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Mark B. McClellan, MD, PhD
National Bureau of Economic Research Cambridge, Mass

Joseph P. Newhouse, PhD
Harvard School of Public Health

Barbara J. McNeil, MD, PhD
Brigham and Women's Hospital Boston, Mass

JAMA. 1995;273(17):1333.

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In Reply.

—We used empirical data on treatments and outcomes of elderly AMI patients to estimate the mortality consequences of the additional catheterization and revascularization procedures performed by the most intensive hospitals relative to other hospitals. In contrast, Drs Kuller and Detre postulate that invasive procedures prevent death in 1 year in a substantial portion (one fourth) of the 26.2% of patients who received them. Further, their claim that randomized trials can answer this question is inaccurate. Under ideal circumstances, a standard randomized controlled trial estimates the average effect of treatment over an entire study population. Because we suspect that invasive procedures are highly effective in certain kinds of elderly AMI patients and ineffective in others, we instead sought to estimate the average effect on mortality for "incremental" changes in use of these procedures within the population of elderly AMI patients. A more complete discussion of the differences between population . . . [Full Text PDF of this Article]

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