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.

BACKGROUND: Although evidence suggests that a higher hemodialysis dose and/or frequency may be associated with improved outcomes, the cost-effectiveness of a daily hemodialysis strategy for critically ill patients with acute kidney injury (AKI) is unknown. METHODS: We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of daily hemodialysis, compared with alternate-day hemodialysis, for patients with AKI in the intensive care unit (ICU). We employed a societal perspective with a lifetime analytic time horizon. We modeled the efficacy of daily hemodialysis as a reduction in the relative risk of death on the basis of data reported in the 2004 clinical trial published by Schiffl et al. We performed 1- and 2-way sensitivity analyses across cost, efficacy, and utility input variables. The main outcome measure was cost per quality-adjusted life-year (QALY). RESULTS: In the base case for a 60-year-old man, daily hemodialysis was projected to add 2.14 QALYs and $10,924 in cost. We found that the cost-effectiveness of daily hemodialysis compared with alternate-day hemodialysis was $5084 per QALY gained. The incremental cost-effectiveness ratio became less favorable (>$50,000 per QALY gained) when the maintenance hemodialysis rate of the daily hemodialysis group was varied to more than 27% and when the difference in 14-day postdischarge mortality between the alternatives was varied to less than 0.5%. CONCLUSION: Daily hemodialysis is a cost-effective strategy compared with alternate-day hemodialysis for patients with severe AKI in the ICU.

BACKGROUND AND OBJECTIVES: Because there is wide variation in case-mix adjusted outcomes across dialysis facilities, it is possible that top-performing facilities use practices not shared by others. We sought to catalogue "best practices" that may account for interfacility variations in outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This multidisciplinary study identified candidate best practices in dialysis through a staged process, including systematic review, cognitive interviews, and a national "virtual focus group" of dialysis providers. The resulting candidate practices were rank-ordered by perceived importance as determined by mean RAND Appropriateness Scores from a national survey of nephrologists, nurses, and opinion leaders. RESULTS: A total of 155 candidate best practices were identified. Among these, respondents believed dialysis outcomes are most strongly related to 1) characteristics of multidisciplinary care conferences, 2) technician proficiency in protecting vascular access, 3) training of nurses to provide education in fluid management, vascular access, and nutrition, 4) use of random and blinded audits of staff performance, and 5) communication and teamwork among staff. In contrast, there was wide disagreement about the importance of facility-based health maintenance practices, optimal staffing ratios, frequency of dialysis-based physician visits, and optimal frequency of multidisciplinary care. CONCLUSIONS: This study provides a "conceptual map" of candidate dialysis best practices and highlights areas of general agreement and disagreement. These findings can help the dialysis community think critically about what may define "best practice" and provide targets for future research in quality improvement.

It's a girl! My doctor's long-awaited pronouncement heralded one of the most joyous moments of my life. More surprising for this first-time mother was the extent to which so many people shared in our enthusiasm. Not just family and friends but my employer, banker, the owner of the local Chinese restaurant, even the farmers at the local farmer's market. They sent gifts, cards, and messages to demonstrate their affection for the precious addition to our family. The notable exception in this celebration was my health maintenance organization (HMO). When an HMO representative called, it was to deny financial responsibility for my daughter's care.

I have devoted the past ten years of my career to working on ways to make a private, employer-based health care system work more effectively. I believe that HMOs can be part of the solution. From 1997 to 1998 I directed the staff work for the chair of the California Managed Health Care Improvement Task Force. The following year I led a study aimed at improving health coverage decision making in California. To learn that I had been denied health care services was personally disappointing and, considering my professional expertise, ironic. We all hear stories of coverage and claims denials, but when it happened to me, I understood the intense anger people feel about these episodes. My experience resulted in a clearer understanding of why HMOs are so widely disliked.

To understand "managed care," one needs to understand the traditional model of health care organization and finance that managed care was intended to replace. That model was aptly characterized "Guild Free Choice" by Charles Weller to indicate that "free choice" was being used as a restraint of trade to block the emergence of any form of economic competition among doctors. Its principles were: "Free choice of doctor at all times;" "free choice of treatment, i.e. nobody 'interferes with the doctor's decisions and recommendations;'" "fee for service payment;" "direct doctor-patient negotiation of fees;" and "solo (or small single-specialty group) practice." The model was widely accepted because of the pre-Wennberg view of most people that "the medical care they receive [is] a necessity provided by doctors who adhere to scientific norms based on previously tested and proven treatments." In combination with well-insured patients, there was no way that employers or insurers could control health spending in this model. Organized medicine is still fighting to hold on to parts of it. Some people say that managed care is "anything other than Guild Free Choice."

Private health plans and government health insurance programs in the United States base their coverage decisions on evidence criteria, rather than explicit cost-effectiveness criteria. As health spending continues to grow rapidly, however, approaches to coverage policy that ignore costs fail to meet the needs of consumers, employers, health plans, and federal and state governments. I describe the role of evidence-based criteria in formal coverage decision making and contrast the ways that these criteria differ from cost-effectiveness criteria. Finally, I discuss options for incorporating considerations of cost-effectiveness into coverage policy and other aspects of benefit design.