�75 years were less likely than those �65 years of age to filla prescription (HR, 0.63; 95% CI, 0.42–0.93). Gender, raceand being an ideal candidate did not affect beta-blocker use.Among patients who were discharged on beta-blockers,85% of survivors had filled a prescription by 30 days postdischarge and 63% and 61% were current users at 180 and365 days, respectively. These proportions were only 8%,13% and 12%, respectively, for those patients with nodischarge order for beta-blockers.Conclusions: Patients not discharged on beta-blockers have avery low likelihood of being started on them as outpatients.Even in those patients discharged on beta-blockers afterAMI, there is a significant decline in use after discharge.Quality improvement efforts need to be focused not only onimproving discharge use of beta-blockers but also strategiesto improve their long-term adherence.Perspective: Appropriate use of evidence-based therapies atdischarge is associated with their long-term adherence aswell as improved long-term outcomes (Fonarow GC, et al.Cardiac Hospitalization Atherosclerosis Management Pro-gram [CHAMP]. Am J Cardiol 2001;87:819–22). Physi-cians should aim at initiating evidence–based treatments inhospital or at the time of discharge to improve goals oflong-term adherence. RM

Change in the Quality of Care Delivered toMedicare Beneficiaries, 1998 –1999 to 2000 –2001

Jencks SF, Huff ED, Cuerdon T. JAMA 2003;289:305–12.

Study Question: What are the national- and state-levelchanges in performance on quality indicators for care ofacute myocardial infarction (AMI) and congestive heartfailure (CHF) in Medicare beneficiaries?Methods: 12 cardiac quality indicators targeted for improve-ment in Quality Improvement Organization (QIO) pro-gram were evaluated in national observational cross-sec-tional studies of national- and state-level fee-for-servicedata for Medicare beneficiaries during 1998–1999 (base-line) and 2000–2001 (follow-up). Absolute (change inperformance from baseline to follow-up) and relative (ab-solute improvement divided by the difference between thebaseline performance and perfect performance [100%])improvements were assessed.Results: The median state performance improved from base-line to follow-up on 10 of the 12 cardiac indicators. Themedian indicator rates in the follow-up sample for AMI(absolute change from baseline) were as follows: aspirin in24 hours � 85% (4%), aspirin at discharge � 86% (2%),beta-blockers within 24 hours of admission � 69% (6%),beta-blockers at discharge � 79% (7%), angiotensin-con-verting enzyme blockers � 74% (4%), documentation ofsmoking cessation counseling � 43% (4%), time to throm-bolysis 45 minutes (4 minutes) and time to percutaneouscoronary angioplasty � 107 minutes (�19 minutes). Sim-

ilarly, the median indicator rates in the follow-up samplefor CHF were as follows: measurement of left ventricularejection fraction � 70% (4%) and angiotensin-convertingenzyme inhibitors � 68% (�4%). Absolute improvementwas greater in states in which performance was low atbaseline than those in which it was high at baseline. Whenstates were ranked on each indicator, the state’s averagerank was highly stable over time.Conclusions: Care for AMI and CHF in Medicare fee-for-service plan beneficiaries improved substantially between1998–1999 and 2000–2001 and paralleled the consistentQIO activities over this time. However, a much largeropportunity remains for further improvement. These dataindicate that the relative rankings among states havechanged little.Perspective: It is heartening to see the slow but definiteimprovement in the quality of care of Medicare bene-ficiaries with AMI and CHF. The Medicare QIO experiencedata provide yet another look at the room that stillexists to improve the care of Medicare beneficiaries.These data should stimulate caregivers to improve thecare of AMI and CHF patients further by investing insystems changes that promote reliable evidence-based car-diac care. RM

Cardioselective �-Blockers in Patients WithReactive Airway Disease: A Meta-AnalysisSalpeter SR, Ormistonm TM, Salpeter EE. Ann Intern Med 2002;137:715–25.

Study Question: What is the effect of cardioselective �-block-ers on respiratory function of patients with reactive airwaydisease?Methods: A meta-analysis was performed in randomized,blinded, placebo-controlled trials that studied the effects ofcardioselective �-blockers on FEV1, symptoms and the useof inhaled �2-agonists in patients with reactive airway dis-ease. The sources of these trials were comprehensivesearches of the EMBASE, MEDLINE and CINAHL databasesfrom 1966 to May 2001 and scans of references of theidentified articles and related reviews. Administration of acardioselective �-blocker and administration of �2-agonistafter the study drug were the interventions studied, whereasthe main outcome measures evaluated were the change inFEV1 from baseline, the number of patients with respiratorysymptoms and the use of inhaled �2-agonists with activetreatment compared with placebo.Results: 19 studies gave information on single-dose treat-ment and 10 studies on continued treatment and wereincluded for the purpose of this analysis. The use of a singledose of a cardioselective �-blocker was associated with a7.5% (95% CI, 5.6%–9.3%) decrease in FEV1 and a 4.6%(CI, 2.5%–6.8%) increase in FEV1 response to �-agonistcompared with placebo, with no increase in symptoms.Trials of continued treatment lasting from 3 days to 4 weeks

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produced no significant change in FEV1, symptoms orinhaler use compared with placebo but maintained an 8.7%(CI, 2.0–15.5%) increase in �-agonist response. No signif-icant treatment effect in terms of FEV1 was found in patientswith concomitant chronic obstructive pulmonary disease.Conclusions: Cardioselective �-blockers do not produceclinically significant adverse respiratory effects in patientswith mild-to-moderate reactive airway disease or in thosewith concomitant chronic airways obstruction. Thus, car-dioselective �-blockers should not be withheld from pa-tients with a variety of cardiovascular conditions with mild-to-moderate reactive airway disease.Perspective: Although the studies included in this meta-analysis had small number of patients, it is reassuring to seethat the cardioselective �-blockers had no significant clini-cally relevant broncho-spastic effects in patients with mild-to-moderate reactive airway disease or in patients withchronic obstructive pulmonary disease. Thus, physiciansshould not withhold these beneficial agents in appropriatepatients with acute coronary syndromes, atrial fibrillation,congestive heart failure and hypertension. RM

The Multicentre Aneurysm Screening Study (MASS)into the Effect of Abdominal Aortic AneurysmScreening on Mortality in Men: A RandomizedControlled Trial

The Multicentre Aneurysm Screening Study Group. Lancet 2002;360:1531–9.

Study Question: Is routine ultrasound screening for abdom-inal aortic aneurysms beneficial in patients at high-risk forthis disease?Methods: In this population-based study, men (n�67,800)aged 65–74 years were randomly allocated to either receivean invitation for an abdominal ultrasound scan (invitedgroup, n�33,839) or not (control group, n�33,961). Menwith normal abdominal aorta (�3 cm diameter) or in whomaorta was not visualized were not rescanned. Men in whomabdominal aortic aneurysms (�3 cm in diameter) weredetected were followed with repeat ultrasound scans for amean of 4.1 years. Surgery was considered for aneurysmdiameter of 5.5 cm, expansion �1 cm per year or in thosewith symptoms. The primary outcome measure was mor-tality related to abdominal aortic aneurysm (obtained fromthe Office of National Statistics). Quality of life was assessedwith four standardized scales.Results: 80% of 33,839 men in the invited group acceptedthe invitation to screen, and 1333 aneurysms were detectedin these patients. Aneurysm-related deaths were lower inthe invited group compared to the control group (0.19% vs.0.33%, risk reduction, 42%, 95% CI, 22–58%; p�0.0002),with a 53% reduction (95% CI, 30–64) in those whoattended screening. Similarly, the incidence of non-fatalrupture of abdominal aneurysm was also lower in the

invited group (0.24% vs. 0.41%, risk reduction, 41%;p�0.00006). There were fewer emergency operations donein the invited group compared to the control patients (27vs. 54). The 30-day mortality was higher after electivesurgery for an aneurysm than after emergency surgery (6%vs. 37%).Conclusions: These results provide reliable evidence of ben-efit from screening for abdominal aortic aneurysms.Perspective: These data together with a cost-effective analy-sis build on the current data, and suggest that routineultrasound screening for abdominal aortic aneurysm inmen aged 65–74 is not only beneficial but also cost-effectiveand should be utilized routinely in men in this age group.RM

Multicentre Aneurysm Screening Study (MASS): CostEffectiveness Analysis of Screening for AbdominalAortic Aneurysms Based on 4-Year Results fromRandomized Controlled Trial

Multicentre Aneurysm Screening Study Group. BMJ 2002;325:1135– 42.

Study Question: What is the cost effectiveness of ultrasoundscreening for abdominal aortic aneurysms?Methods: During 1997 and 1999, 67,800 males aged 65–74years from four centers in the United Kingdom were indi-vidually randomized to be invited for screening (interven-tion arm) or not (control arm). Screening with portableultrasound was delivered in primary care settings withfollow-up and surgery offered in main centers. Four-yearcost effectiveness analysis based directly on results from thisrandomized controlled trial (primary analysis) and projec-tion of the data, based on conservative assumptions, toindicate likely cost effectiveness at 10 years (secondaryanalysis) were assessed. Main outcome measures were mor-tality from and costs (screening, follow-up, elective andemergency surgery) related to abdominal aortic aneurysmand cost per life year gained.Results: There were 47 fewer deaths related to abdominalaortic aneurysms in the screening group (hazard ratio 0.58,95% confidence interval [CI] 0.42–0.78) than in the con-trol group at an incremental cost of £2.2m over a 4-yearperiod. The difference between the arms of the trial inoverall mean costs was £63.39 (95% CI, £53.31–£73.48)per patient. The mean incremental cost effectiveness ratiofor screening was £28,400 (£15,000–£146,000) per lifeyear gained, equivalent to about £36,000 per quality ad-justed life year. After 10 years, this figure was estimated tobe around £8000 per life year gained.Conclusions: The cost effectiveness of screening for abdom-inal aortic aneurysms is at the margin of acceptability ac-cording to current National Health Service thresholds andwill improve substantially over 10 years.

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