Showing papers by "Lee Goldman published in 1997"

The Recent Decline in Mortality From Coronary Heart Disease, 1980-1990: The Effect of Secular Trends in Risk Factors and Treatment

Abstract: Objective. —To examine whether secular trends in risk factor levels and improvements in treatment can account for the observed decline in coronary heart disease mortality in the United States from 1980 to 1990 and to analyze the proportional contribution of these changes. Data Sources. —Literature review, US statistics, health surveys, and ongoing clinical trials. Study Selection. —Data representative of the US situation nationwide reported in adequate detail. Data Extraction. —A computer-simulation state-transition model of the US population between the ages of 35 and 84 years was developed to forecast coronary mortality. The input variables were estimated such that the combination of values led to an adequate agreement with reported coronary mortality figures. Subsequently, secular trends were modeled. Data Synthesis. —Actual coronary mortality in 1990 was 34% (127 000 deaths) lower than would be predicted if risk factor levels, case-fatality rates, and event rates in those with and without coronary disease remained the same as in 1980. When secular changes in these factors were included in the model, predicted coronary mortality in 1990 was within 3% (10 000 deaths) of the observed mortality and explained 92% of the decline; only 25% of the decline was explained by primary prevention, while 29% was explained by secondary reduction in risk factors in patients with coronary disease and 43% by other improvements in treatment in patients with coronary disease. Conclusions. —These results suggest that primary and secondary risk factor reductions explain about 50% of the striking decline in coronary mortality in the United States between 1980 and 1990 but that more than 70% of the overall decline in mortality has occurred among patients with coronary disease.

Adverse Outcomes of Underuse of β-Blockers in Elderly Survivors of Acute Myocardial Infarction

Abstract: Objectives. —To study determinants and adverse outcomes (mortality and rehospitalization) of β-blocker underuse in elderly patients with myocardial infarction; and whether the relative risks (RRs) of survival associated with β-blocker use were comparable to those reported in the large randomized controlled trials (RCTs). Setting. —New Jersey Medicare population. Design. —Retrospective cohort design using linked Medicare and drug claims data from 1987 to 1992. Patients. —Statewide cohort of 5332 elderly 30-day acute myocardial infarction (AMI) survivors with prescription drug coverage, of whom 3737 were eligible for β-blockers. Main Outcome Measures. —β-Blocker and calcium channel blocker use in the first 90 days after discharge and mortality rates and cardiac hospital readmissions over the 2-year period after discharge, controlling for sociodemographic and baseline risk variables. Results. —Only 21% of eligible patients received β-blocker therapy; this rate remained unchanged from 1987 to 1991. Patients were almost 3 times more likely to receive a new prescription for a calcium channel blocker than for a new β-blocker after their AMIs. Advanced age and calcium channel blocker use predicted underuse of β-blockers. Controlling for other predictors of survival, the mortality rate among β-blocker recipients was 43% less than that for nonrecipients (RR=0.57; 95% confidence interval [CI], 0.47-0.69). Effects on mortality were substantial in all age strata (65-74 years, 75-84 years, and ≥85 years) and consistent with the results for elderly subgroups of 2 large RCTs. β-Blocker recipients were rehospitalized 22% less often than nonrecipients (RR=0.78; 95% CI, 0.67-0.90). Use of a calcium channel blocker instead of a β-blocker was associated with a doubled risk of death (RR=1.98; 95% CI, 1.44-2.72), not because calcium channel blockers had a demonstrable adverse effect, but because they were substitutes for β-blockers. Conclusions. —β-Blockers are underused in elderly AMI survivors, leading to measurable adverse outcomes. These data suggest that the survival benefits of β-blockade after an AMI may extend to eligible patients older than 75 years, a group that has been excluded from RCTs.

Correlates of Early Hospital Readmission or Death in Patients With Congestive Heart Failure

Abstract: Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of ≤100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients. To determine correlates of early readmission or death, we prospectively followed 257 patients admitted to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph. Single marital status, increasing comorbidity, relative hypotension, and absence of new ST-T-wave changes on initial electrocardiogram were the correlates, but we could not reliably identify a truly low-risk group.

Factors contributing to the hospitalization of patients with congestive heart failure.

Abstract: OBJECTIVES: This study identifies acute precipitants of hospitalization and evaluates utilization of angiotension-converting enzyme inhibitors in patients admitted with congestive heart failure. METHODS: Cross-sectional chart-review study was done of 435 patients admitted nonelectively from February 1993 to February 1994 to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure. RESULTS: The most common identifiable abnormalities associated with clinical deterioration prior to admission were acute anginal chest pain (33%), respiratory infection (16%), uncontrolled hypertension with initial systolic blood pressure > or = 180 mm Hg (15%), atrial arrhythmia with heart rate > or = 120 (8%), and noncompliance with medications (15%) or diet (6%); in 34% of patients, no clear cause could be identified. After exclusion of those who were already on a different vasodilator or who had relative contraindications, 18 (32%) of the patients with ejection ...

Health-related quality of life after elective surgery: measurement of longitudinal changes.

Abstract: Objective: To examine the responsiveness of the 36-Item Short Form Health Survey (SF-36) to clinical changes in three surgical groups and to study how health-related quality of life (HRQL) changes with time among patients who undergo total hip arthroplasty, thoracic surgery for treatment of non-small-cell lung cancer, or abdominal aortic aneurysm (AAA) repair.

Patient experience of pain after elective noncardiac surgery

Abstract: The purpose of this study was to examine the extent and evolution of pain after common major surgical procedures and to establish correlates of three types of pain: pain at rest, pain with movement, and maximum pain over the previous 24 h. Patients completed a preoperative questionnaire to obtain data on age, gender, narcotic use, baseline level of pain, chronicity of pain, and level of anxiety. Patients were then interviewed on Postoperative Days 1, 2, and 3 to assess their pain on a scale of 0 (none) to 10 (worst imaginable). The mean pain score at rest was 2.6 on Postoperative Day 1 and decreased to 2.3 on Postoperative Day 3 (P = 0.06). The mean pain score with movement was 4.5 on Postoperative Day 1, which decreased to 4.2 on Postoperative Day 3 (P = 0.03). The mean maximum pain score over the previous 24 h was 6.3, which decreased to 5.6 (P = 0.0001). Preoperative narcotic use and high baseline preoperative pain, defined as a score > or = 4, were significantly (P < 0.05) associated with increased pain at rest, pain with movement, and maximum pain. Epidural analgesia was the only mode of analgesia significantly associated with both decreased postoperative pain at rest and decreased pain with movement (P < 0.05). These relatively high pain scores and minimum decreases in pain from Postoperative Days 1 to 3 emphasizes the need for more effective pain management continuing into the postoperative period to facilitate mobilization and recovery.

Cost-effectiveness of populationwide educational approaches to reduce serum cholesterol levels.

Abstract: Background The aim of the present study was to estimate the cost-effectiveness of populationwide approaches to reduce serum cholesterol levels in the US adult population. Methods and Results This cost-effectiveness analysis was made from data from the literature and the Coronary Heart Disease Policy Model and was based on the US population age 35 to 84 years. Study interventions were populationwide programs to reduce serum cholesterol levels with costs and cholesterol-lowering effects similar to those reported from the Stanford Three-Community Study, the Stanford Five-City Project, and in North Karelia, Finland. The main outcome measures were cost-effectiveness ratios, defined as the change in projected cost divided by the change in projected life-years when the population receives the intervention compared with the population without the intervention. A populationwide program with the costs ($4.95 per person per year) and cholesterol-lowering effects (an average 2% reduction in serum cholesterol levels) of the Stanford Five-City Project would prolong life at an estimated cost of only $3200 per year of life saved. Under a wide variety of assumptions, a populationwide program would achieve health benefits at a cost equivalent to that of many currently accepted medical interventions. Such programs would also lengthen life and save resources under many scenarios, especially if the program affected persons with preexisting heart disease or altered other coronary risk factors. Conclusions Populationwide programs should be part of any national health strategy to reduce coronary heart disease.

Is Experience a Good Teacher? How Interns and Attending Physicians Understand Patients' Choices for End-of-life Care

Abstract: Background. Recent studies have shown that physicians do not accurately assess patients' health status or treatment preferences. Little is known, however, about how physicians' levels of training or experience relate to their abilities to assess these preferences. To better understand this phenomenon, the authors compared the abilities of medical interns and attending physicians to predict the choices of their adult patients for end-of-life care. Methods. 230 seriously-ill adult inpatients were surveyed about their desires for cardiopulmonary resuscitation, their current quality of life, and their attitudes toward six other common adverse outcomes. The medical intern and attending physician who cared for these patients were asked to estimate the patient's responses for all of the same items. Agreement was assessed using the kappa statistic. Results. Compared with interns, attending physicians had known patients longer, had talked with patients more frequently about prognosis, and felt they knew more about...

Adult (Not Internal) Medicine

Abstract: The term internal medicine originated from the German Inneren Medizin, which came into common usage in the 1880s [1]. Internal medicine in Germany was distinguished from clinical medicine because of its new emphasis on experimental physiology and chemistry rather than the progression of disease manifestations [1]. Unlike most specialists, who are clearly identified by technique (for example, surgery), body part (for example, ophthalmology), or target population (for example, pediatrics) [1], internists are commonly confused with interns and are frequently asked by patients and friends, Exactly what does internal medicine mean? Although everyone understands the meaning of the word family and ascribes value to it, the word internal suggests something mysterious, unseen, and quite possibly unpleasant. In recognition of this problem, the American College of Physicians has developed a brochure entitled Internal medicine. Doctors for adults. Where we fit in today's primary care picture [2] and a campaign to educate the public on the role and function of the internist. An analogous but far less ambitious campaign was undertaken more than a decade ago, when the upsurge in primary care internal medicine was just beginning and the distinction between the diagnostic consultant [3] and the primary care internist needed to be clarified. At that time, Kurtz and Goodman [4] argued that internists, including both generalists and subspecialists, should be called adult medicine specialists. Many years later, it still seems that an unhelpful or poorly descriptive name should be changed, not clarified with subtitles. My suggestion is that we change the name from internal medicine to adult medicine. Why adult? The answer is simple: Internists care for adults and only adults. Family physicians will always have an advantage for persons who are looking for one doctor to take care of all members of a family, but physicians who specialize in adult medicine should be distinguished for their expertise and be able to benefit from it. Why medicine? Medicine has historically been differentiated from surgery, and it capitalizes on such concepts as medical doctor. The strong cache and tradition associated with that term would quickly be adopted by various pretenders if it were abandoned. Any time an individual or an organization changes its name, the first question is, Why? Does the change imply different missions or values? Will the new name be preferable in explanatory power, marketability, or prestige? For practitioners of internal medicine, professional pride is linked to the German roots of our name. We have historically emphasized the scientific basis of diagnosis and therapy, and both our training and practice emphasize an understanding of disease mechanisms rather than a symptom-driven approach. This detailed knowledge of the physiology, chemistry, cell biology, and genetics of the human organism is a fundamental part of our heritage, and our belief that an improved understanding of normal and abnormal biology is the cornerstone for better patient care. Unfortunately, in the modern English vernacular, the word internal does not symbolize this emphasis. In our current lexicon, the term scientific more closely captures the distinction sought in 19th-century Germany. It seems unlikely, however, that we would want to rename our field scientific medicine or expect to be called scientists. Although we must be sure that our training, continuing education, and practice emphasize the scientific basis that engendered the term internal and that still distinguishes our culture, adult medicine must also indicate expertise in screening, preventive care, common ambulatory problems, and the behavioral and ethical aspects of health and disease. Adoption of the term adult medicine does not mean an abandonment of diagnostic or therapeutic skills that are based firmly in fundamental biomedical and psychosocial sciences, yet it can symbolize that our discipline now expresses these skills in a spectrum that includes prevention and comprehensive care as well as acute disease. Adult medicine could easily apply to both generalists and specialists. For general adult medical doctors, the new label would probably be helpful in explaining how their expertise can be distinguished from that of a family physician. When patients in a managed care environment choose a primary care physician, a listing under adult medicine is likely to be far more understandable than a listing under internal medicine. Adult medical subspecialists would probably notice little (if any) difference, and their disciplinary labels, which generally refer to body parts, would remain unchanged. A cardiologist, with or without the prefix adult, would be an adult heart specialist, whereas a counterpart who cares for children would continue to be a pediatric cardiologist. Of course, any name change has some potential downsides. For example, internists specializing in adolescent medicine may feel abandoned by the new name, although it is consistent with the reality that this specialty sits at the interface between pediatrics and adult medicine. A name change might also be seen as the first step down a slippery slope toward a merger of general internal medicine with family medicine, with joint programs and a single certification process, whereas medical specialists would diverge from general internal medicine with separate certifying boards, academic departments, and so forth. The change in name from internal medicine to adult medicine should not have a major effect on this generalist-specialist debate. If anything, a clearer definition of adult general medicine may enhance unity among adult generalists and specialists. For physicians from disciplines other than internal medicine, the change in name is unlikely to have profound implications. A possible exception is that family physicians may contend that the new name represents advertisement or aggrandizement. However, just as pediatrics and family medicine are labels that recognize the segment of the population served, the same is clearly true of the label adult medicine. From the patients' perspective, there seem to be few disadvantages. Of course, the occasional patient who understands what an internist is would have to be reeducated about the new name. Informal surveys, however, suggest that most patients do not understand the current name, and those cognoscenti who do are probably the easiest to reeducate. An implicit effect of naming a specialty is that its practitioners assume an analogous name. Doctors who do surgery are surgeons, doctors who do family medicine are family physicians, and doctors who do internal medicine are internists. The term internist is often confused with intern and is thus ambiguous at best. A potential concern is that adult medicine physicians would be called adultists; however, an analogous issue has been successfully addressed in family medicine, whose practitioners are routinely called family physicians, not familialists. Practitioners of adult medicine could promulgate such terms as doctors for adults [2], adult doctor, adult physician, or adult medical doctor. A name change, although certainly not sufficient to address the many vexing issues facing internal medicine, would capitalize on the current initiatives of the American College of Physicians and related groups. The change in name and its implied extension of professional scope to include prevention and comprehensive care as well as science-based diagnostics and acute therapy will not signify an abandonment of traditional strengths but rather a recognition that broader strengths are likely to be more important for the foreseeable future. If adult medicine doctors do those things well, their value and role in the health care system of the future will be apparent to everyone.

Factors Contributing to Declines in Cardiac Mortality-Reply

Abstract: In Reply. —Dr Rumm and colleagues are incorrect in their assertion that our model was designed to favor treatment over prevention. In fact, we modeled known changes in risk factors and in outcomes of treatment to determine whether these changes could explain the known decline in mortality. As with any model, it is possible that any of our estimates could be incorrect, but we provided detailed information for peer review and believe it is inappropriate to claim we were somehow biased in favor of treatment over prevention. As we acknowledge in the Comment section, trends in aspirin use, estrogen replacement therapy, and exercise regimens may be important factors that we omitted from our analysis. Although causes other than risk factors or medical interventions may have played a major role as suggested by Rumm and colleagues, this remains speculative in the absence of data to support such a statement with respect to CHD

Adverse Outcomes of Underuse of β-Blockers in Elderly Patients-Reply

Abstract: In Reply. —Dr Gambassi and colleagues and Dr Holt suggest that the nondihydropyridine calcium channel blockers (eg, verapamil and diltiazem) may be safer or more effective than dihydropyridine calcium channel blockers. However, our study was designed to measure outcomes of β-blocker underuse, not to assess the comparative efficacy of calcium channel blockers. A comparative study would require a different sample (not only patients eligible for β-blockers). Instead, we studied the effects of the substitution of any calcium channel blocker for a trial of β-blockers in patients eligible for β-blockers, a practice at odds with national evidence-based guidelines.1 Gambassi et al also question whether 2 effective drug classes, aspirin and lipid-lowering agents, might be correlated with β-blocker use. Because aspirin is an over-thecounter drug, administrative claims databases do not contain reliable data on its use in community settings. However, a previous report from the United Kingdom indicates much greater use of aspirin