EDITORIALS
ANNALS of Internal Medicine
Myocardial Infarction: Unit Care or Home Care?
Volume 8 8 • Number 2 February 1 9 7 8 P U B L I S H E D monthly by the American College of Physicians under the direction of the Publications Committee of t h e Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy A N N A L S O F I N T E R N A L M E D I C I N E pub-
lishes original papers, topical reviews, editorials, book reviews, a n d medical news in the broad field of internal medicine and allied sciences. Detailed information on the kinds of papers that will be considered for publication, the proper form and style for manuscripts, and submission of manuscripts to the Editor are given in " I N F O R M A T I O N F O R A U T H O R S " on advertising page 1-6. Selected books will be reviewed monthly. Review copies should be sent to the Editor. T h e content of this journal is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all o r in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by t h e express consent of the Editor. A N N A L S O F I N T E R N A L M E D I C I N E accepts n o
responsibility for statements made by contributors. Subscriptions A N N A L S O F I N T E R N A L M E D I C I N E is is-
sued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid: $25.00 in N o r t h a n d Central American countries, Puerto Rico, and Canal Zone; $28.00 in other countries; half price to medical students a n d to physicians within four years after graduation from medical school. Single copies of recent issues: $3.00 in N o r t h a n d Central American countries, Puerto Rico, and Canal Zone; $3.25 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4 2 0 0 Pine St. Philadelphia, PA 1 9 1 0 4 USA Phone: 2 1 5 / 2 4 3 - 1 2 0 0
A B O U T 1940, the late Maurice B. Strauss, then a junior faculty member of Harvard's Thorndike Laboratory, presented a graph showing the natural history of a new drug's use. His graph showed that, in 1940, a newly marketed drug was at first accepted slowly by clinicians. A period of accelerated growth soon resulting in wide use followed, and then excessive use. This excess, together with appearances of drug reactions, caused the initial enthusiasm to fade, bringing about a sharp decline. This was followed in turn by reassessment of the drug, which, Strauss felt, resulted in more judicious use. Since Strauss formulated his description of drug use, there have been three major changes that have influenced and changed the hit-or-miss testing process he described. First, drugs must now pass tests of efficacy and safety before they are released for human use. Second, the introduction of the randomized clinical trial into medical science by Bradford Hill, shortly after World War II, provided clinicians for the first time with a uniquely powerful tool for determining efficacy of medical treatments. Third, there has been more recently a growing interest in the application of cost-benefit techniques to medical treatment. A recent monograph, Cost, Risks, and Benefits of Surgery (1), contains a number of essays illustrating the importance of the latter two scientific tools. For example, one essay describes the adoption and abandonment of gastric freezing as a treatment for duodenal ulcer (2). This therapy, introduced after uncontrolled experiments, was soon subjected to randomized clinical trials that established its worthlessness. It was particularly easy in this case to provide sham treatments that made convincing controls. A n essay on the treatment of breast cancer points out that the radical mastectomy, introduced by Halstead in the last century, became the standard treatment for this disease because it was so reasonable. Only relatively recently when competing treatments, including radiation plus simple mastectomy (3-5), have been compared with radical surgery has it become clear that benefits claimed for radical mastectomy were overstated. Indeed, McPherson and Fox's essay (6) on breast cancer quotes B.A. Stoll: " A highly responsible body of scientific opinion has suggested that neither surgical treatment nor radiation therapy is likely to affect the outcome of the disease [that is, breast cancer] in the vast majority of patients presenting." Indeed, Stoll raised the possibility that extensive surgery or radiotherapy may even accelerate the course of disease rather than lead to a cure. Clearly the substitution of randomized clinical trials for dogma, or logic, has given physicians a more scientific basis for patient treatment. In the same collection, Neuhauser (7) examines the generally accepted thesis that all patients with inguinal hernias should have elective herniorrhaphy, the generally recommended treatment. The supporting logic is impeccable. Hernia repair prevents incarceration or strangulation. Correction after strangulation is associated with substantially greater risk than that faced by a patient undergoing a routine, elective repair. There are also considerations of comfort in using or not using a truss. Finding Editorials
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19530/ by a University of California San Diego User on 04/03/2017
259
the appropriate statistics on which to base cost-benefit calculations proved difficult, attesting to the general acceptance of surgery. Application of cost-benefit analysis did not support the thesis that an operation to prevent later strangulation saved lives. Indeed, the older patient undergoing hernia repair could expect to lose, on average, 2 weeks of life as a result of this operation compared with the patient who chose a truss. Many patients, Neuhauser pointed out, might for reasons of comfort still choose to have their hernia repaired, since the increased risk is so small. Units for intensive care of patients with myocardial infarcts have followed Strauss' growth curve. Multiplication of coronary care units, following Day's original description, has been unusually rapid (8). Among the dozens of clinical papers supporting the efficacy of intensive care there, only two could be described as serious investigations. Hofvendahl in Sweden (9) and Christensen, Iverson, and Skouby in Denmark (10) assigned patients with myocardial infarction to specialized intensive care units or normal ward care solely on the basis of bed availability. Analysis of results seemed to show that results were better for patients receiving intensive care. A recent clinical study by Hill, Holdstock, and Hampton (11) published in the British Medical Journal, repeated in essence the Hofvendahl and Christensen studies. This study, however, did not demonstrate a lower mortality among patients receiving intensive care. These three studies seem to fit Strauss' curve for drug acceptance. The initial reports were favorable, and the later one is not. In addition to these more serious efforts, a spate of clinical studies during the 60s and early 70s strongly favored coronary care unit effectiveness, but these were of too indifferent a quality to merit review. The Hill, Hofvendahl, and Christensen studies were, of course, very imperfect investigations. Allocating patients to the ward or intensive care unit on the basis of bed availability clearly opens investigations to biases. It would seem likely that sicker patients are likely to displace the recovering patients in the intensive care unit or to take precedence, given simultaneous arrival of two patients. This, of course, is why randomized trials are so much more powerful as tools in determining real outcome. If randomization is adhered to, the physician's biases and beliefs about treatment cannot influence the treatment received—or presumably the study outcome. There is an additional base for investing confidence in the negative results obtained by Hill, Holdstock, and Hampton (11). Mather's study (12), in which the patients were randomized into either home care or intensive care in hospitals, demonstrated conclusively that there was no improved survival among patients receiving intensive care. Indeed, for older male patients, survival at home was significantly better. The Mather study inclines one to believe that intensive care may not be superior to normal hospital ward care, but this was not, of course, what was established. It seems probable that cost-benefit calculations would also favor home treatment. It is an acceptable alternative in England. Similarly, normal ward care would probably 260
have cost advantages over intensive care in the United States. Dr. Bloom and 1(13) demonstrated that the intensive care in New England hospitals costs about twice as much per diem as normal ward care. So the potential savings from substituting nursing home or ward care for intensive care are great. Martin's study (14) of treatment intensity of patients with myocardial infarct, published in this journal several years ago, provides further evidence bearing on this point. In this investigation, patients with myocardial infarction who were treated during the period 1939-40 through 1969-70 were compared as to mortality and intensity of treatment. The latter included frequency of observation, analgesia, oxygen, laboratory tests, ECGs, and others. The intensity of treatment increased markedly from year to year, and the rate of increase also went up during this study period. Nevertheless, the severity-adjusted death rates in the study institution remained quite stable except in the interval 1939-1949 when there was a significant decline, evidently due to fewer deaths from intercurrent infection. One interesting detail was noted in this study: There was no relation between the severity of the infarct and the intensity of treatment as might have been expected. We are left with the uncomfortable possibility that increased expenditure has purchased useless service. The data from the Bloom and the Martin studies leave little doubt about the costliness of intensive care of patients with myocardial infarction. It is discouraging that these expensive services and their increasing application have taken place without regard to efficacy, much less to their costs. It is perhaps idle to suggest that American physicians should, like British general practitioners, treat their patients with myocardial infarct at home. Clearly, this would be relatively inexpensive care. If this idea is too radical, is it too late to conduct a randomized trial comparing a quiet, less expensive hospital room with intensive care? After all, many cardiologists feel that the atmosphere of the coronary care unit is responsible for the induction of the arrythmias that coronary care unit personnel have become so adept at treating. The issues raised by intensive care of patients with myocardial infarction are part of a larger problem that should concern our profession deeply. The first issue is efficacy. Clearly, the value of intensive care of patients with myocardial infarct should have been established at its inception. The Hill study (11) has swept away whatever moral problems may have hampered some investigators. Second, the costs and benefits should have been weighed. There is clearly a widespread national concern about medical care costs and their rapid increase. The cause of this phenomena is plain. The payments of medical care have to a large extent been socialized, whereas the providers of medical care have been left as private entrepreneurs to prescribe what they will, with insufficient attention to efficacy and costs. This is the situation that has led to the nationalization or a substantial measure of control over medical personnel, services, and costs in many other countries. The final issue is scientific. Are poorly controlled clini-
February 1978 • Annals of Internal Medicine • Volume 88 • Number 2
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19530/ by a University of California San Diego User on 04/03/2017
cal studies to be as influential as clinical experiments in determining what services are provided? Are decisions to be shaped by opinion rather than a systematic approach such as a cost-benefit calculation? T h e questions raised by the paper of Hill, Holdstock, and Hampton (11) are not only about clinical efficacy and cost but about the scientific basis for medicine. ( O S L E R L. P E T E R S O N , M.D.; Leonard Davis Institute of Health Economics, University of Pennsylvania; Philadelphia, Pennsylvania) References 1. BUNKER JP, BARNES BA, MOSTELLER F (eds.): Costs, Risks, and Benefits of Surgery. Oxford, Oxford University Press, 1977 2. M I A O LL: Gastric freezing, in Costs, Risks, and Benefits of Surgery, edited by BUNKER JP, BARNES BA, MOSTELLER F. Oxford, Oxford University Press, 1977, pp. 198-211 3. M C W H I R T E R R: Treatment of cancer of the breast by simple mastectomy and reontgenotherapy. Arch Surg 59:830-842, 1949 4. K A A E S, JOHANSEN H: Simple mastectomy plus post operative irradiation by the method of McWhirter for mammary carcinoma. Ann Surg 170:895-899, 1969
5. A T K I N S H, H A Y W A R D HL, K L U G M A N DJ, W A Y T E AB: Treatment of
breast cancer: Report of a clinical trial. Br Med J 2:423-429, 1972 6. M C P H E R S O N F, F O X MS: Treatment of breast cancer, in Costs, Risks, and Benefits of Surgery, edited by BUNKER JP, BARNES BA, MOSTELLER F. Oxford, Oxford University Press, 1977, pp. 308-322 7. NEUHAUSER D: Elective herniorrhaphy versus truss in the elderly, in Cost, Risks, and Benefits of Surgery, edited by BUNKER JP, BARNES BA, MOSTELLER F. Oxford, Oxford University Press, 1977, pp. 323-339 8. D A Y HH: An intensive coronary care area. Dis Chest 44:423-427, 1963 9. HOFVENDAHL S: Influence of treatment in a CCU on prognonis in acute myocardial infarction. Acta Med Scand [Suppf] 519:1-78, 1971 10. C H R I S T E N S E N I, IVERSON K, SKOUBY AP: Benefits obtained by the
introduction of a coronary-care unit. Acta Med Scand 189:285-291, 1971 11. H I L L JD, HOLDSTOCK G, H A M P T O N JR: Comparison of mortality of
patients with heart attacks admitted to a CCU and an ordinary medical ward. Br Med J 2:81-83, 1977 12. M A T H E R H D , M O R G A N DC, PEARSON N G , R E A D KLQ, S H A W DB, S T E E D GR, T H O R N E MG, L A W R E N C E CJ, R I L E Y IS: Myocardial in-
farction: a comparison between home and hospital care for patients. Br Med J 1:925-929, 1976 13. BLOOM BS, PETERSON OL: End results, cost and productivity of coronary care units. N Engl J Med 288:72-78, 1973 14. M A R T I N SP, D O N A L D S O N MC, L O N D O N CD, P E T E R S O N OL, C O L T O N
T: Inputs into coronary care during 30 years. A cost effectiveness study. Ann Intern Med 81:289-293, 1974
Editorials
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261
ANNALS of Internal Medicine
Myocardial Infarction: Unit Care or Home Care?
Volume 8 8 • Number 2 February 1 9 7 8 P U B L I S H E D monthly by the American College of Physicians under the direction of the Publications Committee of t h e Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy A N N A L S O F I N T E R N A L M E D I C I N E pub-
lishes original papers, topical reviews, editorials, book reviews, a n d medical news in the broad field of internal medicine and allied sciences. Detailed information on the kinds of papers that will be considered for publication, the proper form and style for manuscripts, and submission of manuscripts to the Editor are given in " I N F O R M A T I O N F O R A U T H O R S " on advertising page 1-6. Selected books will be reviewed monthly. Review copies should be sent to the Editor. T h e content of this journal is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all o r in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by t h e express consent of the Editor. A N N A L S O F I N T E R N A L M E D I C I N E accepts n o
responsibility for statements made by contributors. Subscriptions A N N A L S O F I N T E R N A L M E D I C I N E is is-
sued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid: $25.00 in N o r t h a n d Central American countries, Puerto Rico, and Canal Zone; $28.00 in other countries; half price to medical students a n d to physicians within four years after graduation from medical school. Single copies of recent issues: $3.00 in N o r t h a n d Central American countries, Puerto Rico, and Canal Zone; $3.25 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4 2 0 0 Pine St. Philadelphia, PA 1 9 1 0 4 USA Phone: 2 1 5 / 2 4 3 - 1 2 0 0
A B O U T 1940, the late Maurice B. Strauss, then a junior faculty member of Harvard's Thorndike Laboratory, presented a graph showing the natural history of a new drug's use. His graph showed that, in 1940, a newly marketed drug was at first accepted slowly by clinicians. A period of accelerated growth soon resulting in wide use followed, and then excessive use. This excess, together with appearances of drug reactions, caused the initial enthusiasm to fade, bringing about a sharp decline. This was followed in turn by reassessment of the drug, which, Strauss felt, resulted in more judicious use. Since Strauss formulated his description of drug use, there have been three major changes that have influenced and changed the hit-or-miss testing process he described. First, drugs must now pass tests of efficacy and safety before they are released for human use. Second, the introduction of the randomized clinical trial into medical science by Bradford Hill, shortly after World War II, provided clinicians for the first time with a uniquely powerful tool for determining efficacy of medical treatments. Third, there has been more recently a growing interest in the application of cost-benefit techniques to medical treatment. A recent monograph, Cost, Risks, and Benefits of Surgery (1), contains a number of essays illustrating the importance of the latter two scientific tools. For example, one essay describes the adoption and abandonment of gastric freezing as a treatment for duodenal ulcer (2). This therapy, introduced after uncontrolled experiments, was soon subjected to randomized clinical trials that established its worthlessness. It was particularly easy in this case to provide sham treatments that made convincing controls. A n essay on the treatment of breast cancer points out that the radical mastectomy, introduced by Halstead in the last century, became the standard treatment for this disease because it was so reasonable. Only relatively recently when competing treatments, including radiation plus simple mastectomy (3-5), have been compared with radical surgery has it become clear that benefits claimed for radical mastectomy were overstated. Indeed, McPherson and Fox's essay (6) on breast cancer quotes B.A. Stoll: " A highly responsible body of scientific opinion has suggested that neither surgical treatment nor radiation therapy is likely to affect the outcome of the disease [that is, breast cancer] in the vast majority of patients presenting." Indeed, Stoll raised the possibility that extensive surgery or radiotherapy may even accelerate the course of disease rather than lead to a cure. Clearly the substitution of randomized clinical trials for dogma, or logic, has given physicians a more scientific basis for patient treatment. In the same collection, Neuhauser (7) examines the generally accepted thesis that all patients with inguinal hernias should have elective herniorrhaphy, the generally recommended treatment. The supporting logic is impeccable. Hernia repair prevents incarceration or strangulation. Correction after strangulation is associated with substantially greater risk than that faced by a patient undergoing a routine, elective repair. There are also considerations of comfort in using or not using a truss. Finding Editorials
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19530/ by a University of California San Diego User on 04/03/2017
259
the appropriate statistics on which to base cost-benefit calculations proved difficult, attesting to the general acceptance of surgery. Application of cost-benefit analysis did not support the thesis that an operation to prevent later strangulation saved lives. Indeed, the older patient undergoing hernia repair could expect to lose, on average, 2 weeks of life as a result of this operation compared with the patient who chose a truss. Many patients, Neuhauser pointed out, might for reasons of comfort still choose to have their hernia repaired, since the increased risk is so small. Units for intensive care of patients with myocardial infarcts have followed Strauss' growth curve. Multiplication of coronary care units, following Day's original description, has been unusually rapid (8). Among the dozens of clinical papers supporting the efficacy of intensive care there, only two could be described as serious investigations. Hofvendahl in Sweden (9) and Christensen, Iverson, and Skouby in Denmark (10) assigned patients with myocardial infarction to specialized intensive care units or normal ward care solely on the basis of bed availability. Analysis of results seemed to show that results were better for patients receiving intensive care. A recent clinical study by Hill, Holdstock, and Hampton (11) published in the British Medical Journal, repeated in essence the Hofvendahl and Christensen studies. This study, however, did not demonstrate a lower mortality among patients receiving intensive care. These three studies seem to fit Strauss' curve for drug acceptance. The initial reports were favorable, and the later one is not. In addition to these more serious efforts, a spate of clinical studies during the 60s and early 70s strongly favored coronary care unit effectiveness, but these were of too indifferent a quality to merit review. The Hill, Hofvendahl, and Christensen studies were, of course, very imperfect investigations. Allocating patients to the ward or intensive care unit on the basis of bed availability clearly opens investigations to biases. It would seem likely that sicker patients are likely to displace the recovering patients in the intensive care unit or to take precedence, given simultaneous arrival of two patients. This, of course, is why randomized trials are so much more powerful as tools in determining real outcome. If randomization is adhered to, the physician's biases and beliefs about treatment cannot influence the treatment received—or presumably the study outcome. There is an additional base for investing confidence in the negative results obtained by Hill, Holdstock, and Hampton (11). Mather's study (12), in which the patients were randomized into either home care or intensive care in hospitals, demonstrated conclusively that there was no improved survival among patients receiving intensive care. Indeed, for older male patients, survival at home was significantly better. The Mather study inclines one to believe that intensive care may not be superior to normal hospital ward care, but this was not, of course, what was established. It seems probable that cost-benefit calculations would also favor home treatment. It is an acceptable alternative in England. Similarly, normal ward care would probably 260
have cost advantages over intensive care in the United States. Dr. Bloom and 1(13) demonstrated that the intensive care in New England hospitals costs about twice as much per diem as normal ward care. So the potential savings from substituting nursing home or ward care for intensive care are great. Martin's study (14) of treatment intensity of patients with myocardial infarct, published in this journal several years ago, provides further evidence bearing on this point. In this investigation, patients with myocardial infarction who were treated during the period 1939-40 through 1969-70 were compared as to mortality and intensity of treatment. The latter included frequency of observation, analgesia, oxygen, laboratory tests, ECGs, and others. The intensity of treatment increased markedly from year to year, and the rate of increase also went up during this study period. Nevertheless, the severity-adjusted death rates in the study institution remained quite stable except in the interval 1939-1949 when there was a significant decline, evidently due to fewer deaths from intercurrent infection. One interesting detail was noted in this study: There was no relation between the severity of the infarct and the intensity of treatment as might have been expected. We are left with the uncomfortable possibility that increased expenditure has purchased useless service. The data from the Bloom and the Martin studies leave little doubt about the costliness of intensive care of patients with myocardial infarction. It is discouraging that these expensive services and their increasing application have taken place without regard to efficacy, much less to their costs. It is perhaps idle to suggest that American physicians should, like British general practitioners, treat their patients with myocardial infarct at home. Clearly, this would be relatively inexpensive care. If this idea is too radical, is it too late to conduct a randomized trial comparing a quiet, less expensive hospital room with intensive care? After all, many cardiologists feel that the atmosphere of the coronary care unit is responsible for the induction of the arrythmias that coronary care unit personnel have become so adept at treating. The issues raised by intensive care of patients with myocardial infarction are part of a larger problem that should concern our profession deeply. The first issue is efficacy. Clearly, the value of intensive care of patients with myocardial infarct should have been established at its inception. The Hill study (11) has swept away whatever moral problems may have hampered some investigators. Second, the costs and benefits should have been weighed. There is clearly a widespread national concern about medical care costs and their rapid increase. The cause of this phenomena is plain. The payments of medical care have to a large extent been socialized, whereas the providers of medical care have been left as private entrepreneurs to prescribe what they will, with insufficient attention to efficacy and costs. This is the situation that has led to the nationalization or a substantial measure of control over medical personnel, services, and costs in many other countries. The final issue is scientific. Are poorly controlled clini-
February 1978 • Annals of Internal Medicine • Volume 88 • Number 2
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19530/ by a University of California San Diego User on 04/03/2017
cal studies to be as influential as clinical experiments in determining what services are provided? Are decisions to be shaped by opinion rather than a systematic approach such as a cost-benefit calculation? T h e questions raised by the paper of Hill, Holdstock, and Hampton (11) are not only about clinical efficacy and cost but about the scientific basis for medicine. ( O S L E R L. P E T E R S O N , M.D.; Leonard Davis Institute of Health Economics, University of Pennsylvania; Philadelphia, Pennsylvania) References 1. BUNKER JP, BARNES BA, MOSTELLER F (eds.): Costs, Risks, and Benefits of Surgery. Oxford, Oxford University Press, 1977 2. M I A O LL: Gastric freezing, in Costs, Risks, and Benefits of Surgery, edited by BUNKER JP, BARNES BA, MOSTELLER F. Oxford, Oxford University Press, 1977, pp. 198-211 3. M C W H I R T E R R: Treatment of cancer of the breast by simple mastectomy and reontgenotherapy. Arch Surg 59:830-842, 1949 4. K A A E S, JOHANSEN H: Simple mastectomy plus post operative irradiation by the method of McWhirter for mammary carcinoma. Ann Surg 170:895-899, 1969
5. A T K I N S H, H A Y W A R D HL, K L U G M A N DJ, W A Y T E AB: Treatment of
breast cancer: Report of a clinical trial. Br Med J 2:423-429, 1972 6. M C P H E R S O N F, F O X MS: Treatment of breast cancer, in Costs, Risks, and Benefits of Surgery, edited by BUNKER JP, BARNES BA, MOSTELLER F. Oxford, Oxford University Press, 1977, pp. 308-322 7. NEUHAUSER D: Elective herniorrhaphy versus truss in the elderly, in Cost, Risks, and Benefits of Surgery, edited by BUNKER JP, BARNES BA, MOSTELLER F. Oxford, Oxford University Press, 1977, pp. 323-339 8. D A Y HH: An intensive coronary care area. Dis Chest 44:423-427, 1963 9. HOFVENDAHL S: Influence of treatment in a CCU on prognonis in acute myocardial infarction. Acta Med Scand [Suppf] 519:1-78, 1971 10. C H R I S T E N S E N I, IVERSON K, SKOUBY AP: Benefits obtained by the
introduction of a coronary-care unit. Acta Med Scand 189:285-291, 1971 11. H I L L JD, HOLDSTOCK G, H A M P T O N JR: Comparison of mortality of
patients with heart attacks admitted to a CCU and an ordinary medical ward. Br Med J 2:81-83, 1977 12. M A T H E R H D , M O R G A N DC, PEARSON N G , R E A D KLQ, S H A W DB, S T E E D GR, T H O R N E MG, L A W R E N C E CJ, R I L E Y IS: Myocardial in-
farction: a comparison between home and hospital care for patients. Br Med J 1:925-929, 1976 13. BLOOM BS, PETERSON OL: End results, cost and productivity of coronary care units. N Engl J Med 288:72-78, 1973 14. M A R T I N SP, D O N A L D S O N MC, L O N D O N CD, P E T E R S O N OL, C O L T O N
T: Inputs into coronary care during 30 years. A cost effectiveness study. Ann Intern Med 81:289-293, 1974
Editorials
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19530/ by a University of California San Diego User on 04/03/2017
261
