Financial information at district level: experiences from five countries

Management information systems are intended to help managersmake decisions. But few management information systems in primaryhealth care include information on costs, even though resourceallocation and budgeting are key functions of primary healthcare managers. Drawing on five papers presented to a WHO conferenceon strengthening district health systems, this article illustratesthe potential usefulness of financial data to district managers.The examples come from individual districts in Ethiopia, Indonesia,Kenya, Sri Lanka and Tanzania.No original data were collectedfor the studies - much can be learned from budgets and expenditureledgers. Some problems were encountered with the reliabilityof the data - a particular confusion was between allocated andrealized budgets. Allocated budgets area stated intention tospend money; realized budgets show that the expenditure actuallyoccurred. For planning purposes, realized amounts are of moreinterest.Managers can use financial information to questionthe allocation of resources in various ways. Providing informationon how much is being spent on what activities enables an explicitconsideration of the desirability of the existing use of resources,relative to priorities. Comparing unit costs can raise questionsabout the relative efficiency of different units, be they healthcentres, vaccination points or wards. Looking at the distributionof resources according to geographical areas, or other waysof grouping people, provides background data for the considerationof equity. Finally, the paper discusses how financial informationmight be used to identify areas of wastage.The paper concludesthat health systems already produce a good deal of financialinformation. At present, however, this information is oftenonly used by accountants or finance officers. Financial informationshould be incorporated into the larger management informationsystem.     

Multiparametric Analysis of Heart Rate Variability Used for Risk Stratification Among Survivors of Acute Myocardial Infarction

A multiparametric heart rate variability analysis was performed to prove if combined heart rate variability (HRV) measures of different domains improve the result of risk stratification in patients after myocardial infarction. In this study, standard time domain, frequency domain and non-linear dynamics measures of HRV assessment were applied to 572 survivors of acute myocardial infarction. Three parameter sets each consisting of 4 parameters were applied and compared with the standard measurement of global heart rate variability HRVi. Discriminant analysis technique and t-test were performed to separate the high risk groups from the survivors. The predictive value of this approach was evaluated with receiver operator (ROC) and positive predictive accuracy (PPA) curves. Results - The discriminant analysis shows a separation of patients suffered by all cause mortality in 80% (best single parameter 74%) and sudden arrhythmic death in 86% (73%). All parameters of set I show a high significant difference (p<0.001) between survivors and non-survivors based on two-tailed t-test. The specificity level of the multivariate parameter sets is at the 70% sensitivity level (ROC) about 85–90%, whereas HRVi shows maximum levels of 70%. The PPA in the all cause mortality group is at the 70% sensitivity level twice as high as the univarihate HRV measure and increases to more than fourfold as high within the VT/VF group. In conclusion, in this population, the multiparametric approach with the combination of four parameters from all domains especially from NLD seems to be a better predictor of high arrhythmia risk than the standard measurement of global heart rate variability.     

T Wave Complexity in Patients with Hypertrophic Cardiomyopathy

The complexity of the T wave assessed by principal component analysis (PCA) has been proposed to reflect obnormal repolarization, which may be arrhythmogenic. To determine whether PCA can differentiate patients with hypertrophic cardiomyopathy (HCM) from normal subfects and whether PCA is of prognostic importance in HCM, 112 patients with HCM (41 ±14 years, 64 males) and 72 healthy subjects (39 ± 9 years, 41 males) were studied. Patients with sinus node dysfunction, AV conduction block, flat T waves, QRS > 140 ms, and those < 15 years were excluded from this study. Standard 12-lead ECGs were recorded digitally using the MAC-VU system (Marquette Medical Systems). PCA parameters were computed using the QT Guard software package by Marquette. PCA ratio was significantly greater in HCM patients than in normal controls (23.9%± 12.4% vs 16.1%± 7.6%, P < 0.0001) and was correlated with QT-end dispersion (r = 0.24. P = 0.01) and QT peak (Q point to T peak) dispersion (r = 0.35, P < 0.0001). HCM patients with syncope (n = 23) had increased PCA ratios compared with those without syncope (29.1%± 11.5% vs 22.5%± 12.3%, P = 0.01). PCA ratio was similar in patients with and without nonsustained ventricular tachycardia on Holter (25.9%± 11.4% vs 22.7%± 12.1%, P = 0.2), as well as in patients treated with amiodarone or sotalol versus those not on therapy. In conclusion, assessment of the complexity of the T wave by PCA differentiates HCM patients from normal subjects. PCA ratio correlated with QT dispersion and an increased PCA ratio was associated with a history of syncope in HCM.     

Comparative Reproducibility of QT, QT Peak, and T Peak-T End Intervals and Dispersion in Normal Subjects, Patients with Myocardial Infarction, and Patients with Hypertrophic Cardiomyopathy

Abnormal repolarizaiion is associated with arrhythmogenesis. Because of controversies in existing methodology, new computerized methods may provide more reliable tools for the noninvasive assessment of myocardial repolarization from the surface electrocardiogram (ECC). Measurement of the interval between the peak and the end of the T wave (TpTe interval) has been suggested for the detection of repolarization abnormalities, but its clinical value has not been fully studied. The intrasubject reproducibility and reliability of automatic measurements of QT, QT peak, and TpTe interval and dispersion were assessed in 70 normal subjects, 49 patients with acute myocardial infarction (5th day; MI), and 37 patients with hypertrophic cardiomyopathy (HC). Measurements were performed automatically in a set of 10 ECCs obtained from each subject using a commercial software package (Marquette Medical Systems, Milwaukee, WI, U.S.A.). Compared to normal subjects, all intervals were significantly longer in HC patients (P < 0.001 for QT and QTp; p < 0.05 for TpTe); in MI patients, this difference was only significant for the maximum QT and QTp intervals (P < 0.05). In both patient groups, the QT and QTp dispersion was significantly greater compared to normal subjects (P < 0.05) but no consistent difference was observed in the TpTe dispersion among all three groups. In all subjects, the reproducibility of automatic measurement of QT and QTp intervals was high (coefficient of variation, CV, 1%-2%) and slightly lower for that of TpTe interval (2%–5%; p < 0.05). The reproducibility of QT, QTp, and TpTe dispersion was lower (12%–24%, 18%–28%, 16%–23% in normal subjects, MI and HC patients, respectively). The reliability of automatic measurement of QT, QTp, and TpTe intervals is high but the reproducibility of the repeated measurements of QT, QTp and TpTe dispersion is comparatively low.     

The Effect of Age on the Electrophysiological and Autonomic Correlates of Sudden Death After Acute Myocardial Infarction

To examine the influence of age on the autonomic and electrophysiological correlates of sudden death after myocardial infarction, 223 patients aged <60 and 195 patients aged ≥60 were followed up for a mean of 790 days. The patients had Holter monitoring and a signal-averaged EGG 5–11 days after infarction. A mean ventricular ectopic beat frequency >10 beats/ hour (VE10) was present in 17.0% of young versus 28.2% of old patients (P < 0.01); a low heart heart variability index in 17.9% of young but in 32.3% of old patients (P < 0.001) and late potentials in 17.5% but 32% of young and old patients, respectively (P < 0.01). There was no difference in the incidence of sudden death between young and old patients (3.6% vs 3.1%). However, sudden death accounted for 50%, compared with 24% of all deaths in the young and old groups, respectively (P < 0.01). Sudden death was more closely associated with low heart rate variability and VE10 in the young than in the older group. The predictive values of a heart rate variability index <20 units with VE10 in younger patients were a sensitivity of 50%, a positive predictive accuracy (PPA) of 33% and risk ratio (RR) of 18 (P < 0.001); these values did not reach significance in older patients (16.7%, 4.3% and 1.4%, respectively.) Late potentials had a sensitivity of 50%, a PPA of 12.1%, and an RR of 4.7 in young patients (P < 0.05): the corresponding values in the older group were 80%, 8.9, and 8.4 (P < 0.02). It is concluded that sudden death is a more predominant mode of death and is more strongly associated with lower heart rate variability and with the VE10 incidence in young than in older postinfarction patients. Age should be taken into account when assessing the risk of sudden death after myocardial infarction.     

Assessment of Noise in Digital Electrocardiograms

BATCHVAROV, V., et al. : Assessment of Noise in Digital Electrocardiograms. Technically related noise in 12-lead ECGs recorded with ambulatory recorders has never been systematically compared with that in ECGs recorded with conventional ECGs. This study compared serial 10-second ECGs obtained in ten healthy men, age 22–45 years, who were recorded in the supine resting position using a (1) MAC VU recorder, (2) digital ambulatory SEER MC recorder with a Multi-Link detachable ECG cable, and (3) digital ambulatory SEER MC recorder with a light ambulatory ECG cable. In each ECG, averaged sinus rhythm cycles of the entire recording were realigned with the native signal and subtracted. The resulting "residuum" was quantified by computing its standard deviation and root mean square of successive differences (RMSSD). While the RMSSD residuum values were significantly lower with the MAC VU recorder (  6.27 ± 0.98 μV  ) than with the SEER MC recorder with either ECG cables (  7.29 ± 1.31 and 7.17 ± 1.31 μV, P < 0.003 and p < 0.02  ), the difference was practically negligible and there was no detectable difference in the standard deviation residuum values. The study concludes that valid ECG investigations of serial ECG testing may be conducted using the ambulatory SEER MC recorders providing the biological sources of ECG noise are controlled. The available technology for noise assessment suggests that studies involving advanced analysis of serial ECGs (e.g., of drug related changes), should incorporate objective characterisation of ECG quality.     

Termination of Macro-Reentrant Tachycardia by a Single Extrastimulus Delivered During the ''Effective'' Refractory Period: A Computer Modeled ''Case Report''

A computer model of cardiac excitation sequences was used to reproduce atrioventricular (AV) reentrant tachycardia (AVRT) and its termination by a single 'on-circuit' extrastimulus. The model simulated activation waves revolving along a one-dimensional circular pathway, the portions of which represented the atrial, AV nodal, His-Purkinje, ventricular, and accessory pathway sections of the tachycardia circuit. The modeled pathway was composed of 289 elements. The model distinguished only the depolarised and resting states of constituent elements, but introduced differential refractoriness and conduction velocity for each element. These values approximated the natural situation established in a patient suffering from AVRT associated with the right bundle branch block. The results of the study suggest that: (A) the usual impression of a regular recovery wave and of a regular excitable window moving uniformly along the macro-reentrant circular path is incorrect; (B) during the tachycardia, islands of repolarized cells appear which are surrounded by tissue that is still refractory; (C) an extrastimulus which captures the island of early repolarized tissue may cause an excitation restricted to a small part of the myocardium but the local refractoriness following such an extrastimulus may be sufficient to terminate the tachycardia.