain on presentation to the hospital. This group of MI patients was, on average, 7 years older than those with chest pain (74.2 vs 66.9 years), with a higher proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6% vs 25. 4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3 hours), were less likely to be diagnosed as having confirmed MI at the time of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), beta-blockers (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients without chest pain had a 23.3% in-hospital mortality rate compared with 9.3% among patients with chest pain (adjusted odds ratio for mortality, 2. 21 [95% confidence interval, 2.17-2.26]).

CONCLUSIONS

Our results suggest that patients without chest pain on presentation represent a large segment of the MI population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality. JAMA. 2000;283:3223-3229

Weight gain continues in the 1990s: 10-year trends in weight and overweight from the CARDIA study. Coronary Artery Risk Development in Young Adults

The prevalence of obesity increased in the United States through the 1980s. The authors examined 10-year aging and secular (time-related) trends in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort for indications of whether these trends are continuing and for ages of peak weight gain in young adults. CARDIA is a population-based, prospective study of 5,115 African-American and White men and women aged 18-30 years at baseline. Body weight and overweight prevalence were measured at five time points from 1985-1986 to 1995-1996. Linear, mixed-model regression was used to partition weight gain into that due to secular trends and that due to aging. Prevalence of overweight (body mass index (BMI) > or = 25.0 kg/m2) increased markedly, and prevalence of severe obesity (BMI > or = 40.0 kg/m2) doubled in all race-sex groups. Each race-sex group experienced significant secular weight gains, ranging from 0.96 kg/year (95% confidence interval: 79, 1.13) in African-American women to 0.55 kg/year (95% confidence interval: 0.41, 0.69) in White women. Significant secular gains were present during each follow-up period. Each race-sex group also experienced significant weight increases related to aging during their early to midtwenties. Secular trends for weight gain are continuing in CARDIA, but the magnitude of weight gain differed among the four race-sex groups.

Veterans Affairs Quality Enhancement Research Initiative in chronic heart failure

Chronic heart failure (CHF) is a highly prevalent condition associated with serious morbidity, intense levels of health services use, and shortened survival. It is also a condition for which ameliorative therapies exist. The evidence indicates that there is substantial need to change clinical practice and health care delivery for people with CHF and thereby improve their outcomes. The goal of the Veterans Affairs (VA) Quality Enhancement Research Initiative in CHF (CHF QUERI) is to create measurable, rapid, and sustainable improvements in quality of care and health outcomes of veterans with heart failure. This article describes the current state of knowledge and practice in care for people with CHF. Using the framework of the 5 steps of the QUERI process, we point out the gaps in research and practice that must be filled if the CHF QUERI is to achieve its goal. We relate our recommendations for how the VA can put its research and administrative infrastructure to work to fill the gaps. Lessons learned about CHF in the course of the CHF QUERI will be applicable to all people with heart failure and to all health care systems--VA as well as non-VA--that care for them.

The volume of primary angioplasty procedures and survival after acute myocardial infarction. National Registry of Myocardial Infarction 2 Investigators

BACKGROUND

There is an inverse relation between mortality from cardiovascular causes and the number of elective cardiac procedures (coronary angioplasty, stenting, or coronary bypass surgery) performed by individual practitioners or hospitals. However, it is not known whether patients with acute myocardial infarction fare better at centers where more patients undergo primary angioplasty or thrombolytic therapy than at centers with lower volumes.

METHODS

We analyzed data from the National Registry of Myocardial Infarction to determine the relation between the number of patients receiving reperfusion therapy (primary angioplasty or thrombolytic therapy) and subsequent in-hospital mortality. A total of 450 hospitals were divided into quartiles according to the volume of primary angioplasty. Multiple logistic-regression models were used to determine whether the volume of primary angioplasty procedures was an independent predictor of in-hospital mortality among patients undergoing this procedure. Similar analyses were performed for patients receiving thrombolytic therapy at 516 hospitals.

RESULTS

In-hospital mortality was 28 percent lower among patients who underwent primary angioplasty at hospitals with the highest volume than among those who underwent angioplasty at hospitals with the lowest volume (adjusted relative risk, 0.72; 95 percent confidence interval, 0.60 to 0.87; P<0.001). This lower rate, which represented 2.0 fewer deaths per 100 patients treated, was independent of the total volume of patients with myocardial infarction at each hospital, year of admission, and use or nonuse of adjunctive pharmacologic therapies. There was no significant relation between the volume of thrombolytic interventions and in-hospital mortality among patients who received thrombolytic therapy (7.0 percent for patients in the highest-volume hospitals vs. 6.9 percent for those in the lowest-volume hospitals, P=0.36).

CONCLUSIONS

Among hospitals in the United States that have full interventional capabilities, a higher volume of angioplasty procedures is associated with a lower mortality rate among patients undergoing primary angioplasty, but there is no association between volume and mortality for thrombolytic therapy.

Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction

BACKGROUND

There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction.

METHODS

To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women.

RESULTS

Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93).

CONCLUSIONS

After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.

Compliance with post-hospitalization follow-up visits: rationing by inconvenience?

OBJECTIVES

Appointment-keeping after hospitalization is a poorly understood link between inpatient and outpatient care. We investigated how health care system and patient characteristics influence appointment-keeping after discharge from an acute care hospitalization.

DESIGN

Prospective cohort study.

SETTING

Urban public teaching hospital.

SUBJECTS

All 372 consecutive eligible patients admitted over a 15 week period to medicine wards.

METHODS AND MEASURES

We interviewed patients during hospitalization and after discharge, searched the hospital's electronic databases, and reviewed charts. We measured medication compliance, health care access and use, health status (SF-36), previous appointment compliance, and physician recommended follow-up appointments. Main outcome was appointment adherence after discharge.

RESULTS

Patients were primarily African American (71%), uninsured (64%), female (53%), and had a mean age of 48 years; 64% of first appointments after discharge were kept. Adjusted odds ratios (95% confidence intervals) for appointment-keeping were 3.3 (1.7, 6.5) for receiving a written appointment at discharge, and 0.50 (0.27, 0.90) for previous difficulty with obtaining health care. Readmission rates were not associated with appointment adherence.

CONCLUSION

Modifiable system, as well as patient, characteristics are associated with follow-up appointment-keeping. The practice of not giving patients written appointments at the time of discharge may constitute an implicit form of "rationing by inconvenience." Further studies should also evaluate potential associations between appointment-keeping and re-hospitalization.

Comparison of outcomes research with clinical trials using preexisting data

Outcomes research using analysis of preexisting data is a relatively new field with the potential to improve the quality and effectiveness of medical care, and may provide a useful complement to randomized studies. Motivated by the growth of this research in the cardiovascular literature, this review offers a framework to identify the core concepts of outcomes research from database analyses by comparing and contrasting it with the randomized clinical trial.

The art and science of searching MEDLINE to answer clinical questions. Finding the right number of articles

The current medical environment makes information retrieval a matter of practical importance for clinicians. Many avenues present themselves to the clinician, but here we focus on MEDLINE by summarizing the current state of the art and providing an innovative approach for skill enhancement. Because new search engines appear rapidly, we focus on generic principles that can be easily adapted to various systems, even those not yet available. We propose an idealized classification system for the results of a MEDLINE search. Type A searches produce a few articles of high quality that are directly focused on the immediate question. Type B searches yield a large number of articles, some more relevant than others. Type C searches produce few or no articles, and those that are located are not germane. Providing that relevant, high-quality articles do exist, type B and C searches may often be improved with attention to search technique. Problems stem from poor recall and poor precision. The most daunting task lies in achieving the balance between too few and too many articles. By providing a theoretical framework and several practical examples, we prepare the searcher to overcome the following barriers: a) failure to begin with a well-built question; b) failure to use the Medical Subject Headings; c) failure to leverage the relationship between recall and precision; and d) failure to apply proper limits to the search. Thought and practice will increase the utility and enjoyment of searching MEDLINE.

Achievable benchmarks of care: the ABCs of benchmarking

Benchmarking is generally considered to be an important tool for quality improvement. Traditional approaches to benchmarking have relied on subjective identification of 'leaders in the field'. We derive an objective, reproducible and attainable Achievable Benchmark of Care (ABC) by measuring and analysing performance on process-of-care indicators. Three characteristics of the ABC that we deem essential are: (1) benchmarks represent a measurable level of excellence; (2) benchmarks are demonstrably attainable; (3) benchmarks are derived from data in an objective, reproducible and predetermined fashion. From these characteristics it follows that (4) providers with high performance are selected to define a level of excellence in a predetermined fashion, but (5) providers with high performance on small numbers of cases do not influence unduly benchmark levels. We use the 'pared mean' to operationalize the ABC. Roughly, the pared mean summarizes the performance of top-ranked providers whereby at least 10% of the patient pool across all providers is included. Bayesian estimators for adjustment of performance of providers with small sample sizes are used to rank providers. Randomized controlled trials to assess the independent effect of the ABC in quality improvement projects are under way. We have developed a methodology objectively and reproducibly to derive a level of excellent, attainable performance, based on measured performance by a group of providers. The ABC can be applied to groups of providers in communities, to institutions and departments within them, or to individual practitioners.

Effect of clinical factors on length of stay after coronary artery bypass surgery: results of the cooperative cardiovascular project

BACKGROUND

Rising health care costs have prompted careful review of comparative hospital resource use. Length of stay after bypass surgery has received particular attention. However, many providers assert that these variations are caused by differences in the clinical mix of patients treated. Our goals were to identify the major clinical predictors of postoperative length of stay (PLOS) after coronary artery bypass graft surgery (CABG), document variations in PLOS among 28 hospitals, and assess the degree to which patient characteristics account for hospital variations in PLOS.

METHODS

Detailed clinical data on 3605 Medicare patients undergoing CABG in 28 Alabama and Iowa hospitals were analyzed by stepwise linear regression to identify significant clinical predictors of PLOS. Analysis of variance was used to compare hospitals' PLOS while controlling for significant patient risk factors.

RESULTS

The mean age was 72.1 years, 34.7% were female, and the in-hospital mortality rate was 5.6%. The median and mean PLOS were 8 and 11.1 days, respectively. Significant predictors of longer PLOS included increasing age, female sex, history of chronic obstructive pulmonary disease, cerebrovascular disease, or mitral valve disease, elevated admission blood urea nitrogen, and preoperative placement of an intraaortic balloon pump. Hospitals varied significantly (P =.0001) in their unadjusted PLOS. These hospital-level variations persisted despite adjustment for both preoperative patient characteristics (P =.0001) and postoperative complications and death (P =.0001).

CONCLUSIONS

This study found significant between-hospital variations in PLOS that were not explained by patient factors. This finding suggests the potential for increased efficiency in the care of patients undergoing CABG at many institutions. Further research is needed to determine the practice patterns contributing to variations in length of stay after bypass surgery.

Compliance with mammography guidelines: physician recommendation and patient adherence

BACKGROUND

Guidelines recommend that women ages 50-75 years receive screening mammography every 1-2 years. We related receipt of physician recommendations for mammography and patient adherence to such recommendations to several patient characteristics.

METHODS

We retrospectively reviewed medical records of 1,111 women ages 50-75 attending three clinics in an urban university medical center. We ascertained overall compliance with mammography guidelines and two components of compliance: receipt of a physician recommendation and adherence to a recommendation. Outcome measures were the proportion of patients demonstrating each type of compliance and adjusted odds ratios, according to several patient-related characteristics.

RESULTS

Overall, 66% of women received a recommendation. Of women receiving a documented recommendation, 75% adhered. Factors showing significant positive associations with receiving a recommendation included being a patient in the general internal medicine clinic, having private insurance, visiting the clinic more often, and having a recent Pap smear. Patient adherence was positively associated with private insurance and Pap smear history, negatively associated with internal medicine, and not associated with visit frequency.

CONCLUSIONS

Patient factors influencing physician mammography recommendations may be different from those associated with patient adherence, except for having private health insurance, which was a predictor of both.

Heart rate and subsequent blood pressure in young adults: the CARDIA study

The objective of the present study was to examine the hypothesis that baseline heart rate (HR) predicts subsequent blood pressure (BP) independently of baseline BP. In the multicenter longitudinal Coronary Artery Risk Development in Young Adults study of black and white men and women initially aged 18 to 30 years, we studied 4762 participants who were not current users of antihypertensive drugs and had no history of heart problems at the baseline examination (1985-1986). In each race-sex subgroup, we estimated the effect of baseline HR on BP 2, 5, 7, and 10 years later by use of repeated measures regression analysis, adjusting for baseline BP, age, education, body fatness, physical fitness, fasting insulin, parental hypertension, cigarette smoking, alcohol consumption, oral contraceptive use, and change of body mass index from baseline. The association between baseline HR and subsequent systolic BP (SBP) was explained by multivariable adjustment. However, HR was an independent predictor of subsequent diastolic BP (DBP) regardless of initial BP and other confounders in white men, white women, and black men (0.7 mm Hg increase per 10 bpm). We incorporated the part of the association that was already present at baseline by not adjusting for baseline DBP: the mean increase in subsequent DBP was 1.3 mm Hg per 10 bpm in white men, white women, and black men. A high HR may be considered a risk factor for subsequent high DBP in young persons.

Can data-driven benchmarks be used to set the goals of healthy people 2010?

OBJECTIVES

Expert panels determined the public health goals of Healthy People 2000 subjectively. The present study examined whether data-driven benchmarks provide a better alternative.

METHODS

We developed the "pared-mean" method to define from data the best achievable health care practices. We calculated the pared-mean benchmark for screening mammography from the 1994 National Health Interview Survey, using the metropolitan statistical area as the "provider" unit. Beginning with the best-performing provider and adding providers in descending sequence, we established the minimum provider subset that included at least 10% of all women surveyed on this question. The pared-mean benchmark is then the proportion of women in this subset who received mammography.

RESULTS

The pared-mean benchmark for screening mammography was 71%, compared with the Healthy People 2000 goal of 60%.

CONCLUSIONS

For Healthy People 2010, benchmarks derived from data reflecting the best available care provide viable alternatives to consensus-derived targets. We are currently pursuing additional refinements to the data-driven pared-mean benchmark approach.

Identifying achievable benchmarks of care: concepts and methodology

Webster's Dictionary defines a benchmark as 'something that serves as a standard by which others can be measured'. Benchmarking pervades the health care quality improvement literature, and benchmarks are usually based on subjective assessment rather than on measurements derived from data. As such, benchmarks may fail to yield an achievable level of excellence that can be replicated under specific conditions. In this paper, we provide an overview of benchmarking in health care. We then describe the evolution of our data-driven method for identifying an Achievable Benchmark of Care (ABC) on the basis of process-of-care indicators. Here, our experience leads us to postulate the following premises for sound benchmarks: (i) benchmarks should represent a level of excellence; (ii) benchmarks should be demonstrably attainable; (iii) providers with high performance should be selected from among all providers in a predefined way using reliable data; (iv) all providers with high performance levels should contribute to the benchmark level; and (v) providers with high performance levels but small numbers of cases should not unduly influence the level of the benchmark. An example of an ABC applied to the cooperative cardiovascular project leads the reader through the computation of an ABC. Finally, we consider several refinements of the original ABC concept that are in progress, e.g. how to approach the special problems posed by very small denominators. The ABC methodology has been well accepted in multiple quality improvement projects. This approach lends objectivity and reliability to benchmarks that have been a widely used, but until now, arbitrarily defined tool.

Health care access and seven-year change in cigarette smoking. The CARDIA Study

OBJECTIVES

To determine associations among health care access, cigarette smoking, and change in cigarette smoking status over 7 years.

METHODS

A cohort of 4,086 healthy young adults was followed from 1985-1986 through 1992-1993. Participants were recruited from four urban sites balanced on gender, race (African Americans and whites), education (high school or less, and more than high school), and age (18-23 and 24-30). Outcome measures were smoking status at Year 7, as well as 7-year rates of smoking cessation and initiation.

RESULTS

For each of three access barriers reported at Year 7 (lack of health insurance, lack of regular source of medical care, and expense), participants experiencing the barrier had a higher prevalence of smoking, quit smoking less frequently, and started smoking more frequently; e.g., only 15% of participants with health insurance lapses quit smoking over the 7-year period, compared with 26% of those with insurance (P < 0.001). Results were similar for each race/gender stratum, and persisted after adjustment for usual markers of socioeconomic status: education, income, employment, and marital status.

CONCLUSIONS

Health care access was associated with lower prevalence of smoking and beneficial 7-year changes in smoking, independent of socioeconomic status. The possibility that this is a causal relationship has implications in the prevention of cardiovascular disease, cancer and multiple other smoking-related diseases, and deserves further exploration.

The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO

PURPOSE

To explore the association between the attitudes of primary care physicians toward uncertainty and risk taking, as measured by a validated survey, with resource use in a Medicare HMO.

DESIGN

All primary-care internists (n=20) in a large, multi-specialty clinic were surveyed to measure their attitudes about uncertainty and risk taking using three previously developed scales. Results were linked with administrative data for 792 consecutive patients in a recently created Medicare HMO. The patients' index visits occurred between April 1, 1995, and November 30, 1995.

ANALYSIS

Charges stemming from several claim types (primary care and subspecialty physician, laboratory, radiology, and ambulatory procedures) in the 30 days following the index visit were summed. The physician scales were dichotomized at the median to seek unadjusted associations with charges. Generalized estimation equations were used to account for the correlation of charges resulting from patients' being nested within physicians and adjusted for physician characteristics (age, sex, years in practice) and patient characteristics (age, sex, comorbidity).

MAIN RESULTS

The physician response rate was 90%. Most physicians (90%) were male. The mean age of the patients was 74 years, and 69% were female. The mean cost (+/-SD) per patient was $621.61+/-1,737.31. From the unadjusted analysis, high "anxiety due to uncertainty" was associated with higher patient charges ($197.85 vs $158.21, p=0.01). From the multivariable analysis, each standard deviation increase in "anxiety due to uncertainty" (3.5 points) corresponded to a 17% increase in mean charges (p < 0.01) and each similar increase in "reluctance to disclose uncertainty to patients" (1.92 points) corresponded to a 12% increase (p=0.03). However, increasing "reluctance to disclose mistakes to physicians" and increasing physician risk-taking propensity were associated with decreased total charges [-10% per standard deviation (1.34 points), p=0.02, and -8% per standard deviation (3.26 points), p=0.02, respectively].

CONCLUSION

Physician attitudes toward uncertainty were significantly associated with patient charges. Further investigation may improve prediction of patient-care charges, offer insight into the medical decision-making process, and perhaps clarify the relationship between cost, uncertainty, and quality of care.

Chronic disease as a barrier to breast and cervical cancer screening

OBJECTIVE

To assess whether chronic disease is a barrier to screening for breast and cervical cancer.

DESIGN

Structured medical record review of a retrospectively defined cohort.

SETTING

Two primary care clinics of one academic medical center.

PATIENTS

All eligible women at least 43 years of age seen during a 6-month period in each of the two study clinics (n = 1,764).

MEASUREMENTS AND MAIN RESULTS

Study outcomes were whether women had been screened: for mammogram, every 2 years for ages 50-74; for clinical breast examinations (CBEs), every year for all ages; and for Pap smears, every 3 years for ages under 65. An index of comorbidity, adapted from Charlson (0 for no disease, maximum index of 8 among our patients), and specific chronic diseases were the main independent variables. Demographics, clinic use, insurance, and clinical data were covariates. In the appropriate age groups for each test, 58% of women had a mammogram, 43% had a CBE, and 66% had a Pap smear. As comorbidity increased, screening rates decreased (p < .05 for linear trend). After adjustment, each unit increase in the comorbidity index corresponded to a 17% decrease in the likelihood of mammography (p = .005), 13% decrease in CBE (p = .006), and 20% decrease in Pap smears (p = .002). The rate of mammography in women with stable angina was only two fifths of that in women without.

CONCLUSIONS

Among women who sought outpatient care, screening rates decreased as comorbidity increased. Whether clinicians and patients are making appropriate decisions about screening is not known.

Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project

CONTEXT

Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement programs has been difficult to establish.

OBJECTIVE

To improve the quality of care for Medicare patients with acute myocardial infarction.

DESIGN

Quality improvement project with baseline measurement, feedback, remeasurement, and comparison samples.

SETTING

All acute care hospitals in the United States.

PATIENTS

Preintervention and postintervention samples included all Medicare patients in Alabama, Connecticut, Iowa, and Wisconsin discharged with principal diagnoses of acute myocardial infarctions during 2 periods, June 1992 through December 1992 and August 1995 through November 1995. Indicator comparisons were made with a random sample of Medicare patients in the rest of the nation discharged with acute myocardial infarctions from August 1995 through November 1995. Mortality comparisons involved all Medicare patients nationwide with inpatient claims for acute myocardial infarctions during 2 periods, June 1992 through May 1993 and August 1995 through July 1996.

INTERVENTION

Data feedback by peer review organizations.

MAIN OUTCOME MEASURES

Quality indicators derived from clinical practice guidelines, length of stay, and mortality.

RESULTS

Performance on all quality indicators improved significantly in the 4 pilot states. Administration of aspirin during hospitalization in patients without contraindications improved from 84% to 90% (P< .001), and prescription of beta-blockers at discharge improved from 47% to 68% (P < .001). Mortality at 30 days decreased from 18.9% to 17.1% (P = .005) and at 1 year from 32.3% to 29.6% (P < .001). These improvements in quality occurred during a period when median length of stay decreased from 8 days to 6 days. Performance on all quality indicators except reperfusion was better in the pilot states than in the rest of the nation in 1995, and the differences were statistically significant for aspirin use at discharge (P < .001), beta-blocker use (P < .001), and smoking cessation counseling (P = .02). Postinfarction mortality was not significantly different between the pilot states and the rest of the nation during the baseline period, although it was slightly but significantly better in the pilot states during the follow-up period (absolute mortality difference at 1 year, 0.9%; P = .004).

CONCLUSIONS

The quality of care for Medicare patients with acute myocardial infarction has improved in the Cooperative Cardiovascular Project pilot states. Performance on the defined quality indicators appeared to be better in the pilot states than in the rest of the nation in 1995 and was associated with reduced mortality.

Increased platelet activation and fibrinogen in Asian Indians. Potential implications for coronary risk

AIMS

To determine whether Asian Indians (Indians), a group known to have high rates of coronary heart disease, have increased platelet activation and fibrinogen levels relative to white Americans of European origin (whites).

METHODS AND RESULTS

Forty healthy, non-smoking Indians, aged 25-45, were matched with 40 healthy whites for age (within 3 years) and gender. Platelet activation was tested in blood exiting a bleeding time wound at 1 and 2 min post-incision (wound-induced activation), as well as in venous blood stimulated in vitro with collagen, using whole blood flow cytometry. Other risk factors, including fibrinogen levels, family history of diabetes or coronary heart disease, fasting insulin and lipid levels, and Lp(a) were also assessed. Fibrinogen levels were higher among Indians than whites, even after adjustment for gender or family history of coronary heart disease (P < 0.05). Indians had higher levels of wound-induced glycoprotein IIb/IIIa binding and platelet secretion (P-selectin expression) than whites, with the greatest differences found when comparing the upper quintile of activation for each group (Ps < 0.05). Indians with a family history of coronary heart disease (n = 15) had higher levels of platelet secretion (wound-induced and in vitro) than Indians without a family history (Ps < 0.05), while the relationship was reversed among whites. Platelet activation measures were not consistently related to other coronary risk factors, while fibrinogen was related to triglyceride and insulin levels among Indians.

CONCLUSION

Indians have elevated fibrinogen and platelet activation levels relative to whites. These factors may contribute to the increased coronary risk observed in Indians.

A hypertension control program tailored to unskilled and minority workers

PURPOSE

A comprehensive worksite health promotion program designed to reduce risk factors for cardiovascular disease among 4000 city of Birmingham employees was used to develop and implement a tailored antihypertensive educational intervention. The mean age of the underlying population was 36 years, 89% were blue-collar or unskilled workers, 50% were African Americans and 20% were female.

METHODS

First, we identified barriers to hypertension control: low literacy, difficulty understanding the need for treatment of asymptomatic disease, and wide variability of health beliefs and priorities. We then tailored an educational program, which offered employees health education sessions on a variety of different topics, including heart disease, cancer, sleep disorders and back injury. All program materials focused on lifestyle changes and the need to seek medical care. This program was offered to all hypertensive workers; 130 chose to enroll, and 81 completed the program. These 81 participants were matched by age, sex, race and baseline BP with nonparticipating hypertensive workers (controls). Changes in SBP and DBP from before to after the educational program were used to evaluate the program.

RESULTS

Overall, intervention participants had a decrease of 4.5 mm Hg in mean SBP (different from zero, [p = 0.03]). African American participants showed a significant decrease (7.4 mm Hg, [p = 0.004]), as did unskilled intervention participants (SBP changes = 7.7 mm Hg, [p = 0.004]). Although not statistically significant, controls showed decreases in BP in the same direction.

CONCLUSION

An educational intervention tailored to the specific health perceptions and working conditions of a low literacy population is feasible, and may have a significant effect on hypertension control.

Differences in cardiovascular disease risk factors in black and white young adults: comparisons among five communities of the CARDIA and the Bogalusa heart studies. Coronary Artery Risk Development In Young Adults

PURPOSE

To examine community differences in cardiovascular disease (CVD) risk factors among black and white young adults by combining data from two large epidemiologic studies.

METHODS

Data are from participants aged 20-31 years in the Coronary Artery Risk Development In Young Adults (CARDIA) study (1987-1988; N = 4129) and the Bogalusa Heart study (1988-1991; N = 1884), adjusting for data collection differences prior to analysis. CARDIA includes four urban sites: Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. Bogalusa is a semi-rural town in Southeastern Louisiana. CVD risk factors examined were smoking status, body habitus, and blood pressure.

RESULTS

In Birmingham and Bogalusa, more white than black women were current smokers; no ethnic differences were observed among men. In Chicago, Minneapolis, and Oakland, more blacks were current smokers than were whites. For all sites, educational level was strongly inversely related to current smoking status; ethnic differences were more apparent among those with up to a high school education. Among white men and women, prevalence of obesity (body mass index > 31.1 kg/m2 in men and 32.3 kg/m2 in women) was greater in Birmingham and Bogalusa than in Chicago. Minneapolis, and Oakland. Mean systolic blood pressures were highest in Bogalusa, and the proportion of black men with elevated blood pressure (> or = 130/85 mmHg) was higher in Bogalusa and Birmingham.

CONCLUSIONS

Community and ethnic differences in CVD risk factors were observed among young adults in two large epidemiologic studies. Further studies may enhance our understanding of the relationship of geographic differences in CVD risk to subsequent disease.

Regional disparities in the incidence of elevated blood pressure among young adults: the CARDIA study

BACKGROUND

Within the United States, little is known about regional disparities in blood pressure (BP), their changes over time, or explanations for their existence.

METHODS AND RESULTS

A population-based cohort of 5115 black and white men and women, 18 to 30 years old in 1985-1986 (balanced on age, race, sex, and education), was followed up for 7 years in four centers: Birmingham, Ala; Chicago, Ill; Minneapolis, Minn; and Oakland, Calif. Differences in elevated BP (EBP) prevalence among centers at years 0, 2, 5, and 7 and in 7-year incidence of EBP were assessed. Sociodemographic and dietary variables, physical activity, weight, smoking, and alcohol were considered. At year 0, no regional differences were seen. Seven years later, there was marked variability in prevalence of EBP overall and for both black and white men, from a low in Chicago (9% for black men and 5% for white men) to a high in Birmingham (25% for black men and 14% for white men). Birmingham also had the highest 7-year incidence (11%) and overall prevalence at year 7 (14%). The adjusted odds ratios, with Birmingham as referent (95% CIs), for 7-year incidence of EBP overall were 0.38 (0.24, 0.60) for Chicago, 0.37 (0.24, 0.57) for Minneapolis, and 0.74 (0.52, 1.07) for Oakland.

CONCLUSIONS

Regional disparities are absent at baseline but become apparent as the cohort ages. These differences are not fully explained by the available behavioral and sociodemographic characteristics.

Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction

OBJECTIVE

To compare the use of medications in African-American and Caucasian elderly Medicare patients hospitalized with acute myocardial infarction (AMI) in Alabama.

DESIGN

Retrospective medical record review.

SETTING

All acute care hospitals in Alabama.

PATIENTS

All Medicare patients with a principal discharge diagnosis of AMI from June 1992 through February 1993. We excluded those patients less than 65 years of age and those of ethnicity other than African-American or Caucasian (N = 4,052).

MEASUREMENTS

We first performed a crude analysis using all cases to compare by race the use of thrombolysis, beta-adrenergic blockade, and aspirin in the setting of AMI. In addition, we developed a multivariable model with receipt of therapy as the outcome and demographics, severity of illness, comorbidity, and algorithm-determined candidacy for therapy as covariates. The algorithms, developed as part of the Cooperative Cardiovascular Project, were designed to identify an "ideal" pool of candidates for each therapy.

MAIN RESULTS

For all cases, 9.2% (95% confidence interval [CI] 6.8, 12.1) of African Americans received thrombolysis compared with 17.3% (95% CI 16.0, 18.6) of Caucasians. Approximately 16.4% of patients received beta-adrenergic blockade, and 45.1% received aspirin, both with no racial difference. By multivariate analysis, the adjusted odds ratio for African Americans receiving thrombolysis was 0.55 (95% CI 0.41, 0.76). The corresponding odds ratio was 1.25 (95% CI 0.99, 1.59) for beta-adrenergic blockade and 1.13 (95% CI 0.96, 1.37) for aspirin. African Americans presented later after the onset of chest pain, but the refusal rate of thrombolytic therapy did not differ.

CONCLUSIONS

According to this analysis, Alabama physicians used beta-adrenergic blockade and aspirin equivalently in African Americans and Caucasians. African Americans received thrombolysis less often according to the crude analysis. The multivariable analysis suggests less use of thrombolytics, even after adjusting for several covariates including indication by clinical algorithm. However, the small number of African-American patients deemed ideal candidates for thrombolysis attenuates the precision of this finding.

Delayed tuberculin reactivity in persons of Indochinese origin: implications for preventive therapy

OBJECTIVES

To 1) study a variant delayed reaction to tuberculin testing as a way to enhance screening for tuberculosis among high-risk persons and 2) correlate the delayed reaction with lymphocyte blastogenesis.

DESIGN

Cross-sectional study.

SETTING

2 public health department clinics in North Carolina.

PARTICIPANTS

121 adults who had recently emigrated from Vietnam to North Carolina and who were ethnic Vietnamese and ethnic Dega, a minority population group from the central highlands region of Vietnam.

MEASUREMENTS

Medical history, physical examination, laboratory evaluation, and standard purified protein derivative (PPD) testing (Mantoux method). Skin test results were read at 72 hours and again at 6 days. Variant reactivity was defined as induration of less than 10 mm at 72 hours that, when reassessed at 6 days, had increased in size to 10 mm or greater. Persons with negative (n=54) and variant (n=32) PPD results also had booster testing at 10 to 12 weeks. Serum samples were obtained from 57 participants for lymphocyte blastogenesis studies.

RESULTS

26% of participants had variant tuberculin reactivity. Variant reactivity was strongly associated with booster positivity: Sixty-five percent of persons with variant PPD results had booster positivity compared with 16% of persons with negative PPD results (P<0.001). The lymphocyte blastogenesis response of persons with variant PPD results was between the response of persons with negative PPD results and that of persons with positive PPD results.

CONCLUSION

Variant reactivity in this high-risk group was a predictor of booster positivity. Together with the blastogenic response pattern, this association strongly suggests that variant reactivity has a high positive predictive value for tuberculous infection. Clinicians should incorporate these findings into their approach for choosing candidates for preventive therapy.

Body mass index in young adults: Associations with parental body size and education in the CARDIA Study

OBJECTIVES

Associations of parental education, parental body size, and offspring's education with body mass index and 7-year change in body mass index were examined among participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

METHODS

CARDIA is a study of coronary artery disease risk factors in 5115 Black and White persons aged 18 to 30 at baseline. Analyses of covariance were carried out with body mass index and change in body mass index as the dependent variables, and with parental education, parental body size, and participant education as the major independent variables.

RESULTS

Father's body size was positively associated with participant's baseline body mass index among Black men, White men, and White women. Mother's body size was positively associated with baseline body mass index among all race-sex groups, and with change in body mass index among White women. Father's education was inversely associated with baseline body mass index among Black men and White women, and with change among White women.

CONCLUSIONS

Parental education may influence body mass index and changes in young adulthood, especially among White women. Such associations may be both genetic and environmental and may be important for obesity prevention efforts.

Do public clinic systems provide health care access for the urban poor? A cross-sectional survey

The purpose of this study was to describe the health care access provided to a low-income urban population by a system of county run public clinics. We conducted a cross-sectional interview survey of a random sample of subjects applying for or renewing eligibility to use the public system. The setting was a public system consisting of inner-city community health centers and hospital-based clinics delivering primary care. We interviewed 547 adult nonpregnant subjects; mean age was 41 years; 55% were women, 54% were Hispanic and 28% were non-Hispanic Blacks; 78% had household income below $15,000 per year, and 75% had no health insurance. Access to health care was measured in three ways: physician contact during year prior to survey; and answers to two separate questions concerning delaying needed medical care because it cost too much, and delaying care because it would take too long to be seen. Although 80% of subjects had seen a physician at least once, 46% had stayed away sometime during the year due to financial reasons and 24% had stayed away because of waiting time. Surprisingly, 35% reported private sector use. These rates varied significantly with insurance status. Hispanics had significantly less access by all three measures, even after multivariable adjustment for potential confounders such as sex, age, chronic disease and insurance status. We conclude that this study demonstrates financial barriers to access, while showing substantial private sector contact, even by low-income subjects already using the public sector.

Impact of father's education and parental smoking status on smoking behavior in young adults. The CARDIA study. Coronary Artery Risk Development in Young Adults

Associations of parents' education and smoking with young adults' smoking were examined in participants aged 18-30 years at baseline (1985-1986) in the Coronary Artery Risk Development in Young Adults study. Significant (p < 0.05) inverse age-adjusted associations of father's education with participant smoking status among black men, white men, and white women disappeared after adjustment for participant's education. Parental smoking status was directly related to participant smoking status for all race/sex groups. Participant education was strongly inversely related to participant smoking. Public health campaigns should consider influences of parental behaviors on children's behaviors and associations of limited education with adverse lifestyles.

Is cost a barrier to screening mammography for low-income women receiving Medicare benefits? A randomized trial

BACKGROUND

In 1991, Medicare began covering screening mammograms subject to copayment and deductible. This study evaluated the effectiveness of Medicare in removing financial barriers to screening mammography among low-income older women.

METHODS

In an inner-city public hospital's General Medicine Clinic, 119 consecutive, eligible, and consenting Medicare-enrolled women without known risk factors for breast cancer other than age, and no mammogram in the previous 2 years, were entered into a randomized controlled trial with follow-up after 2 months. The mean age was 71 years; 77% were black, 92% had an annual income below $10,000, and 52% had had a previous mammogram. All patients were counseled concerning indications for screening mammograms and Medicare coverage, and all were referred to a low-cost mammography facility. Sixty-one subjects were randomly assigned a voucher for a free screening mammogram at the referral facility. Obtaining a mammogram within 60 days of study entry was the main outcome measure.

RESULTS

Of the women given vouchers, 27 (44%) obtained screening mammograms, compared with six (10%) of those without vouchers (P < .001). Adjustment by multiple logistic regression confirmed this association, yielding an adjusted odds ratio of 7.4 (95% confidence interval, 2.5 to 21.4). Knowledge concerning mammography and breast cancer increased significantly overall (and within randomization groups) between initial interview and follow-up; fear did not change. For women without the voucher, the main reason for not obtaining a mammogram was financial; the main reason for women with the voucher was transportation.

CONCLUSION

In a low-income, inner-city population of older women, financial barriers to screening mammography persist despite Medicare coverage.

Post-hospitalization followup appointment-keeping among the medically indigent

The purpose of this study was to measure followup appointment-keeping in patients discharged from a General Medicine Inpatient Service and to identify possible predictors of compliance. Patients were interviewed on hospital admission and all charts were reviewed on discharge. A subset of patients were interviewed by telephone an average of one month after first followup appointment date. The study was conducted in an urban public teaching hospital with hospital-based and community clinics. A convenience sample of 209 patients were selected from admissions to the General Medicine Inpatient Service over a three month period. Followup appointment-keeping was recorded on all 195 patients discharged alive. Seventy-five percent of patients had no medical insurance, public or private. A compliance rate of 60% (95% confidence interval: 53% to 67%) with first followup appointment was found. Variables associated with compliance and which retained independence on multiple logistic regression analysis, followed by adjusted odds ratios (95% confidence intervals) were: no copayment requirement, odds ratio 3.2 (1.6 to 6.3), single followup appointment 2.9 (1.4 to 5.9), apartment dwelling 3.2 (1.4 to 7.3) and non-primary care clinic appointment 2.3 (1.1 to 4.8). We conclude that health-care-delivery related factors such as no copayment requirements are strongly associated with appointment-keeping in a public hospital population.

The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery

OBJECTIVES

To determine the incidence of and risk factors for perioperative myocardial infarction with noncardiac surgery and to test the accuracy of a risk stratification system.

DESIGN

Prospective cohort study.

SETTING

A large urban Veterans Affairs hospital.

PARTICIPANTS

A total of 1487 men older than 40 years undergoing major, nonemergent, noncardiac operations.

MEASUREMENTS

Infarction was established by at least two of the following: development of new Q waves, typical change in creatine kinase MB, and positive technetium pyrophosphate scintigraphy. Patients were stratified preoperatively into high-, intermediate-, low-, and negligible-risk strata based on clinical markers corresponding to different levels of coronary artery disease prevalence.

MAIN RESULTS

Patients with coronary disease (high-risk stratum) had a 4.1% incidence of infarction (13 of 319; 95% CI, 1.8% to 6.4%); patients with peripheral vascular disease but no evidence of coronary disease (intermediate-risk stratum) had a 0.8% incidence (2 of 260, upper bound of CI, 2.0%); patients with high atherogenic risk factor profiles but no clinical atherosclerosis (low-risk stratum) had a 0% incidence (0 of 256, upper bound of CI, 1.2%). No cardiac deaths occurred in 652 men who had no atherosclerosis and low atherogenic risk factor profiles (the negligible-risk stratum). Factors independently associated with infarction included age more than 75 years (adjusted odds ratio, 4.77; CI, 1.17 to 19.41), signs of heart failure on the preoperative examination (adjusted odds ratio, 3.31; CI, 0.96 to 11.38), coronary disease (adjusted odds ratio, 10.39; CI, 2.27 to 47.46), and a planned vascular operation (adjusted odds ratio, 3.72; CI, 1.12 to 12.37).

CONCLUSIONS

Coronary artery disease is the major risk factor for perioperative infarction. The stratification scheme identifies subsets of patients with different risks, and finer within-stratum distinctions can be made using additional variables.

The frequency and significance of ECG changes after transurethral prostate resection

Although many clinicians routinely recommend a base-line preoperative electrocardiogram (ECG) and obtain frequent postoperative ECGs to screen for myocardial infarction or ischemia, the diagnostic utility of screening perioperative ECGs is unknown. The present analysis evaluates the sensitivity and specificity of the perioperative ECG and examines its value as a predictor of early postoperative cardiac events and outcomes during the postoperative year. ECGs obtained preoperatively and on the first 3 postoperative days in 206 men undergoing transurethral prostate resection were analyzed using the Minnesota Code. The occurrence of cardiac events during the operative stay was assessed by measurement of the cardiospecific MB creatine kinase isoenzyme on the first 3 postoperative days and review of the entire clinical course. Twenty-one percent of patients developed postoperative ECG changes, mostly involving the T wave; none had cardiac symptoms or sustained creatine kinase MB elevation. Changes were not significantly more common in men known to have coronary disease. The single patient who had a perioperative myocardial infarction confirmed by enzymes had no codable ECG changes. The specificity of any ECG change for perioperative infarction was 78%; of ST segment changes only, 95%. Only one of the patients (2%) who had postoperative ECG changes had a cardiac event in the year after surgery. Routine perioperative ECGs is of little diagnostic/predictive utility in situations in which the incidence of perioperative myocardial infarction is low.