- Email: [email protected]
Workshop II: Deliberations and recommendations
Workshop I1: Deliberations and Recommendations WorkShop II considered cost-effective issues relating to patients hospitalized for acute myocardial infarction (AMI) and to methods for improving the cost-effective operation of coronary care units (CCUs). Controversy existed on many issues but several areas of consensus were reached by the group, including the following.
1. Patients with AMI who are seen earlier than 4 hours after onset of symptoms generated considerable discussion. The present data base does not support early coronary angiography and acute intervention until the results of clinical trials now under way are reported. If it can be proven in the long run that morbidity and mortality are reduced by such early intervention, an increase in short-term cost resulting from the intervention and the longer period of hospitalization may be justified based on a decrease in cost for following such patients on a long-term basis until their return to a more useful life-style. 2. There was general consensus that patients with uncomplicated myocardial infarction could be moved from the CCU after 48 hours. It was also suggested that such patients might be moved earlier if their beds were required for other patients. Further, it was thought that the course of such patients and their need for continuous stay in the CCU before removal to a step-down unit should be reassessed more frequently than every 24 hours. 3. In patients with uncomplicated AMI, studies such as radionuclide angiograms, 2-dimensional echocardiograms, thallium radionuclide study or coronary angiography are not required for routine clinical decisions. There was concern that we have blurred the distinction between studies necessary for clinical research and stratification of patients for clinical investigation and the needs for routine clinical practice. Clearly, such tools will continue to be of importance in clinical research in this particular group of patients. 4. It is recognized that a group of patients developing the complication of angina in the early period after myocardial infarction requires early angiography to plan their continued treatment with a view toward early bypass surgery. In those patients who develop difficult-to-treat congestive heart failure and lifethreatening or potentially life-threatening arrhythmias, a greater intensity of care and a longer stay in the intensive care unit or the CCU are required. It is also recognized that this would be a fruitful area for further clinical research. 5. Those patients with A M I and hopeless brain damage or severe p u m p failure requiring artificial means to maintain circulation are considered to represent moral and ethical issues as well as cost containment issues. A broader population involving other elements of society needs to consider this problem, and physicians involved in intensive care should play an important role in these considerations.
General Comments About Coronary Care Units The CCU was judged necessary and effective in reducing the hospital mortality for AMI. Over time the character of CCUs has evolved; they now serve as acute cardiac care units caring for patients with congestive heart failure, arrhythmias, suspected myocardial infarction and other potentially major cardiac problems. Small units were considered inefficient and not costeffective. Combining such units as medical intensive care Units, respiratory units and others maximizes efficiency and provides for more flexibility. However, the loss of general objectives for combined units and the loss of specialized staff with a high "esprit" may offset any gains. Where units of sufficient size are present, combination of units is not indicated. General agreement was reached that the upper limit of size for efficiency was probably 15 to 18 patients.
Stratifying Patients Before Admission tO the Coronary Care Unit Several categories were considered: 1. Patients with A M I determined clinically and by electrocardiogram were considered by all to require hospitalization in a CCU. 2. Those patients who present with chest pain and ischemic electrocardiographic changes that are not diagnostic of myocardial infarction were considered by most to require admission to a CCU. 3. There was controversy regarding those patients who have no previous history of coronary artery disease, and uncertainty regarding chest pain and negative electrocardiograms at the time they are seen. Most workshop participants favored hospitalization of such patients in a CCU. A minority view was that such patients with a "soft story" of myocardial infarction and no electrocardiographic changes might require hospitalization, but not necessarily in a CCU.
Early Stratification of Acute Myocardial Infarction Patients After Admission to the Coronary Care Unit Several categories were considered and much diversity of opinion was expressed.
70C
August 23, 1985
6. Patients with uncomplicated periods of convalescence after an AMI now have markedly shortened hospital stays compared with previous practices. This differed in various parts of the country, but ranges from 7 to 14 days and averages approximately 10 days. Factors involved in reaching this decision are changing continuously and need careful monitoring. It was agreed that these patients did not routinely require 24 hours of ambulatory monitoring before discharge but the general consensus was that low-level exercise testing before discharge or maximal exercise testing early after discharge in most uncomplicated patients is indicated. For those patients having angina in the early convalescent period or on exercise testing, coronary arteriography is indicated. For those patients with less life-threatening ventricular arrhythmias (although the group could not reach consensus on what these arrhythmias were in specific patient groups), the routine administration of antiarrhythmic drugs and the stratification of patients into groups requiring antiarrhythmic drug therapy cannot be agreed upon at this time. Such questions await answers from studies now in progress.
Effective Coronary Care Units More efficient and effective CCUs would be very important in cost containment because such specialized units use a large fraction of total medical and cardiologic resources. Several strategies to accomplish this were considered. 1. Multilevel cardiac care units, including stepdown units, are generally desirable. In such units the ratio of personnel to the level of care must be carefully monitored and regulated on a frequent basis. Such units could be used for the early discharge of patients from
THE AMERICAN JOURNAL OF CARDIOLOGY Volume 56
71C
the CCU or as alternate admission sites for other patients requiring less intense cardiac care, such as those with uncomplicated atrial fibrillation requiring digitalis therapy. 2. Routine orders in the CCU are still used in many units throughout the country. There was consensus that such strategies unnecessarily increase the cost of coronary care admissions. It is recognized that such routine orders may play a role in training centers and it is suggested that routine orders might be modified to minimize cost of hospitalization in a CCU if they were reconsidered in modern terms. 3. It is recognized that technology is not optimally used in CCUs. Technology could provide a higher level of monitoring with a reduction in personnel time if carried out effectively. Nurses and physicians in CCUs frequently use a considerable amount of time for information handling. Better use of technology to increase the' efficiency of information handling would reduce cost of such units. 4. Coronary care units need a cardiologist director who routinely reviews admissions and discharges and has the power to influence these decisions and direct the cost-effective use of resources in the CCU to improve its effectiveness. Participants in workshop II agreed that the cost of care for the patient with AMI could be decreased, as could hospitalization costs of patients with cardiac disorders. Appropriate algorithms for the care of such patients would be important in cost containment strategies for the future and other forums for these considerations were recommended. The distinction between what is now clinical research and what should be general diagnostic and management algorithms for these patient subsets must be more sharply defined if cost containment policies are to be successful.
1. Patients with AMI who are seen earlier than 4 hours after onset of symptoms generated considerable discussion. The present data base does not support early coronary angiography and acute intervention until the results of clinical trials now under way are reported. If it can be proven in the long run that morbidity and mortality are reduced by such early intervention, an increase in short-term cost resulting from the intervention and the longer period of hospitalization may be justified based on a decrease in cost for following such patients on a long-term basis until their return to a more useful life-style. 2. There was general consensus that patients with uncomplicated myocardial infarction could be moved from the CCU after 48 hours. It was also suggested that such patients might be moved earlier if their beds were required for other patients. Further, it was thought that the course of such patients and their need for continuous stay in the CCU before removal to a step-down unit should be reassessed more frequently than every 24 hours. 3. In patients with uncomplicated AMI, studies such as radionuclide angiograms, 2-dimensional echocardiograms, thallium radionuclide study or coronary angiography are not required for routine clinical decisions. There was concern that we have blurred the distinction between studies necessary for clinical research and stratification of patients for clinical investigation and the needs for routine clinical practice. Clearly, such tools will continue to be of importance in clinical research in this particular group of patients. 4. It is recognized that a group of patients developing the complication of angina in the early period after myocardial infarction requires early angiography to plan their continued treatment with a view toward early bypass surgery. In those patients who develop difficult-to-treat congestive heart failure and lifethreatening or potentially life-threatening arrhythmias, a greater intensity of care and a longer stay in the intensive care unit or the CCU are required. It is also recognized that this would be a fruitful area for further clinical research. 5. Those patients with A M I and hopeless brain damage or severe p u m p failure requiring artificial means to maintain circulation are considered to represent moral and ethical issues as well as cost containment issues. A broader population involving other elements of society needs to consider this problem, and physicians involved in intensive care should play an important role in these considerations.
General Comments About Coronary Care Units The CCU was judged necessary and effective in reducing the hospital mortality for AMI. Over time the character of CCUs has evolved; they now serve as acute cardiac care units caring for patients with congestive heart failure, arrhythmias, suspected myocardial infarction and other potentially major cardiac problems. Small units were considered inefficient and not costeffective. Combining such units as medical intensive care Units, respiratory units and others maximizes efficiency and provides for more flexibility. However, the loss of general objectives for combined units and the loss of specialized staff with a high "esprit" may offset any gains. Where units of sufficient size are present, combination of units is not indicated. General agreement was reached that the upper limit of size for efficiency was probably 15 to 18 patients.
Stratifying Patients Before Admission tO the Coronary Care Unit Several categories were considered: 1. Patients with A M I determined clinically and by electrocardiogram were considered by all to require hospitalization in a CCU. 2. Those patients who present with chest pain and ischemic electrocardiographic changes that are not diagnostic of myocardial infarction were considered by most to require admission to a CCU. 3. There was controversy regarding those patients who have no previous history of coronary artery disease, and uncertainty regarding chest pain and negative electrocardiograms at the time they are seen. Most workshop participants favored hospitalization of such patients in a CCU. A minority view was that such patients with a "soft story" of myocardial infarction and no electrocardiographic changes might require hospitalization, but not necessarily in a CCU.
Early Stratification of Acute Myocardial Infarction Patients After Admission to the Coronary Care Unit Several categories were considered and much diversity of opinion was expressed.
70C
August 23, 1985
6. Patients with uncomplicated periods of convalescence after an AMI now have markedly shortened hospital stays compared with previous practices. This differed in various parts of the country, but ranges from 7 to 14 days and averages approximately 10 days. Factors involved in reaching this decision are changing continuously and need careful monitoring. It was agreed that these patients did not routinely require 24 hours of ambulatory monitoring before discharge but the general consensus was that low-level exercise testing before discharge or maximal exercise testing early after discharge in most uncomplicated patients is indicated. For those patients having angina in the early convalescent period or on exercise testing, coronary arteriography is indicated. For those patients with less life-threatening ventricular arrhythmias (although the group could not reach consensus on what these arrhythmias were in specific patient groups), the routine administration of antiarrhythmic drugs and the stratification of patients into groups requiring antiarrhythmic drug therapy cannot be agreed upon at this time. Such questions await answers from studies now in progress.
Effective Coronary Care Units More efficient and effective CCUs would be very important in cost containment because such specialized units use a large fraction of total medical and cardiologic resources. Several strategies to accomplish this were considered. 1. Multilevel cardiac care units, including stepdown units, are generally desirable. In such units the ratio of personnel to the level of care must be carefully monitored and regulated on a frequent basis. Such units could be used for the early discharge of patients from
THE AMERICAN JOURNAL OF CARDIOLOGY Volume 56
71C
the CCU or as alternate admission sites for other patients requiring less intense cardiac care, such as those with uncomplicated atrial fibrillation requiring digitalis therapy. 2. Routine orders in the CCU are still used in many units throughout the country. There was consensus that such strategies unnecessarily increase the cost of coronary care admissions. It is recognized that such routine orders may play a role in training centers and it is suggested that routine orders might be modified to minimize cost of hospitalization in a CCU if they were reconsidered in modern terms. 3. It is recognized that technology is not optimally used in CCUs. Technology could provide a higher level of monitoring with a reduction in personnel time if carried out effectively. Nurses and physicians in CCUs frequently use a considerable amount of time for information handling. Better use of technology to increase the' efficiency of information handling would reduce cost of such units. 4. Coronary care units need a cardiologist director who routinely reviews admissions and discharges and has the power to influence these decisions and direct the cost-effective use of resources in the CCU to improve its effectiveness. Participants in workshop II agreed that the cost of care for the patient with AMI could be decreased, as could hospitalization costs of patients with cardiac disorders. Appropriate algorithms for the care of such patients would be important in cost containment strategies for the future and other forums for these considerations were recommended. The distinction between what is now clinical research and what should be general diagnostic and management algorithms for these patient subsets must be more sharply defined if cost containment policies are to be successful.