Relationships between emerging measures of heart failure processes of care and clinical outcomes
Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA. American heart journal
(Impact Factor: 4.46).
03/2010; 159(3):406-13. DOI: 10.1016/j.ahj.2009.12.024
Previous studies have not confirmed associations between some current performance measures for inpatient heart failure processes of care and postdischarge outcomes. It is unknown if alternative measures are associated with outcomes.
Using data for 20,441 Medicare beneficiaries in OPTIMIZE-HF from March 2003 through December 2004, which we linked to Medicare claims data, we examined associations between hospital-level processes of care and patient outcomes. Performance measures included any beta-blocker for patients with left ventricular systolic dysfunction (LVSD); evidence-based beta-blocker for patients with LVSD; warfarin for patients with atrial fibrillation; aldosterone antagonist for patients with LVSD; implantable cardioverter-defibrillator for patients with ejection fraction < or =35%; and referral to disease management. Outcome measures were unadjusted and adjusted associations of each process measure with 60-day and 1-year mortality and cardiovascular readmission at the hospital level.
Adjusted hazard ratios for 1-year mortality with a 10% increase in hospital- level adherence were 0.94 for any beta-blocker (95% CI, 0.90-0.98; P = .004), 0.95 for evidence-based beta-blocker (95% CI, 0.92-0.98; P = .004); 0.97 for warfarin (95% CI, 0.92-1.03; P = .33); 0.94 for aldosterone antagonists (95% CI, 0.91-0.98; P = .006); 0.92 for implantable cardioverter-defibrillator (95% CI, 0.87-0.98; P = .007); and 1.01 for referral to disease management (95% CI, 0.99-1.03; P = .21).
Several evidence-based processes of care are associated with improved outcomes, can discriminate hospital-level quality of care, and could be considered as clinical performance measures.
Available from: Mandeep Mehra
- "In contrast, aldosterone antagonist use was not associated with lower mortality after multivariable adjustment. These findings are in contrast to randomized clinical trials demonstrating efficacy1 and prior studies of aldosterone antagonist use being associated with lower mortality risk.14 These findings may have resulted from confounding by indication or other forms of observational bias. "
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ABSTRACT: Several therapies are guideline-recommended to reduce mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction, but the incremental clinical effectiveness of these therapies has not been well studied. We aimed to evaluate the individual and incremental benefits of guideline-recommended HF therapies associated with 24-month survival.
We performed a nested case-control study of HF patients enrolled in IMPROVE HF. Cases were patients who died within 24 months and controls were patients who survived to 24 months, propensity-matched 1:2 for multiple prognostic variables. Logistic regression was performed, and the attributable mortality risk from incomplete application of each evidence-based therapy among eligible patients was calculated. A total of 1376 cases and 2752 matched controls were identified. β-Blocker and cardiac resynchronization therapy were associated with the greatest 24-month survival benefit (adjusted odds ratio for death 0.42, 95% confidence interval (CI), 0.34-0.52; and 0.44, 95% CI, 0.29-0.67, respectively). Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, implantable cardioverter-defibrillators, anticoagulation for atrial fibrillation, and HF education were also associated with benefit, whereas aldosterone antagonist use was not. Incremental benefits were observed with each successive therapy, plateauing once any 4 to 5 therapies were provided (adjusted odds ratio 0.31, 95% CI, 0.23-0.42 for 5 or more versus 0/1, P<0.0001).
Individual, with a single exception, and incremental use of guideline-recommended therapies was associated with survival benefit, with a potential plateau at 4 to 5 therapies. These data provide further rationale to implement guideline-recommended HF therapies in the absence of contraindications to patients with HF and reduced left ventricular ejection fraction. (J Am Heart Assoc. 2012;1:16-26.).
Journal of the American Heart Association 02/2012; 1(1):16-26. DOI:10.1161/JAHA.111.000018 · 4.31 Impact Factor
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ABSTRACT: A new "all NPN" configuration for temperature transducers and bandgap references has been developed. It is shown that with this circuit there is no need for an accurate ratio of collector currents. With simple circuits high performance is achieved.
Solid State Circuits Conference - Digest of Technical Papers, 1978. ESSCIRC 78. 4th European; 10/1978
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ABSTRACT: A new NTC thick film paste called 3K3-95/2 was composed of
submicron powder (a mixture of Mn, Co and Fe oxides), 4% Bi<sub>2</sub>O
<sub>3</sub> and an organic vehicle. The paste was screen printed on an
alumina substrata and sintered in a thick film conveyor furnace at
temperatures in the range 650 to 1000 °C. Thick film thermistor
layers were characterized by X-ray data, optical microscopy and SEM.
Electrical measurements were performed on the samples after printing Ag
epoxy electrodes on the top of the NTC layers. Then, new test NTC thick
film matrices with different planar thermistor geometries were
constructed and realized: “sandwich”,
“multilayer”, “segmented” and
“interdigitated” geometries. Their resistivity varied as a
function of layer thickness, electrode size and shape in the range of 10
Ω to 100 MΩ. The electrical resistivity of planar
thermistors was measured in the climate chamber in the range -30°C
to 120°C, when the thermistor temperature parameters B and Tc were
obtained (B=4200 K, Tmax=130°C). The main advantages of planar thick
film thermistor geometries over bulk types are faster temperature
response and custom design possibility for sensor applications
Microelectronics, 1997. Proceedings., 1997 21st International Conference on; 10/1997
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