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Articles by B. K Nallamothu
Total Records ( 4 ) for B. K Nallamothu
  P. S Chan , G Nichol , H. M Krumholz , J. A Spertus , B. K Nallamothu and for the American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR) Invest

Background  Delays to defibrillation are associated with worse survival after in-hospital cardiac arrest, but the degree to which hospitals vary in defibrillation response times and hospital predictors of delays remain unknown.

Methods  Using hierarchical models, we evaluated hospital variation in rates of delayed defibrillation (>2 minutes) and its impact on survival among 7479 adult inpatients with cardiac arrests at 200 hospitals within the National Registry of Cardiopulmonary Resuscitation.

Results  Adjusted rates of delayed defibrillation varied substantially among hospitals (range, 2.4%-50.9%), with hospital-level effects accounting for a significant amount of the total variation in defibrillation delays after adjusting for patient factors. We found a 46% greater odds of patients with identical covariates getting delayed defibrillation at one randomly selected hospital compared with another. Among traditional hospital factors evaluated, however, only bed volume (reference category: <200 beds; 200-499 beds: odds ratio [OR], 0.62 [95% confidence interval {CI}, 0.48-0.80]; ≥500 beds: OR, 0.74 [95% CI, 0.53-1.04]) and arrest location (reference category: intensive care unit; telemetry unit: OR, 1.92 [95% CI, 1.65-2.22]; nonmonitored unit: OR, 1.90 [95% CI, 1.61-2.24]) were associated with differences in rates of delayed defibrillation. Wide variation also existed in adjusted hospital rates of survival to discharge (range, 5.3%-49.6%), with higher survival among hospitals in the top-performing quartile for defibrillation time (compared with the bottom quartile: OR for top quartile, 1.41 [95% CI, 1.11-1.77]).

Conclusions  Rates of delayed defibrillation vary widely among hospitals but are largely unexplained by traditional hospital factors. Given its association with improved survival, future research is needed to better understand best practices in the delivery of defibrillation at top-performing hospitals.

  T. Y Wang , G. C Fonarow , A. F Hernandez , L Liang , G Ellrodt , B. K Nallamothu , B. R Shah , C. P Cannon and E. D. Peterson

Background  Recent initiatives have focused on reducing door-to-balloon (DTB) times among patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. However, DTB time is only one of several important AMI care processes. It is unclear whether quality efforts targeted to a single process will facilitate concomitant improvement in other quality measures and outcomes.

Methods  This study examined 101 hospitals (43 678 patients with AMI) in the Get With the Guidelines program. For each hospital, DTB time improvement from 2005 to 2007 was correlated with changes in composite Centers for Medicare and Medicaid Services/Joint Commission on Accreditation of Healthcare Organizations (CMS/JCAHO) core measure performance and in-hospital mortality.

Results  Between 2005 and 2007, hospital geometric mean DTB time decreased from 101 to 87 minutes (P < .001). Mean overall hospital composite CMS/JCAHO core measure performance increased from 93.4% to 96.4% (P < .001), and mortality rates were 5.1% and 4.7% (P = .09) in the early and late periods, respectively. Improvement in hospital DTB time, however, was not significantly correlated with changes in composite quality performance (r = –0.06; P = .55) or with in-hospital mortality (r = 0.06; P = .58). After adjustment for patient mix, hospitals with the most improvement in DTB time did not have significantly greater improvements in either CMS/JCAHO measure performance or mortality.

Conclusions  Within the Get With the Guidelines program, DTB times decreased significantly over time. However, there was minimal correlation between DTB time improvement and changes in other quality measures or mortality. These results emphasize the important need for comprehensive acute myocardial infarction quality-improvement efforts, rather than focusing on single process measures.

  R Fazel , H. M Krumholz , E. R Bates , W. J French , P. D Frederick , B. K Nallamothu and for the National Registry of Myocardial Infarction (NRMI) Investigators

Background— Many hospitals with percutaneous coronary intervention (PCI) capability also use fibrinolytic therapy in patients with ST-segment elevation myocardial infarction, but factors influencing the choice of reperfusion strategy at these hospitals are poorly understood. We examined clinical and system-related factors associated with choice of reperfusion strategy in patients with ST-segment elevation myocardial infarction at PCI-capable hospitals.

Methods and Results— We analyzed patients with ST-segment elevation myocardial infarction who presented to PCI-capable hospitals between July 1, 2000, and December 31, 2006, in the National Registry of Myocardial Infarction. Hierarchical multivariable logistic regression was used to examine the association between choice of reperfusion strategy and patient-, hospital-, and system-related factors. We identified 25 579 patients who received primary PCI and 14 332 patients who received fibrinolytic therapy at 444 PCI-capable hospitals. Use of reperfusion strategies varied widely across hospitals, although primary PCI use increased over the study period. Among the key clinical factors that favored primary PCI, cardiogenic shock and delayed presentation were associated with greater use of primary PCI (adjusted odds ratios 2.14 [95% confidence interval 1.72 to 2.66] and 1.18 [95% confidence interval 1.09 to 1.27], respectively), whereas a Thrombolysis in Myocardial Infarction risk score ≥5 was not. In contrast, female gender, advanced age, and nonwhite race, all risk factors for intracranial hemorrhage after fibrinolytic therapy, were not associated with increased use of primary PCI. Off-hours presentation had the strongest association overall, with an 70% lower likelihood of patients undergoing primary PCI (adjusted odds ratio 0.27, 95% confidence interval 0.25 to 0.29).

Conclusions— Use of primary PCI, although increasing over recent years, is not universal at PCI-capable hospitals, and optimization of its use at such hospitals represents a potential opportunity to improve outcomes in patients with ST-segment elevation myocardial infarction.

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