Disease
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Coronary heart disease is the leading cause of death for both men and women in the United States. One of the most characteristic and troubling features of coronary disease is the sudden and unexpected onset of symptoms in clinically stable patients and sometimes in even previously healthy individuals.

The development of symptoms is associated with an increased risk of sudden death, acute myocardial infarction, and other life-threatening complications. The development of symptoms suggestive of coronary disease therefore mandates prompt and accurate diagnosis and treatment.

The cardinal symptom of coronary artery disease (CAD) is angina, which classically presents as a squeezing or strangulating deep chest discomfort that may radiate to the arm or jaw. Angina that is brought on by exercise stress and is relieved promptly after cessation of exertion is termed "typical angina." Stable angina is a pattern of symptoms that has been unchanged for 6 or more weeks. Unstable angina is a pattern of symptoms that is new in onset, changing in severity or frequency, occurring at rest, or lasting longer than 20 minutes.

The evaluation of suspected coronary disease is complicated by the fact that chest discomfort has many causes, and bona fide coronary disease may present in an atypical fashion. Thus, a population of patients with symptoms suggestive of coronary disease includes some patients with acute, life-threatening medical problems, some patients with other medical problems mimicking CAD, and even some "worried well" in need only of reassurance.

The evaluation and treatment of this highly heterogeneous population is the difficult task for clinicians in emergency departments (ED) and in office practice. The key goal of these clinicians must be to identify the patient's short-term risk. The high-risk patient may develop life-threatening complications and require hospitalization and immediate therapy. The low-risk patient may need further evaluation, but in a less urgent and less costly setting. Because identification of patient risk is central to all further patient management in unstable angina, this evidence report focuses on clinical and laboratory markers of patient risk, such as results of diagnostic tests (troponin values, stress testing, echocardiography, and nuclear scintigraphy).

Because chest pain units attempt to "risk stratify" (group patients according to their degree of risk) based on readily available data, an assessment of the efficacy of chest pain units is significant to this report. Our in-depth review focused on information that would be readily available to all providers caring for patients with suspected unstable angina. Information in this report applies to adult men and women.

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1
Publication Type
Working Papers
Publication Date
Journal Publisher
UCSF-Stanford Evidence-Based Practice Center, Agency for Health Care Research and Quality
Authors
Paul A. Heidenreich
Mark A. Hlatky
Number
01-E001, Evidence Report no. 31
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To assess the benefits of intervention programs against Helicobacter pylori infection, we estimated the baseline curves of its incidence and prevalence. We developed a mathematical (compartmental) model of the intrinsic dynamics of H. pylori, which represents the natural history of infection and disease progression. Our model divided the population according to age, infection status, and clinical state. Case-patients were followed from birth to death. A proportion of the population acquired H. pylori infection and became ill with gastritis, duodenal ulcer, chronic atrophic gastritis, or gastric cancer. We simulated the change in transmissibility consistent with the incidence of gastric cancer and duodenal ulcer over time, as well as current H. pylori prevalence. In the United States, transmissibility of H. pylori has decreased to values so low that, should this trend continue, the organism will disappear from the population without targeted intervention; this process, however, will take more than a century.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Emerging Infectious Diseases
Authors
Ross D. Shachter
Douglas K. Owens
Julie Parsonnet

The TECH project is an international collaboration aimed at understanding patterns of technology adoption and diffusion of medical care and the effects of these patterns on patient outcomes. The team, organized from 17 developed countries, is exploring whether individuals living in countries that rapidly adopted new revascularization technologies and clot-dissolving drugs are more likely to survive heart attacks than individuals living in countries that have adopted such interventions more slowly.

The TECH project has three specific goals:

Grant Building, Room S156
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Professor of Medicine (Infectious Diseases and Geographic Medicine) and of Health Research and Policy
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Stanford Health Policy Associate

Encina Commons,
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Professor, Health Policy
Professor, Medicine (Cardiovascular Medicine)
Professor, Epidemiology & Population Heath (by courtesy)
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Mark Hlatky is a Professor of Health Policy and a Professor of Medicine (Cardiovasular Medicine) at the Stanford University School of Medicine. His major interests are in outcomes research, evidence-based medicine, and cost-effectiveness analysis. He introduced data collection about economic and quality of life endpoints in several randomized trials, principally trials of therapies for cardiovascular disease.

Hlatky received his MD from the University of Pennsylvania, and, after residency at the University of Arizona, studied as a Robert Wood Johnson Clinical Scholar at the University of California, San Francisco. He trained in cardiology at Duke University Medical Center, and then joined the Duke faculty. He has been at the Stanford University School of Medicine since 1989.

VA Palo Alto Medical Center
111C Cardiology
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Professor of Medicine (Cardiovascular) and Professor by courtesy of Health Research and Policy at the VA Palo Alto Health Care System
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Paul Heidenreich MD, MS is Professor and Vice-Chair for Clinical, Quality, and Analytics in the Department of Medicine. He also directs VA's Quality Enhancement Research Initiative (QUERI) in Medication Management and the Echocardiography Laboratory at the VA Palo Alto Health Care System. His research focuses on interventions to improve the quality of care for heart disease patients; the use of echocardiography to predict prognosis; the cost-effectiveness of new cardiovascular technologies; and outcomes research using existing clinical and administrative data. His administrative efforts focuses on measuring, improving, and disseminating the quality of care provided by faculty in the Department of Medicine.

Stanford Health Policy Associate
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Irving Schulman, MD Endowed Professor in Child Health
Professor of Pediatrics and of Medicine
thomas-n-robinson-thumb.jpg MD, MPH

Thomas N. Robinson, MD, MPH is the Irving Schulman, MD Endowed Professor in Child Health, Professor of Pediatrics and of Medicine, in the Division of General Pediatrics and the Stanford Prevention Research Center at Stanford University School of Medicine, and Director of the Center for Healthy Weight at Stanford University and Lucile Packard Children's Hospital at Stanford. Dr. Robinson focuses on "solution-oriented" research, developing and evaluating health promotion and disease prevention interventions for children, adolescents and their families to directly inform medical and public health practice and policy.

His research is largely experimental in design, conducting school-, family- and community-based randomized controlled trials to test the efficacy and/or effectiveness of theory-driven behavioral, social and environmental interventions to prevent and reduce obesity, improve nutrition, increase physical activity and decrease inactivity, reduce smoking, reduce children's television and media use, and demonstrate causal relationships between hypothesized risk factors and health outcomes. Robinson's research is grounded in social cognitive models of human behavior, uses rigorous methods, and is performed in generalizable settings with diverse populations, making the results of his research more relevant for clinical and public health practice and policy.

His research is published widely in the peer-reviewed scientific literature. Robinson received both his B.S. and M.D. from Stanford University and his M.P.H. in Maternal and Child Health from the University of California, Berkeley. He completed his internship and residency in Pediatrics at Children's Hospital, Boston and Harvard Medical School, and then returned to Stanford for post-doctoral training as a Robert Wood Johnson Clinical Scholar. Robinson joined the faculty at Stanford in 1993, was appointed Assistant Professor in 1996, and promoted to Associate Professor with tenure in 2003. He was a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar, was a member of the Institute of Medicine's Committees on Prevention of Obesity in Children and Adolescents and Progress in Preventing Childhood Obesity, and is Principal Investigator on numerous prevention studies funded by the National Institutes of Health. Dr. Robinson also is Board Certified in Pediatrics, a fellow of the American Academy of Pediatrics, and practices General Pediatrics at Lucile Packard Children's Hospital at Stanford.

Stanford Health Policy Associate

Sequoia Hall, Room 228 
390 Serra Mall 
Stanford, CA 94305 

Assistant: Bonnie Chung 
bchung@stanford.edu

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Professor of Biomedical Data Science, Emeritus
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Professor Olshen is a Fellow of The Institute of Mathematical Statistics, The American Statistical Association, The American Association for the Advancement of Science, and The Institute of Electrical and Electronics Engineers.  He is an elected member of the International Statistical Institute. He has been a Guggenheim Fellow and the recipient of a Research Scholar in Cancer Award from the American Cancer Society. His interests include the development of statistical methods for prediction and the assessment of accuracy. He is one of the developers of CARTª binary tree-structured methods for classification, regression, and probability class estimation and of their extensions to survival analysis and clustering. In collaboration with others, he has studied these algorithms theoretically and has applied them to the computer-aided diagnosis of heart attack, as well as to making prognoses for patients with lymphoma, extracting features of organic compounds that tend to make them ulcerogenic, to data compression and the automated detection attempt to find the genes that predispose to hypertension, and to the definition of health states in health services research. His current research also involves the development of parsimonious models for describing longitudinal data, especially as they apply to understanding autoimmune disease of the kidney. Typically, these consist of the sum of an overall mean function and subject-specific coefficients of suitably smoothed eigenfunctions of residuals. In the past, he collaborated with Alan Garber in developing technologies for tracking cholesterol longitudinally in time and quantifying the accuracy of findings. Their ideas are now finding wide-ranging application.

Stanford Health Policy Associate

Stanford University School of Medicine
1000 Welch Road, Suite #203
Palo Alto, CA 94304-1808

(650) 723-5906 (650) 723-9656
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Berthold and Belle N. Guggenhime Professor of Medicine, Emeritus
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Halsted Holman is the Berthold and Belle N. Guggenhime Professor of Medicine, Emeritus, and a CHP/PCOR associate. He was Chairman of the Department of Medicine and Director of the Clinical Scholar Program (CSP) at Stanford. His major research interests include the design, organization, and evaluation of experimental health care systems, studies of the effects of patient education programs on health outcomes in chronic disease, and inquiry into the roles of patients in clinical trials and clinical practice. He is a former President of the American Society for Clinical Investigation and the Western Association of Physicians.

Stanford Health Policy Associate
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