Showing papers by "Harlan M. Krumholz published in 2004"
TL;DR: Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists as discussed by the authors, and the purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients
Abstract: Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists.[1–3][1][][2][][3] The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients
8,352 citations
Journal Article•
TL;DR: Elliott M. Antman,MD, FACC, FAHA, Chair; Daniel T. Anbe, MD, F ACC,FAHA; Paul Wayne Armstrong, MD; Eric R. Bates; Lee A. Green; Mary Hand; Judith S. Kushner; and Sidney C. Sloan.
7,134 citations
TL;DR: This document was approved by the American College of Cardiology Foundation Board of Trustees on May 7, 2004 and by theAmerican Heart Association Science Advisory and Coordinating Committee on May 5, 2004.
1,846 citations
TL;DR: Although the total number of trial participants increased during the study period, the representation of racial and ethnic minorities decreased and were less likely to enroll in cooperative group cancer trials than were whites, men, and younger patients, respectively.
Abstract: ContextDespite the importance of diversity of cancer trial participants with
regard to race, ethnicity, age, and sex, there is little recent information
about the representation of these groups in clinical trials.ObjectiveTo characterize the representation of racial and ethnic minorities,
the elderly, and women in cancer trials sponsored by the National Cancer Institute.Design, Setting, and PatientsCross-sectional population-based analysis of all participants in therapeutic
nonsurgical National Cancer Institute Clinical Trial Cooperative Group breast,
colorectal, lung, and prostate cancer clinical trials in 2000 through 2002.
In a separate analysis, the ethnic distribution of patients enrolled in 2000
through 2002 was compared with those enrolled in 1996 through 1998, using
logistic regression models to estimate the relative risk ratio of enrollment
for racial and ethnic minorities to that of white patients during these time
periods.Main Outcome MeasureEnrollment fraction, defined as the number of trial enrollees divided
by the estimated US cancer cases in each race and age subgroup.ResultsCancer research participation varied significantly across racial/ethnic
and age groups. Compared with a 1.8% enrollment fraction among white patients,
lower enrollment fractions were noted in Hispanic (1.3%; odds ratio [OR] vs
whites, 0.72; 95% confidence interval [CI], 0.68-0.77; P<.001) and black (1.3%; OR, 0.71; 95% CI, 0.68-0.74; P<.001) patients. There was a strong relationship between age and
enrollment fraction, with trial participants 30 to 64 years of age representing
3.0% of incident cancer patients in that age group, in comparison to 1.3%
of 65- to 74-year-old patients and 0.5% of patients 75 years of age and older.
This inverse relationship between age and trial enrollment fraction was consistent
across racial and ethnic groups. Although the total number of trial participants
increased during our study period, the representation of racial and ethnic
minorities decreased. In comparison to whites, after adjusting for age, cancer
type, and sex, patients enrolled in 2000 through 2002 were 24% less likely
to be black (adjusted relative risk ratio, 0.76; 95% CI, 0.65-0.89; P<.001). Men were more likely than women to enroll in
colorectal cancer trials (enrollment fractions: 2.1% vs 1.6%, respectively;
OR, 1.30; 95% CI, 1.24-1.35; P<.001) and lung
cancer trials (enrollment fractions: 0.9% vs 0.7%, respectively; OR, 1.23;
95% CI, 1.16-1.31; P<.001).ConclusionsEnrollment in cancer trials is low for all patient groups. Racial and
ethnic minorities, women, and the elderly were less likely to enroll in cooperative
group cancer trials than were whites, men, and younger patients, respectively.
The proportion of trial participants who are black has declined in recent
years.
1,823 citations
Boston Medical Center1, Vanderbilt University Medical Center2, Yale University3, Ohio State University4, Duke University5, University of Maryland, Baltimore6, University of Pennsylvania7, United States Department of Veterans Affairs8, University of California, San Francisco9, Washington University in St. Louis10, Brigham and Women's Hospital11, Cleveland Clinic12
TL;DR: Worsening renal function occurs frequently among hospitalized HF patients and is associated with significantly worse outcomes and clinical characteristics available at hospital admission can be used to identify patients at increased risk for developing WRF.
860 citations
TL;DR: Several medical strategies, including the use of CCBs and a higher dose of loop diuretics, but not ACE inhibitors, were associated with a higher risk of WRF, although assessment of inhospital diuresis was limited and WRF could not be explained by greater fluid loss in patients.
473 citations
TL;DR: The goal of this study was to describe the frequency and timing of discussions about deactivating ICDs and evaluate patient factors associated with these discussions and to characterize the timing of ICD discharges near the end of life.
Abstract: Implantable cardioverter defibrillators (ICDs) may discharge as an inevitable death draws near and make the act of dying more distressing. In this study, deceased patients' next of kin reported tha...
300 citations
TL;DR: A substantial portion of the racial/ethnic disparity in time to treatment was accounted for by the specific hospital to which patients were admitted, in contrast to differential treatment by race/ethnicity inside the hospital.
Abstract: ContextNonwhite patients experience significantly longer times to fibrinolytic
therapy (door-to-drug times) and percutaneous coronary intervention (door-to-balloon
times) than white patients, raising concerns of health care disparities, but
the reasons for these patterns are poorly understood.ObjectivesTo estimate race/ethnicity differences in door-to-drug and door-to-balloon
times for patients receiving primary reperfusion for ST-segment elevation
myocardial infarction; to examine how sociodemographic factors, insurance
status, clinical characteristics, and hospital features mediate racial/ethnic
differences.Design, Setting, and PatientsRetrospective, observational study using admission and treatment data
from the National Registry of Myocardial Infarction (NRMI) for a US cohort
of patients with ST-segment elevation myocardial infarction or left bundle-branch
block and receiving reperfusion therapy. Patients (73 032 receiving
fibrinolytic therapy; 37 143 receiving primary percutaneous coronary
intervention) were admitted from January 1, 1999, through December 31, 2002,
to hospitals participating in NRMI 3 and 4.Main Outcome MeasureMinutes between hospital arrival and acute reperfusion therapy.ResultsDoor-to-drug times were significantly longer for patients identified
as African American/black (41.1 minutes), Hispanic (36.1 minutes), and Asian/Pacific
Islander (37.4 minutes), compared with patients identified as white (33.8
minutes) (P<.01 for all). Door-to-balloon times
for patients identified as African American/black (122.3 minutes) or Hispanic
(114.8 minutes) were significantly longer than for patients identified as
white (103.4 minutes) (P<.001 for both). Racial/ethnic
differences were still significant but were substantially reduced after accounting
for differences in mean times to treatment for the hospitals in which patients
were treated; significant racial/ethnic differences persisted after further
adjustment for sociodemographic characteristics, insurance status, and clinical
and hospital characteristics (P<.01 for all).ConclusionA substantial portion of the racial/ethnic disparity in time to treatment
was accounted for by the specific hospital to which patients were admitted,
in contrast to differential treatment by race/ethnicity inside the hospital.
249 citations
TL;DR: In outpatients with heart failure complicating an acute myocardial infarction, KCCQ-os is strongly associated with subsequent 1-year cardiovascular mortality and hospitalization.
Abstract: Background— Disease-specific health status instruments such as the Kansas City Cardiomyopathy Questionnaire (KCCQ) can quantify symptoms, functional limitations, and quality of life in patients wit...
215 citations
TL;DR: The diversity of hospital based efforts at data feedback is illustrated and strategies that might be most effective are suggested, as well as potential pitfalls in using data to promote performance improvement.
Abstract: Background: Data feedback is a fundamental component of quality improvement efforts, but previous studies provide mixed results on its effectiveness. This study illustrates the diversity of hospital based efforts at data feedback and highlights successful strategies and common pitfalls in designing and implementing data feedback to support performance improvement.
Methods: Open ended interviews with 45 clinical and administrative staff in eight US hospitals in 2000 concerning their perceptions about the effectiveness of data feedback in supporting performance improvement efforts were analysed. The hospitals were chosen to represent a range of sizes, geographical regions, and β blocker improvement rates over a 3 year period. Data were organized and analyzed in NUD-IST 4 using the constant comparative method of qualitative data analysis.
Results: Although the data feedback efforts at the hospitals were diverse, the interviews suggested that seven key themes may be important: (1) data must be perceived by physicians as valid to motivate change; (2) it takes time to develop the credibility of data within a hospital; (3) the source and timeliness of data are critical to perceived validity; (4) benchmarking improves the meaningfulness of data feedback; (5) physician leaders can enhance the effectiveness of data feedback; (6) data feedback that profiles an individual physician’s practices can be effective but may be perceived as punitive; (7) data feedback must persist to sustain improved performance. Embedded in several themes was the view that the effectiveness of data feedback depends not only on the quality and timeliness of the data, but also on the organizational context in which such efforts are implemented.
Conclusions: Data feedback is a complex and textured concept. Data feedback strategies that might be most effective are suggested, as well as potential pitfalls in using data to promote performance improvement.
182 citations
TL;DR: ACE inhibitors were widely underprescribed despite evidence of a favorable impact on survival in a broad range of patients with heart failure, and the importance of ongoing efforts to translate clinical trial results into practice is emphasized.
Abstract: Background— Although ACE inhibitors are underprescribed for heart failure, factors associated with their use are not well described. Furthermore, the effectiveness of ACE inhibitors has been questioned in some populations, potentially contributing to underuse. Our objectives were to assess the correlates of ACE inhibitor use and the relationship between ACE inhibitor prescription and mortality in older patients with heart failure. Methods and Results— We studied a national sample aged ≥65 years who had survived hospitalization for heart failure between April 1998 and March 1999 or July 2000 and June 2001, restricting the analysis to patients with left ventricular systolic dysfunction and without a documented contraindication to use of ACE inhibitors (n=17 456). Factors associated with ACE inhibitor prescription at discharge and the relationship between ACE inhibitor prescription and death within 1 year were assessed with hierarchical logistic models. Secondary analyses assessed therapeutic substitution wi...
TL;DR: Although older patients with heart failure have relatively good HRQL in spite of significant functional limitations, they are at risk for worsening HRQL with further decline in functional status, and the importance of treatments aimed at maintaining functional status in older persons with heart Failure is underscored.
TL;DR: Renal dysfunction is strongly associated with mortality in stable outpatients with heart failure, notably in patients with estimated GFR <50 ml/min per 1.73 m(2); the effect of digoxin did not differ by level of renal function.
Abstract: Renal dysfunction is a common complication for patients with heart failure, but its association with clinical outcomes has not been fully characterized. We evaluated the association of glomerular filtration rate (GFR) with heart failure survival and the effect of digoxin on heart failure outcomes across GFR strata. A secondary analysis from the Digitalis Intervention Group trial was conducted of 6800 outpatients with systolic heart failure. Renal function was categorized as estimated GFR (expressed in ml/min per 1.73 m(2)). All-cause mortality (mean, 3 yr) was inversely proportional to GFR (GFR >60, 31% mortality; GFR 30 to 60, 46% mortality; GFR 70 had a slightly lower mortality hazard (0.89; 95% CI, 0.78 to 1.00). Linear spline analyses confirmed that GFR = 50 was the appropriate risk threshold; above 50, GFR had no association with mortality, whereas below 50, mortality risk increased sharply with declining GFR (spline coefficient, P < 0.0001). Digoxin efficacy did not differ by level of GFR (P = 0.19 for interaction). Renal dysfunction is strongly associated with mortality in stable outpatients with heart failure, notably in patients with estimated GFR <50 ml/min per 1.73 m(2). The effect of digoxin did not differ by level of renal function.
TL;DR: The significant interaction initially observed does not validate and may represent a type I error, and it will become increasingly important to stress model validation in order to ensure that significant effects represent true relationships rather than chance findings.
Abstract: Background
To examine interactions among the angiotensin converting enzyme (ACE) insertion/deletion, plasminogen activator inhibitor-1 (PAI-1) 4G/5G, and tissue plasminogen activator (t-PA) insertion/deletion gene polymorphisms on risk of myocardial infarction using data from 343 matched case-control pairs from the Physicians Health Study. We examined the data using both conditional logistic regression and the multifactor dimensionality reduction (MDR) method. One advantage of the MDR method is that it provides an internal prediction error for validation. We summarize our use of this internal prediction error for model validation.
TL;DR: In this paper, the authors performed an overview of randomized β-blocker trials in patients with chronic heart failure to quantify the risks of these adverse effects, including hypertension, dizziness, and bradycardia.
Abstract: Background β-Blockers substantially improve survival in patients with chronic heart failure (HF) with left ventricular systolic dysfunction, but concerns about cardiovascular adverse effects may deter physicians from prescribing this therapy. We performed an overview of randomized β-blocker trials in patients with HF to quantify the risks of these adverse effects. Methods Heart failure trials of β-blockers were identified by electronic searches of the MEDLINE database from 1966 to 2002. The random-effects model was used to combine results from individual trials and calculate estimates of risks associated with therapy. Results β-Blocker therapy was associated with significant absolute annual increases in risks of hypotension (11 per 1000; 95% confidence interval [CI], 0-22), dizziness (57 per 1000; 95% CI, 11-104), and bradycardia (38 per 1000; 95% CI, 21-54). There was no significant absolute risk of fatigue associated with therapy (3 per 1000; 95% CI, −2 to 9). β-Blocker therapy was associated with a reduction in all-cause withdrawal of medication (14 per 1000; 95% CI, −2 to 29) as well as significant reductions in all-cause mortality (34 per 1000; 95% CI, 20-49), HF hospitalizations (40 per 1000; 95% CI, 22-58), and worsening HF (52 per 1000; 95% CI, 10-94). Conclusions Although β-blocker therapy was associated with hypotension, dizziness, and bradycardia, the absolute increases in risk were small, and overall fewer patients were withdrawn from β-blocker therapy than from placebo. This information should alleviate concerns about prescribing this life-saving therapy to patients with HF.
TL;DR: A 3-tiered framework for characterizing racial differences in health care use on the basis of their clinical consequences for patient outcomes and the extent to which they may reflect other patient or health system factors is proposed.
Abstract: Studies documenting racial differences in health care use are common in the medical literature. However, observational studies of racial differences in health care use lack a framework for interpreting reports of variations in health care use, leading to various terms, ranging from "variations" to "bias," that suggest different causes, consequences, and, ultimately, remedies for such variations in treatment. We propose criteria to assess racial differences in health care use by using a clinical equity (equal treatment based on equal clinical need) framework. This framework differentiates between initial reports of racial differences and subsequent classifications of their findings as racial disparities or racial bias in health care use. Racial variations in health care use may be considered disparities after demonstrating that racial differences are not attributable to treatment eligibility, clinical contraindications, patient preferences, or confounding by other clinical factors and are associated with adverse consequences. Racial bias with adverse consequences in health care may be inferred if a racial variation in treatment that has been characterized as a disparity persists after accounting for health care system factors (for example, type of hospital at which the patient was treated). We apply this framework to published reports of racial differences in treatment to determine which studies provide evidence of differences, disparities, and bias. We discuss the use of such a framework in directing policy interventions for alleviating inappropriate racial variations in health care use.
TL;DR: Patients at high-volume CABG hospitals were, on average, at a lower mortality risk than patients at lower-volume hospitals, but the small size of the volume-associated mortality difference and the heterogeneity in outcomes within all C ABG volume groups suggest individual hospital CABGs volume is not a reliable marker of hospital CabG quality.
Abstract: Patients who undergo coronary artery bypass graft (CABG) surgery at higher-volume hospitals have been found to have better outcomes than patients treated at lower-volume hospitals.1–13 Based on this evidence, popular press reports14–16 and several advocacy groups have endorsed CABG volume as a proxy for hospital CABG quality.17–19 In addition, the Leapfrog Group recommends health care purchasers consider hospital volume when contracting for CABG. The Leapfrog Group explicitly frames the use of a hospital CABG volume minimum as a matter of patient safety20 and estimates that 1486 deaths may be averted by referring CABG patients to hospitals that perform ≥500 procedures annually.21,22 This specific volume threshold is derived from an evaluation of the association of hospital CABG volume and in-hospital mortality based on patents hospitalized in New York in 1989.7 The past decade, however, has witnessed notable changes in CABG practice. Technical modifications, including the increased use of internal mammary artery grafts, warm cardioplegia, off-pump surgery,23,24 and the diffusion of CABG to higher-risk patient populations,25,26 raise the possibility that a hospital CABG volume minimum of 500 cases may no longer be appropriate. No study, to our knowledge, has assessed the association of hospital CABG volume and patient outcomes in an unselected, nationally representative patient population.
To address this issue, we evaluated the association between annual hospital CABG volume and in-hospital mortality in a national cohort of patients who underwent CABG between 1998 and 2000. To assess the potential effectiveness of the Leapfrog Group’s hospital CABG volume minimum, we examined whether patients treated at hospitals with at least 500 cases had lower mortality rates than those at hospitals with lower CABG volumes, and measured heterogeneity in hospital risk-standardized outcomes within CABG volume groups.
TL;DR: It is found that there is no evidence of higher in-hospital mortality in patients undergoing PCI at medium-volume hospitals compared with patients treated at hospitals with annual PCI volumes of 400 cases of more, suggesting current ACC/AHA PCI hospital volume minimums may merit reevaluation.
TL;DR: Treatment of SH in older patients with SBP of at least 160 mm Hg is supported by strong evidence, and treatment decisions should be more sensitive to patient preferences and tolerance of therapy.
Abstract: ContextThe Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure emphasizes the importance
of systolic hypertension (SH), defined as systolic blood pressure (SBP) of
at least 140 mm Hg and diastolic blood pressure of less than 90 mm Hg, in
older persons (≥60 years).ObjectiveTo systematically review the literature on clinical management of SH
in older persons.Data SourcesWe performed a MEDLINE search of English-language literature from 1966-2004
to identify reports about SH in older persons, with particular emphasis on
data from randomized clinical trials.Study Selection and Data ExtractionWe selected 1064 studies by using the search terms hypertension combined with the terms systole (or systolic) and aged.Data SynthesisThere is strong evidence from clinical trials to support the treatment
of SH in older persons with SBP of at least 160 mm Hg. Large-scale trials
to assess the value of antihypertensive therapy for older patients with SBP
of 140 to 159 mm Hg have not been performed, and recommendations to treat
these patients are based on observational studies that show a graded relationship
of cardiovascular risk with increasing SBP. The studies most strongly support
the use of thiazide diuretics and long-acting calcium channel blockers as
first-line therapy to treat SH.ConclusionsTreatment of SH in older patients with SBP of at least 160 mm Hg is
supported by strong evidence. The evidence available to support treatment
of patients to the level of 140 mm Hg or those with baseline SBP of 140 to
159 mm Hg is less strong; thus, these treatment decisions should be more sensitive
to patient preferences and tolerance of therapy.
TL;DR: A classification of work-related ethical conflicts that houseofficers experience is provided, which may be used to improve the working environment for residents and support their professional development.
TL;DR: Changing the 6-minute walk test to a time- and distance-based standard would improve the efficiency of the test while retaining the bulk of the prognostic information.
TL;DR: The use of tissue valve implants versus mechanical valve implants has little influence on improvement in quality of life at 18 months following aortic valve replacement, and decisions about whether to choose a tissue valve or mechanical valve implant should depend upon other factors such as rates of complications and differences in the life span of the implants.
TL;DR: Correlates of social support such as gender, socioeconomic status, and comorbidity burden may have a more important role in cardiac rehabilitation participation than social support itself.
Abstract: PURPOSE Cardiac rehabilitation promotes recovery and enhances quality of life after a coronary artery bypass graft (CABG), but participation in such rehabilitation is low. The role of social support in promoting participation has been suggested by prior studies, but is not clearly defined. The purpose of this study was to investigate the role of social support as an independent predictor of participation in cardiac rehabilitation. METHODS This study examined 944 patients who underwent first isolated CABG between May 1999 and February 2001, then were followed for 6 months after surgery. Social support before CABG and 6 weeks after CABG was assessed using the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Inventory (ESSI) and evaluated for its association with participation in cardiac rehabilitation. RESULTS Of 944 patients, 524 (56%) reported participation in rehabilitation. The participants were younger, better educated, more often employed, and less financially strained. The participants also had a lower prevalence of cardiovascular disease risk factors and better physical function. According to unadjusted analysis, the patients with low social support (ESSI
TL;DR: State coverage policies were associated with a statistically significant increase in phase II cancer trial participation and did not increase phase III cancer trial enrollment.
Abstract: Background: Recruitment of patients into cancer research studies is exceedingly difficult, particularly for early phase trials. Payer reimbursement policies are a frequently cited barrier. We examined whether state policies that ensure coverage of routine medical care costs for cancer trial participants are associated with an increase in clinical trial enrollment. Methods: We used logistic Poisson regressions to analyze enrollment in National Cancer Institute phase II and phase III Clinical Trials Cooperative Group trials and compared changes in trial enrollment rates between 1996 and 2001 of privately insured cancer patients who resided in the four states that enacted coverage policies in 1999 with enrollment rates in states without such policies. All statistical tests were two-sided. Results: Trial enrollment rates increased in the coverage and noncoverage states by 24.9% (95% confidence interval [CI] = 22.8% to 27.0%) and 28.8% (95% CI = 27.7% to 29.8%) per year, respectively, from 1996 through 2001. After implementation of the coverage policies in 1999 in four states, there was a 21.7% (95% CI = 3.8% to 42.6%) annual increase in phase II trial enrollment in coverage states, compared with a 15.6% (95% CI = 8.8% to 21.8%) annual decrease in noncoverage states (P<.001). After accounting for secular trend, cancer type, and race in multivariable analyses, the odds ratio (OR) for a phase II trial participant residing in a coverage versus a noncoverage state after 1999 was 1.59 per year (95% CI = 1.22 to 2.07; P =.001). In a multivariable analysis of phase III trial participation, there was a decrease in the odds of residing in a coverage state after 1999 (OR = 0.90, 95% CI = 0.84 to 0.98; P =.011). Conclusion: State coverage policies were associated with a statistically significant increase in phase II cancer trial participation and did not increase phase III cancer trial enrollment.
TL;DR: This study provides a classification of work-related ethical conflicts that houseofficers experience, which may be used to improve the working environment for residents and support their professional development.
Abstract: Medical ethics and professionalism have come to play an increasingly important role in medical practice since the 1980s, but there still is widespread concern about unethical and unprofessional behavior. This survey, based on in-depth interviews held in 2001 with 31 internal medicine residents in 1 traditional and 1 primary care residency at Yale University, was intended to identify the work-related ethical conflicts experienced by these medical house officers. The interviews, which took 18 to 60 minutes, used a standardized guide with probes for clarification and additional detail. Without exception, the participants reported having uncomfortable, improper, unethical, or unprofessional experiences with patients. In 90% of cases, the respondent had been directly involved. These experiences were classified into 5 broad categories: 1) Telling the truth. Many ways of manipulating information were used to avoid telling patients the truth, including delaying or omitting information and, in some instances, lying. These behaviors were variably ascribed to pressure from attending physicians, families, peers, or patients themselves. Relevant topics were diagnoses, prognoses, and statements about how experienced residents were with specific procedures. 2) Respecting patients' wishes. Residents sometimes were unable to ensure that the patient's wishes were respected because of disagreement on the part of the medical team, the patient, or the family about what the patient truly wished and what was in the patient's best interest. 3) Preventing harm. Several residents were distressed by having to accept the risks inherent in needed treatments or procedures. Occasionally, there was concern about the risk arising from the resident's limited experience with a given procedure. 4) Managing the limits of one's competence. Some residents felt inadequately prepared to perform their duties and were uncertain of what to do about it. They often were concerned about how their attending physician, peers, and patients would perceive the situation. Some residents felt it necessary to act as if they were more experienced than they believed they actually were. Some had trouble acknowledging their shortcomings. 5) Addressing the performance of others that is perceived as inappropriate. Residents experienced conflict when they viewed a peer's or an attending physician's performance as inadequate or inappropriate. They were uncertain about whether to challenge, intervene, or report the behavior while at the same time being accepted and approved by their colleagues. Hopefully, the challenges faced by medical residents will lead to better education in ethics and professionalism. Ultimately, residents must learn when compromising ethical standards might be acceptable and when it is not.
TL;DR: The authors' nurse-based educational intervention did not result in a significant increase in the proportion of patients who reached target LDL cholesterol levels 1 year after hospitalization, and overall rates of LDL cholesterol knowledge remained low, and it was not associated with improved cholesterol management.
TL;DR: The study reveals marked hospital-level variation in improvement in beta-blocker use after acute myocardial infarction, and several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of Beta-blockers.
Abstract: Background: National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics. Methods and Results: We used data (n = 335,244 patients with AMI discharged from 682 hospitals) from the National Registry of Myocardial Infarction (NRMI) and from the American Hospital Association Annual Survey of Hospitals and hierarchical modeling to examine the associations between hospital characteristics and hospital-level rates of change in beta-blocker use during 1996-1999. On average, hospital rates of beta-blocker use for patients with AMI increased 5.9 percentage points (standard deviation, 9.7 percentage points) from the premidpoint time period (April 1996-February 1998) to the postmidpoint time period (March 1998-September 1999) of the study. The range in hospital-level changes in beta-blocker rates was substantial, from a decline of - 50.0 percentage points to an increase of +35.7 percentage points. AMI volume and teaching status, geographic region, and initial beta-blocker use rates were associated with rate of improvement, but the magnitude of these effects was modest. Conclusions: The study reveals marked hospital-level variation in improvement in beta-blocker use after AMI. Several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of beta-blockers.
TL;DR: A systematic review of the literature on clinical management of systolic hypertension (SH) in older persons is presented in this paper, showing that the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy to treat SH is supported by strong evidence.
Abstract: ContextThe Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure emphasizes the importance
of systolic hypertension (SH), defined as systolic blood pressure (SBP) of
at least 140 mm Hg and diastolic blood pressure of less than 90 mm Hg, in
older persons (≥60 years).ObjectiveTo systematically review the literature on clinical management of SH
in older persons.Data SourcesWe performed a MEDLINE search of English-language literature from 1966-2004
to identify reports about SH in older persons, with particular emphasis on
data from randomized clinical trials.Study Selection and Data ExtractionWe selected 1064 studies by using the search terms hypertension combined with the terms systole (or systolic) and aged.Data SynthesisThere is strong evidence from clinical trials to support the treatment
of SH in older persons with SBP of at least 160 mm Hg. Large-scale trials
to assess the value of antihypertensive therapy for older patients with SBP
of 140 to 159 mm Hg have not been performed, and recommendations to treat
these patients are based on observational studies that show a graded relationship
of cardiovascular risk with increasing SBP. The studies most strongly support
the use of thiazide diuretics and long-acting calcium channel blockers as
first-line therapy to treat SH.ConclusionsTreatment of SH in older patients with SBP of at least 160 mm Hg is
supported by strong evidence. The evidence available to support treatment
of patients to the level of 140 mm Hg or those with baseline SBP of 140 to
159 mm Hg is less strong; thus, these treatment decisions should be more sensitive
to patient preferences and tolerance of therapy.
TL;DR: Findings support the use of smaller dose, weight-adjusted heparin in patients with ST-elevation myocardial infarction treated with full-dose tenecteplase.
Abstract: We investigated the effect of smaller dose, weight-adjusted heparin with earlier monitoring of activated partial thromboplastin time on the incidence of ischemic and hemorrhagic complications in patients with ST-elevation myocardial infarction treated with full-dose tenecteplase. We compared the outcomes of patients enrolled in the Second Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT-2; n = 8,461) who received heparin stratified by weight (patients weighing >67 kg received a 5,000-U bolus plus infusion at 1,000 U/hour; those weighing < or =67 kg received a 4,000-U bolus plus infusion at 800 U/hour) with patients in ASSENT-3 who received weight-adjusted heparin (60-U/kg bolus, maximum 4,000 U/hour, followed by a 12-U/kg/hour infusion, maximum 1,000 U/hour). Compared with patients in ASSENT-2, those in ASSENT-3 had similar rates of 30-day mortality, recurrent infarction, and intracranial hemorrhage, less major bleeding (2.2% vs 4.7%, p <0.001), and less refractory ischemia (6.5% vs 8.6%, p <0.001). After adjustment for baseline characteristics, patients in ASSENT-3 had similar rates of 30-day mortality (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.77 to 1.19) and intracranial hemorrhage (OR 1.02, 95% CI 0.61 to 1.69) but less major bleeding (OR 0.49, 95% CI 0.35 to 0.67) than did patients in ASSENT-2. These findings support the use of smaller dose, weight-adjusted heparin in patients with ST-elevation myocardial infarction treated with tenecteplase.
TL;DR: Racial differences in the use of some therapies for myocardial infarction in patients hospitalized between 1994 and 1996 varied by region, suggesting that national evaluations of racial differences in health care use may obscure potentially important regional variations.