From the Department of Epidemiology and Public Health (V.V., H.K., S.K.,
C.W.), the Department of Internal Medicine, Section of Cardiovascular Medicine
(H.K., J.M.), Yale University School of Medicine, New Haven, Connecticut; the
Yale-New Haven Hospital Center for Outcomes Research and Evaluation (H.K.),
New Haven, Connecticut; the Connecticut Peer Review Organization, Middletown,
Connecticut (H.K.); the Department of Medicine, Division of Cardiology,
Vanderbilt University School of Medicine (J.B.), Nashville, Tennessee; Rush
Institute on Aging (C.M.), Chicago, Illinois; the Ethel Percy Andrus
Gerontology Center (T.S.), University of Southern California, Los Angeles,
California; and the Department of Health and Social Behavior (L.B.), Harvard
School of Public Health, Boston, Massachusetts.
Methods and Results—We reviewed the medical records of 292
subjects aged
Conclusions—Among elderly patients hospitalized with clinical
heart failure, the absence of emotional support, measured before
admission, is a strong, independent predictor of the occurrence of
fatal and nonfatal cardiovascular events in the year
after admission. In this cohort, the association is restricted to
women.
Several studies have indicated that a variety of social relationships
are important predictors of morbidity and mortality in patients with
coronary artery disease.4 5 However,
relatively little attention has been focused on the prognostic
importance of these factors in the growing population of elderly
patients with heart failure. We were particularly interested in the
prognostic importance of emotional support (measure of the presence of
intimate contacts) because it had previously been shown to be a
prognostic factor in elderly patients with an acute myocardial
infarction.6 Accordingly, our specific objective
was to determine whether emotional support is associated with fatal and
nonfatal cardiovascular events in elderly patients
admitted with clinical heart failure. To address this objective, we
combined information from a longitudinal, community-based study of
aging that included a comprehensive assessment of psychosocial support
and a thorough follow-up for adverse events7 with
information from hospitalizations for heart failure, based on detailed
medical record review.
The study sample for these analyses was restricted to patients
in the New Haven EPESE cohort who were hospitalized with heart failure.
Throughout the study, the records of the two New Haven hospitals
(Yale-New Haven Hospital and the Hospital of St Raphael) were reviewed
regularly to identify hospital admissions. We previously determined
that >90% of the hospitalizations for this cohort occurred at these
two facilities.
The patients enrolled in EPESE who were admitted to the New Haven
hospitals with a discharge diagnosis (principal or one of the first
three secondary diagnoses) of heart failure (International
Classification of Diseases, Clinical Modification, Ninth Revision
[ICD-9-CM] code 428) between the beginning of the study in 1982 and
December 31, 1992, were identified and their records were reviewed
in detail. In addition, Medicare Part A beneficiary data from the
Health Care Financing Administration, available since 1985, were
matched with EPESE subjects to obtain further information on heart
failure admissions. The diagnosis of heart failure in these subjects
was confirmed, through medical chart review, by the presence of
symptoms of heart failure, and either physical or
radiographic findings consistent with heart failure
in the first day of admission.
Interviews Before the Hospitalization for Heart Failure
Psychosocial Assessments
Emotional support was measured by responses to the following question:
"Can you count on anyone to provide you with emotional support
(talking over problems to help you with a difficult decision)?" The
subjects replied "yes," "no," or that they had "no need" of
emotional support. For the patients who responded "yes," a
follow-up question inquired about the number of sources of support.
Instrumental support was measured using the following question: "When
you need some extra help, can you count on anyone to help with daily
tasks like grocery shopping, house cleaning, cooking, telephoning,
giving you a ride?" The responses were coded as "yes," "no,"
or "no need" of help. For the patients who responded "yes," a
follow-up question inquired about the number of sources of support.
The extent that subjects maintained social connections or ties
was assessed at the same time.8 Specifically,
subjects were asked about marital status, contact with friends and
relatives, membership in religious organizations, and participation in
voluntary groups. The measure was used as a count of social ties (coded
for this analysis as 0,
Depressive symptoms were assessed using the Center for Epidemiologic
Study Depressive Symptomatology Questionnaire. This scale has 20 items
with a scale ranging from 0 to 60. Based on previous studies, it is a
reliable indicator of depressive symptoms in elderly
populations.9
Functional Status
Medical Record Review
Outcome Events
Statistical Analysis
We conducted the multivariable analysis using two
approaches to evaluate the independent association of emotional support
with the occurrence of cardiovascular events. First,
using the variables from the bivariate analysis, we
developed a multivariable logistic regression model with stepwise
selection to predict the occurrence of a cardiovascular
event within 1 year after admission, using an exit level of
P<.10. Age was forced into the model at each step. For the
multivariable analysis, we selected logistic regression
because visual inspection of event curves suggested that they did not
satisfy the assumption of proportionality that is required for the use
of proportional hazards models.
Next, we more formally tested the association of emotional support with
the outcome of cardiovascular events within 1 year of
admission with a series of hierarchical logistic regression models. In
the first model, we included emotional support (no support compared
with any support; an indicator variable was used for patients who
responded that they had no need for emotional support) as the sole
explanatory variable. In the second model, we included emotional
support and demographic variables (age, sex, and race) as
explanatory variables. In the third model, we added clinical
severity variables (ejection fraction, acute physiology score
[quartiles], history of myocardial infarction, and current myocardial
infarction) that were associated with the outcome. In the fourth model,
we added comorbidity (presence of stroke, diabetes, chronic obstructive
pulmonary disease, dementia, chronic renal failure, or tumor)
and functional status variables (limitations in activities of daily
living or gross mobility). Finally, we added two other psychosocial
factors (instrumental support and social ties).
Using the final model, we checked for interactions between emotional
support and sex, age, ejection fraction, and presence of an acute
myocardial infarction. We also used the same hierarchical models to
evaluate the association between emotional support and the secondary
outcome variables.
We repeated the analysis in several ways to be certain that the
results were not dependent on any single factor concerning the assembly
of the study sample or the definition of the variable. First, we
repeated the final model after excluding patients who had been admitted
with an acute myocardial infarction to ensure that the result was not
dependent on this group. We also repeated the model after combining
patients who stated that they did not need emotional support with those
who explicitly stated that they did not have any emotional support.
For all models, we constructed and examined partial residual plots to
evaluate potential problematic areas of model
fit.14 Goodness-of-fit was evaluated by comparing
fitted probabilities of 365-day cardiovascular
mortality or readmission with observed 365-day mortality within deciles
of risk and calculating the corresponding observed
At the time of admission, most of the 292 patients were between 75 and
84 years old (mean age, 80.0±7.2 years), and 57% were female. About
half of the group had a history of heart failure, and 40% had a
history of a myocardial infarction. Before the index hospitalization,
functional impairment was common, occurring in 80% of the
subjects.
Emotional Support
Outcomes
Bivariate Analysis
Patients who reported no source of support had a higher likelihood of a
cardiovascular event within 1 year of admission
(P=.02) compared with those who had sources of support. The
association between the absence of emotional support and the risk of
cardiovascular events, not present within the first
30 days after admission, became prominent over time (Table 3
Patients with no social ties had a higher rate of events than those
with ties, but the result was borderline significant (P=.1).
There was no strong association between depressive symptoms or
instrumental support and the occurrence of
cardiovascular events.
Figs 1 to 4
Multivariable Analysis
The most important clinical variables that predicted
cardiovascular events were the presence of an acute
myocardial infarction on the index admission (OR, 2.2; 95% CI, 1.2 to
4.0), an abnormal (OR, 1.6; 95% CI, 0.7 to 3.6) or missing (OR, 2.5;
95% CI, 1.2 to 5.1) left ventricular ejection fraction,
and a worse acute physiology score (OR, 1.7; 95% CI, 0.94 to 3.2). The
only comorbidity that was independently predictive of an event was a
history of hypertension (OR, 2.0; 95% CI, 1.1 to 3.6). Functional
impairment before admission (OR, 1.7; 95% CI, 0.9 to 3.3) and male sex
(OR, 2.0; 95% CI, 1.1 to 3.4) also entered the model. Age was forced
in the model but was not significantly associated with the outcome (OR,
per year 1.00; 95% CI, 0.96 to 1.04).
The test for interaction between emotional support and sex was
significant (P=.01). In the fully adjusted model, the OR for
women was 8.2 (95% CI, 2.5 to 27.2) compared with 1.0 (95% CI, 0.3 to
3.3) for men. Neither age, myocardial infarction during the index
hospitalization, nor ejection fraction had a significant interaction
with emotional support.
We repeated the analysis with several modifications to examine
the stability of our result. With the addition of covariates that could
have been potential confounders, the association became stronger. In
the final model, after adjustment for demographic factors, clinical
severity, comorbidity and functional status, social ties, and
instrumental support, the absence of emotional support had a
significant association with cardiovascular events (OR,
3.2; 95% CI, 1.4 to 7.8). The absence of emotional support remained an
important predictor of cardiovascular events if the
patients who expressed no need of emotional support were combined with
those who reported no source of support (OR, 2.6; 95% CI, 1.2 to 5.8);
the sample was restricted to the 214 patients who did not experience a
myocardial infarction (OR, 2.8; 95% CI, 1.1 to 7.5); the model was
adjusted for the number of days between the assessment of emotional
support and the index admission (OR, 3.3; 95% CI, 1.4 to 7.9); or the
outcome was cardiovascular deaths (OR, 2.6; 95% CI,
1.0 to 6.6), cardiovascular readmissions (OR, 2.5; 95%
CI, 0.9 to 7.1), or all-cause deaths (OR, 2.0; 95% CI, 0.8 to 5.0).
Emotional support was not a predictor of the 27
noncardiovascular deaths.
Second, this association was not explained by differences in clinical
severity on admission or a susceptibility to early adverse outcomes. In
fact, the converse was observed. Patients who reported no source of
emotional support tended to be admitted with less clinically severe
disease and the association with adverse outcomes was not apparent
until several months after discharge. Thus, it is unlikely that disease
severity influenced the availability of emotional support.
Third, a commonly proposed mechanism that links lack of emotional
support with poor prognosis is related to the ability of patients to
obtain tangible assistance in getting to physician appointments and
maintaining independent living (eg, obtaining groceries, cooking).
Although this is a difficult hypothesis to test, our data indicate that
neither instrumental support nor functional status mediates the
relationship between emotional support and adverse outcomes. In fact,
instrumental support (eg, getting help or assistance with activities
like grocery shopping and transportation to medical appointments) is
not a significant prognostic factor.
This study complements the previous investigation from this cohort that
established the prognostic importance of emotional support for patients
with an acute myocardial infarction.6 Not only do
we extend the observation to patients with heart failure but we also
specifically evaluate the association with
cardiovascular events and evaluate longer-term
follow-up. However, because we included all patients with clinical
heart failure, almost a fourth of our study sample had an acute
myocardial infarction during the index hospitalization. The redundancy
in study samples was minimized because of the different time frame
of the two studies, with 25% of the patients in both study samples.
Nevertheless, the results do not change when patients with an acute
myocardial infarction are excluded from our study sample.
Sex Analysis
Other Psychosocial Factors
In contrast, although other studies have focused on the prognostic
importance of depression in other patient
populations,19 20 21 we did not find depressive
symptoms to be independently associated with
cardiovascular events. Of note, our measure of
depression was based on symptoms, rather than a clinical diagnosis, and
the assessment preceded the hospitalization.
Potential Mechanisms
Interventions
Elderly patients with heart failure may gain the most benefit from
these interventions because their event rates are so high and there are
relatively few therapeutic options available to them. Recently, a trial
of a multidisciplinary intervention with psychosocial components for
patients with heart failure demonstrated a reduction in readmission
within 90 days of discharge from 42.1% to
28.9%.25 The cost of the intervention was more
than offset by the saving from the readmissions that were avoided.
Limitations
Conclusions
Received July 21, 1997;
revision received October 14, 1997;
accepted November 19, 1997.
2.
Krumholz HM, Parent EM, Tu N, Vaccarino V, Wang Y,
Radford MJ, Hennen J. Readmission after hospitalization for congestive
heart failure among Medicare beneficiaries. Arch Intern Med. 1997;157:99–104.
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Chin M, Goldman L. Correlates of major complications
or death in patients admitted to the hospital with congestive heart
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Berkman LF. The role of social relations in health
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Berkman LF, Leo-Summers L, Horwitz RI. Emotional
support and survival after myocardial infarction. Ann Intern
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Berkman LF, Berkman CS, Kasl SV, Freeman DJ Jr, Leo L,
Ostfeld AM, Cornoni-Huntley J, Brody JA. Depressive symptoms in
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The APACHE III prognostic system: risk prediction of hospital mortality
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methods for assessing logistic regression models. JASA. 1984;79:61–63.
15.
Hosmer DW, Lemeshow S. Applied Logistic
Regression. New York, NY: Wiley; 1989.
16.
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alone after myocardial infarction. JAMA. 1992;267:515–519.
17.
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18.
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and support and neuroendocrine function. Ann Behav Med. 1994;16:95–106.
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as a risk factor for cardiac events in established coronary
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© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Prognostic Importance of Emotional Support for Elderly Patients Hospitalized With Heart Failure
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—Several studies have
indicated that a variety of social relationships are important
predictors of morbidity and mortality in patients with coronary
artery disease, but little attention has been focused on the prognostic
importance of these factors in the growing population of elderly
patients with heart failure. To address this issue, we sought to
determine whether emotional support is associated with fatal and
nonfatal cardiovascular events in elderly patients
hospitalized with heart failure. 
65 years who were hospitalized with clinical heart
failure and were part of the New Haven, Conn, cohort of the Established
Population for the Epidemiologic Study of the Elderly, a longitudinal,
community-based study of aging that included a comprehensive assessment
of psychosocial support. In the unadjusted analysis, lack of
emotional support was significantly associated with the 1-year risk of
fatal and nonfatal cardiovascular outcomes [odds
ratio, 2.4; 95% confidence interval, 1.1 to 4.9]. After adjustment
for demographic factors, clinical severity, comorbidity and functional
status, social ties, and instrumental support, the absence of emotional
support remained associated with a significantly higher risk (odds
ratio, 3.2; 95% confidence interval, 1.4 to 7.8). The test for
interaction between emotional support and sex was significant
(P=.01). In the fully adjusted model, the odds ratio for
women was 8.2 (95% confidence interval, 2.5 to 27.2) compared with 1.0
(95% confidence interval, 0.3 to 3.3) for men.
Key Words: heart failure • elderly • emotional support
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Heart failure, the
most common cause of hospitalization for elderly Medicare
patients,1 is associated with high rates of
mortality and recurrent cardiovascular
events.2 There is great interest in identifying
risk factors for adverse outcomes in patients with heart failure to
assess prognosis and design interventions to improve outcomes. However,
despite advances in risk stratification, there remains much unexplained
variation in the outcome of these patients.3
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Study Sample
The study sample population was derived from subjects enrolled
in the New Haven, Conn, site of the Established Population for the
Epidemiologic Study of the Elderly (EPESE)
program.7 This program, which was established in
1982, is a longitudinal, community-based cohort study of 2812
noninstitutionalized men and women aged 65 years and older who are
living in New Haven, Conn. The initial cohort was drawn from a
probability sample, with stratification by housing type and an
oversampling of men.
Demographic and Medical Information
Demographic information was collected as part of the initial
EPESE interview. For this study, subjects were classified as white or
nonwhite. For education, subjects were classified as having less than a
high school education, having a high school education, or having more
than a high school education. Information about comorbidity (a history
of stroke, diabetes, myocardial infarction, hypertension and cancer)
was collected based on self-report.
The social and psychological data were collected prospectively
in 1982, 1985, and 1988 by trained EPESE interviewers. Annual
interviews were conducted in most intervening years but did not include
information about psychosocial conditions. The psychosocial data for
this study were based on the interview that occurred most directly
before the hospitalization for heart failure. 1).
Information about functional status was collected from the
annual EPESE interview directly preceding the admission for heart
failure. Physical functioning was assessed based on self-report items
related to basic activities of daily living, physical
performance, and gross mobility.10 11 12
These variables were coded as "no impairment" versus "any
impairment."
The presence and severity of heart failure were determined from
hospital record review. Clinical characteristics included heart
rate, mean blood pressure, respiratory rate, temperature, hematocrit,
white blood cell count, creatinine, sodium, and potassium.
These variables were combined in an acute physiology score, based
on the work of Knaus et al.13 A variable was
created to indicate whether the index admission was associated with an
acute myocardial infarction. Comorbid conditions also were based on the
medical chart review and the EPESE interview preceding the
hospitalization.
The principal outcome of this study was the occurrence of any
fatal or nonfatal cardiovascular event in the year
after hospital admission with heart failure. Since the inception of the
cohort, <1% of the subjects have been lost to follow-up. Deaths or
hospitalizations due to cardiovascular disease were
defined by ICD-9-CM codes (391–398, 402, 404, 410–416, and 420–429)
on the death certificate or as the principal discharge diagnosis. The
death certificates were coded by a certified nosologist unfamiliar with
the study hypothesis.
We sought to determine the bivariate association of emotional
support and other potential covariates with the outcome variable of
cardiovascular event within 1 year of admission. We
also evaluated the association between patient characteristics and
emotional support. Significant associations were identified using the
2 statistic. We determined
cardiovascular events by level of emotional support
within 30, 60, 90, 180, and 365 days after admission. 2 statistics.15
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Study Sample
A total of 473 hospital admissions were screened, with 295
confirmed with heart failure. Of these patients, 3 were excluded
because of missing mortality data (2 with missing cause of death and 1
with missing death date). The psychosocial interview was conducted
679±517 days before the index hospitalization.
A total of 38 subjects (13%) reported no sources of emotional
support, 48 (16%) reported no need of emotional support, and 206
(71%) had one or more sources of support. We evaluated the stability
of this measurement. Among the 149 patients in our study sample who had
at least two psychosocial interviews before the index hospitalization,
about one fifth changed categories (19.5% for those who subsequently
had a cardiovascular event and 19.4% for those who did
not). Emotional support was not significantly associated with clinical
characteristics, including the acute physiology score, history of heart
failure, myocardial infarction during the index hospitalization,
ejection fraction, diabetes, hypertension, or the number of comorbid
conditions.
In the 1 year after hospital admission, 142 patients (49%)
experienced a cardiovascular death or readmission. A
total of 75 patients were readmitted at least once in the year after
discharge. A hospitalization for heart failure was the most common
reason for readmission (48% of the cases), followed by
coronary artery disease (8%) and unstable angina (7%).
Overall, 110 of the patients died during the year after admission,
including 83 from cardiovascular causes.
In the bivariate analysis, there were several factors that
were associated with an increased risk of
cardiovascular events in the year after admission
(Tables 1
and 2). Men were more likely to have an event
than women (P=.04). Patients with systolic
dysfunction had a higher risk than patients with normal
systolic function (P=.05). Patients who had a
myocardial infarction on the index admission had a much higher risk of
subsequent events (P=.004). A worse acute physiology score
was also associated with an increased risk of
cardiovascular events, although the significance was
borderline (P=.06 for trend).
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Table 1. Percentage of Patients With Cardiac Event by
Demographic and Social Characteristics
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Table 2. Percentage of Patients With Cardiac Event by
Clinical Characteristics ).
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Table 3. Cumulative Probability of
Cardiovascular Events Among Elderly Persons
Hospitalized for Congestive Heart Failure by Sources of Emotional
Support
show the risk of cardiovascular events after
stratification by age, sex, ejection fraction, and acute myocardial
infarction. Except for the stratification by sex, the association
between the lack of emotional support and the risk of
cardiovascular events was evident in each of the
subsets. However, in the sex analysis, the association of
emotional support and cardiovascular events at 1 year
appeared to be restricted to women.
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Figure 1. The association between emotional support (none vs
one or more) and the incidence of 1-year cardiovascular
events by age groups.
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Figure 2. The association between emotional support (none vs
one or more) and the incidence of 1-year cardiovascular events, by
sex.
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Figure 3. The association between emotional support (none vs
one or more) and the incidence of 1-year cardiovascular
events by ejection fraction.
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Figure 4. The association between emotional support (none vs
one or more) and the incidence of 1-year cardiovascular events, by
acute myocardial infarction.
The stepwise multiple logistic regression model predicting the
occurrence of cardiovascular events in the year after
admission is shown in Table 4. In this
model, lack of emotional support was associated with a significant odds
increase in risk (odds ratio [OR], 2.7; 95% confidence interval
[CI], 1.2 to 6.0). The absence of social ties was also borderline
significant in predicting events (OR, 2.1; 95% CI, 0.95 to 4.5). No
other psychosocial factor entered the model.
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Table 4. Predictors of Cardiovascular Events
Within 12 Months After Hospitalization for Heart Failure as Determined
by Stepwise Multivariable Logistic Regression
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
Various aspects of social relationships are being examined with
increasing frequency as potential risk factors for adverse outcomes
among patients with coronary heart disease. We make several
observations that advance this field of inquiry. First, our principal
finding is that the absence of emotional support is a strong predictor
of cardiovascular events in elderly patients admitted
to the hospital with heart failure. Patients without emotional support
had a more-than-threefold odds increase in the risk of
cardiovascular events in the year after admission
compared with patients with emotional support.
A provocative finding in this study is that the
association between emotional support and
cardiovascular events was very strong in women but
absent in men. The test for an interaction in the fully adjusted model
was significant with a value of P=.01, a striking difference
worthy of further investigation. Interestingly, in the study of the
prognostic importance of emotional support after acute myocardial
infarction, there was no interaction with
sex.6
Previous studies have evaluated a variety of psychosocial factors.
Although others, focusing on patients with coronary heart
disease, have examined the effect of living
alone16 or not being married as risk
factors,17 our study also highlights the
importance of social ties as well as emotional support from intimate
contacts. Although not the primary focus of this study, the absence of
social ties did demonstrate a more-than-twofold odds increase in risk
of cardiovascular events that was independent of
emotional support. This factor has been associated with all-cause
mortality,18 but its relationship with
cardiovascular events in patients hospitalized with
heart failure has not been previously described.
Why do subjects who lack emotional support have higher rates of
cardiovascular events? The mechanism is not known. It
is possible that emotional support is associated with greater patient
adherence to medical therapy and lifestyle recommendations. Although an
evaluation of such a mechanism is beyond the scope of this study, it is
relevant to note that the association between emotional support and
cardiovascular outcomes did not appear to be mediated
by smoking, obesity, or physical activity. Another possibility is that
the effect of emotional support is mediated through a direct
physiological pathway. For example, the emotional
support may mitigate potentially damaging effects of negative emotional
interactions on neuroendocrine and physiological
regulatory systems.18 22 23
Whatever the mechanism, it is interesting that it becomes manifest
only months after hospital admission. Consequently, the absence of
psychosocial support may be a good target for intervention in these
patients. This approach is gaining momentum in the treatment of
patients with coronary artery disease. In a
meta-analysis of 23 randomized controlled trials of
psychosocial intervention in the setting of cardiac rehabilitation in
patients with coronary artery disease, the addition of
psychosocial treatments was found to decrease mortality, morbidity, and
psychological distress and improve risk
factors.24 The National Institutes of Health is
sponsoring the Enhancing Recovery in Coronary Heart Disease
(ENRICHD) Patients Study, a clinical trial to evaluate the effect of a
psychosocial intervention for depressed and/or socially isolated
patients hospitalized with an acute myocardial infarction.
This study has several limitations. The timing of the assessment
of support occurred a mean of almost 2 years before the admission with
heart failure. As a result, we may have misclassified some patients
based on their status at the time of admission. In addition, the
assessment was made with a single-item instrument, and there was no
formal assessment of its reliability. These limitations, however, would
tend to bias the study toward the null hypothesis. Despite such
limitations in our measurement, we observed a strong association of
emotional support with cardiovascular outcomes.
Our study identifies emotional support as an important prognostic
factor for elderly patients hospitalized with heart failure, especially
in women. The association, not present in the first 30 days after
admission, grows in strength over time and is independent of
demographic, clinical, and other psychosocial factors. Future studies
are necessary to illuminate the mechanism of this association and
explore the value of interventions designed to augment sources of
emotional support.
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Table 5. Relation of Emotional Support to
Cardiovascular Events Within 12 Months of
Hospitalization for Heart Failure After Sequential Adjustment for
Sociodemographic Characteristics, Clinical Severity, and Functional
Status
Acknowledgments
This work received the following support from the National
Institute on Aging: Contract #N01-AG-0-2105 (EPESE), Grant
#P60-AG-10469 (PEPPER). Dr Krumholz is a Paul Beeson Faculty
Scholar.
Footnotes
Reprint requests to Harlan M. Krumholz, MD, Yale University School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 06520-8025.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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Hennen J, Krumholz HM, Radford MJ. Twenty most
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Connecticut hospitals fiscal years 1991, 1992, and 1993. CT
Med. 1995;59:11–15.
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