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Aims As health systems around the world increasingly look to measure and improve the value of care that they provide to patients, being able to measure the outcomes that matter most to patients is vital. To support the shift towards value-based health care in atrial fibrillation (AF), the International Consortium for Health Outcomes Measurement (ICHOM) assembled an international Working Group (WG) of 30 volunteers, including health professionals and patient representatives to develop a standardized minimum set of outcomes for benchmarking care delivery in clinical settings. Methods and results Using an online-modified Delphi process, outcomes important to patients and health professionals were selected and categorized into (i) long-term consequences of disease outcomes, (ii) complications of treatment outcomes, and (iii) patient-reported outcomes. The WG identified demographic and clinical variables for use as case-mix risk adjusters. These included baseline demographics, comorbidities, cognitive function, date of diagnosis, disease duration, medications prescribed and AF procedures, as well as smoking, body mass index (BMI), alcohol intake, and physical activity. Where appropriate, and for ease of implementation, standardization of outcomes and case-mix variables was achieved using ICD codes. The standard set underwent an open review process in which over 80% of patients surveyed agreed with the outcomes captured by the standard set. Conclusion Implementation of these consensus recommendations could help institutions to monitor, compare and improve the quality and delivery of chronic AF care. Their consistent definition and collection, using ICD codes where applicable, could also broaden the implementation of more patient-centric clinical outcomes research in AF.

We have shown previously that apolipoprotein A (apoA)-I-containing high-density lipoprotein (HDL) particles are formed by the conjugation of lipid-free apoA-I with lipids derived from other lipoprotein fractions in a process dependent on non-esterified fatty acids, generated by the lipolysis of very-low-density lipoprotein (VLDL) or provided exogenously. In the present study, we show that this process is also able to generate HDL particles containing apoA-II (A-II HDL) and both apoA-I and apoA-II (A-I/A-II HDL). When lipid-free apoA-II was incubated with either VLDLs and lipoprotein lipase or LDLs and sodium oleate, a significant proportion of the apoA-II was recovered in the HDL density fraction. This was associated with the formation of several populations of HDL-sized particles with pre-β2 electrophoretic mobility, which contained phospholipids and unesterified cholesterol as their main lipid constituents. When both lipid-free apoA-I and lipid-free apoA-II were incubated with LDL and sodium oleate, both apolipoproteins were recovered in HDLs that contained phospholipids and unesterified cholesterol as their main lipids. Two populations of particles had diameters of 7.4 and 10.8 nm and pre-β2-migration; there was also a population of pre-β1-migrating particles of diameter 4.7 nm. ApoA-I and apoA-II were both present in the larger HDLs, whereas only apoA-I was present in the smaller particles. Immunoaffinity chromatography on an anti-(apoA-I)–Sepharose column revealed that 10–20% of the apoA-II resided in particles that also contained apoA-I. The majority of the A-I/A-II HDL were present in a population of pre-β2 particles of 10.8 nm diameter. These results in vitro illustrate a potential mechanism for the formation of HDLs containing both apoA-I and apoA-II.

Suitably structured computer programmes are effective in helping clinicians understand electrocardiography and interpret ECGs.

Background: Student teaching of surgery has been devolved from the university in an effort to increase and broaden undergraduate clinical experience. In order to ensure uniformity of learning we have defined learning objectives and provided a computerbased package to supplement clinical teaching. A study was undertaken to evaluate the place of computer-based learning in a clinical environment. Methods: Twelve modules were provided for study during a 6-week attachment. These covered clinical problems related to cardiology, neurosurgery and gastrointestinal haemorrhage. Eighty-four fourth-year students undertook a pre-and post-test assessment on these three topics as well as acute abdominal pain. No extra learning material on the latter topic was provided during the attachment. Results: While all students showed significant improvement in performance in the post-test assessment, those who had access to the computer material performed significantly better than did the controls. Within the topics, students in both groups performed equally well on the post-test assessment of acute abdominal pain but the control group's performance was significantly lacking on the topic of gastrointestinal haemorrhage, suggesting that the bulk of learning on this subject came from the computer material and little from the clinical attachment. Conclusions: This type of learning resource can be used to supplement the student's clinical experience and at the same time monitor what they learn during clinical clerkships and identify areas of weakness.

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If not diagnosed by history, examination, or ECG, the diagnosis of syncope can be difficult with a low yield from echocardiography, ambulatory ECG recording, electrophysiological study, and tilt table testing. During 2 years, 48 patients with unexplained syncope or presyncope from three hospitals in one city underwent the implantation of a Medtronic Reveal implantable loop recorder capable of cardiac monitoring for 14 months. All patients had at least two prior episodes of syncope or presyncope. Fifty-two percent of patients had electrophysiological studies, all of which were negative. The implantable loop recorder remained implanted until a diagnostic event was recorded, or until the end of the battery life. After a mean follow-up of 5.6 +/- 5.7 months, symptoms reoccurred in 25 (52.1%) patients at a mean of 2.8 +/- 2.1 months after insertion of an implantable loop recorder. No further symptoms occurred in 23 (47.9%) patients. Of the 25 patients who had a symptom and recorded an event, an arrhythmia was seen in 10 (40%) patients. Seven patients had bradycardia; 4 with profound sinus bradycardia/sinus arrest, 1 with complete heart block, and 2 in association with the cardioinhibitory component of vasovagal syncope. Three patients had tachycardias; two with supraventricular tachycardia and one with atrialflutter. Fifteen (60%) of the 25 patients who activated their device due to syncope or presyncope were in sinus rhythm during the event. The implantable loop recorder was effective in making a cardiological or noncardiological diagnosis for unexplained syncope or presyncope in 52.1% of the patients.

Billing and insurance-related costs are a significant source of wasteful health care spending in Organization for Economic Cooperation and Development nations, but these administrative burdens vary across national systems. We executed a microlevel accounting of these costs in different national settings at six provider locations in five nations (Australia, Canada, Germany, the Netherlands, and Singapore) that supplements our prior study measuring the costs in the US. We found that billing and insurance-related costs for inpatient bills range from a low of $6 in Canada to a high of $215 in the US for an inpatient surgical bill (purchasing power parity adjusted). We created a taxonomy of billing and insurance-related activities (eligibility, coding, submission, and rework) that was applied to data from the six sites and allows crossnational comparisons. Higher costs in the US and Australia are attributed to high coding costs. Much of the savings achieved in some nations is attributable to assigning tasks to people in lower-skill job categories, although most of the savings are due to more efficient billing and insurance-related processes. Some nations also reduce these costs by offering financial counseling to patients before treatment. Our microlevel approach can identify specific cost drivers and reveal national billing features that reduce coding costs. It illustrates a valuable pathway for future research in understanding and mitigating administrative costs in health care.