Faculty Bibliography

The value and necessity of performing right heart catheterizations for coronary artery disease have been increasingly questioned. Preliminary analyses of the procedure among Medicare and Medicaid patients in New York State revealed significant inter-hospital variations in the frequencies with which such catheterizations were performed. These data suggested that right heart catheterizations (RHC) were being performed routinely. Medicare and Medicaid claims data for bilateral catheterizations were analyzed before and after an educational intervention program involving the state's 53 catheterization laboratories. The educational intervention was multifaceted and consisted of disseminating suggested guidelines established with the assistance of the New York State Chapter of the American College of Cardiology, the Committee on Cardiovascular Disease of the Medical Society of the State of New York, and the Cardiac Advisory Council of the New York State Department of Health. Posteducational intervention assessments were made over a 4-year period. The baseline data for 1992 demonstrated that 10 (18.4%) laboratories had performed RHC routinely (70-100%) on Medicare and Medicaid patients undergoing catheterization. In contrast, 34 (64.2%) laboratories performed RHC in less than 20% of their Medicare cases, whereas 39 (73.5%) did so among Medicaid cases. Eighteen (34%) laboratories performed RHC in less than 10% of Medicare cases. These data indicated that there was significant inter-hospital variation in the frequency with which RHC was performed. Beginning in 1993, ongoing educational meetings and conferences were held with all laboratories, but especially with the 10 that were at the high end of the RHC performance level. As a result of this ongoing intervention, the rate of RHC among Medicare patients fell from 89/100,000 in 1992 to 65/100,000 beneficiaries in 1996. From another perspective, the percentage of catheterized Medicare patients undergoing RHC fell from 30.5% in 1992 to 17.4% in 1996. The decline among the 10 laboratories was even more dramatic; the percentage of catheterized Medicare patients undergoing RHC fell from 89.1% in 1992 to 31.6% in 1996. The parallel drop for Medicaid patients over the same time period was from 92.8 to 32.7%. The results of the study indicate that many previously performed RHC in patients with coronary artery disease were routine and not medically indicated. The dramatic decreases in RHC documented in this study over a 4-year period demonstrate the success of quality improvement efforts jointly undertaken by providers and a peer review organization

In June 1955, following his college graduation, David Halberstam tossed a suitcase into his banged-up Chevy and headed south to begin his journalistic career. His first job, at a small-town Mississippi newspaper, lasted less than a year. He was fired for publishing some freelance pieces sympathetic to the emerging civil rights movement. But he landed a position at The Nashville Tennessean, one of the region's most influential newspapers. Though Tennessee bordered the Deep South, racial repression there did not approach the levels of Mississippi and Alabama. The state's senators, Albert Gore Sr. and Estes Kefauver, had refused to sign the infamous "Southern Manfesto," which preached resistance to court-ordered integration, while Gov. Frank Clement had staked out a moderate position on racial issues. Nashville, the state capital, was home to several black colleges, the progressive Vanderbilt Divinity School and a newspaper that covered civil rights in an objective manner. It seemed a model of racial harmony. In 1959, the Vanderbilt Divinity School admitted two blacks as a token gesture, and Nashville would never be the same. One of these students was James Lawson, the key player in "The Children," Halberstam's powerful, densely packed, often unwieldy account of the "Nashville kids" who were instrumental in sparking the civil rights movement and helping to bring legal segregation to its knees. The son of an Ohio minister, Lawson went to Federal prison during the Korean War for refusing to register for the draft. Committed to the pacifist teachings of A. J. Muste, he worked for three years as a missionary in India, learning about nonviolent activism from Gandhi's disciples. Arriving in Nashville, Lawson supplemented his religious studies at Vanderbilt with a workshop designed to train local students for the struggle against racial injustice. He was, Halberstam notes, "as absolutely clear in his mission as he was of his own vision of what America should be."