Showing papers by "Michael J. Fine published in 2005"

Derivation and Validation of a Prognostic Model for Pulmonary Embolism

Abstract: Rationale: An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment.Objectives: To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes.Methods: We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France.Measurements: We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples.Main Results: The prediction rule is based on 11 simple patient ...

Prevalence, Severity, and Importance of Physical and Emotional Symptoms in Chronic Hemodialysis Patients

Abstract: The prevalence, severity, and clinical significance of physical and emotional symptoms in patients who are on maintenance hemodialysis remain incompletely characterized. This study sought to assess symptoms and their relationship to quality of life and depression. The recently developed Dialysis Symptom Index was used to assess the presence and the severity of 30 symptoms. The Illness Effects Questionnaire and Beck Depression Inventory were used to evaluate quality of life and depression, respectively. Correlations among symptom burden, symptom severity, quality of life, and depression were assessed using Spearman correlation coefficient. A total of 162 patients from three dialysis units were enrolled. Mean age was 62 y, 48% were black, 62% were men, and 48% had diabetes. The median number of symptoms was 9.0 (interquartile range 6 to 13). Dry skin, fatigue, itching, and bone/joint pain each were reported by > or =50% of patients. Seven additional symptoms were reported by >33% of patients. Sixteen individual symptoms were described as being more than "somewhat bothersome." Overall symptom burden and severity each were correlated directly with impaired quality of life and depression. In multivariable analyses adjusting for demographic and clinical variables including depression, associations between symptoms and quality of life remained robust. Physical and emotional symptoms are prevalent, can be severe, and are correlated directly with impaired quality of life and depression in maintenance hemodialysis patients. Incorporating a standard assessment of symptoms into the care provided to maintenance hemodialysis patients may provide a means to improve quality of life in this patient population.

Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.

Abstract: Background: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice. Objective: To compare the effectiveness and safety of 3 guideline implementation strategies. Design: Cluster-randomized, controlled trial. Setting: 32 emergency departments in Pennsylvania and Connecticut. Patients: 3219 patients with a clinical and radiographic diagnosis of pneumonia. Interventions: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12). Measurements: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients. Results: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P= 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P< 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P< 0.001). No statistically significant differences in safety outcomes were observed across interventions. Limitations: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial. Conclusions: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.

Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty.

Abstract: Objective The utilization of joint arthroplasty for knee or hip osteoarthritis varies markedly by patient race/ethnicity. Because of concerns about surgical risk, black patients are less willing to consider this treatment. There are few published race/ethnicity-specific data on joint arthroplasty outcomes. The present study was undertaken to examine racial/ethnic differences in mortality and morbidity following elective knee or hip arthroplasty. Methods Using information from the Veterans Administration National Surgical Quality Improvement Program database, data on 12,108 patients who underwent knee arthroplasty and 6,703 patients who underwent hip arthroplasty over a 5-year period were analyzed. Racial/ethnic differences were determined using prospectively collected data on patient characteristics, procedures, and short-term outcomes. The main outcome measures were risk-adjusted 30-day mortality and complication rates. Results Adjusted rates of both non–infection-related and infection-related complications after knee arthroplasty were higher among black patients compared with white patients (relative risk [RR] 1.50, 95% confidence interval [95% CI] 1.08–2.10 and RR 1.42, 95% CI 1.06–1.90, respectively). Hispanic patients had a significantly higher risk of infection-related complications after knee arthroplasty (RR 1.64, 95% CI 1.08–2.49) relative to otherwise similar white patients. Race/ethnicity was not significantly associated with the risk of non–infection-related complications (RR 0.97, 95% CI 0.68–1.38 in blacks; RR 1.18, 95% CI 0.60–2.30 in Hispanics) or infection-related complications (RR 1.27, 95% CI 0.91–1.78 in blacks; RR 1.22, 95% CI 0.63–2.36 in Hispanics) after hip arthroplasty. The overall 30-day mortality was 0.6% following knee arthroplasty and 0.7% following hip arthroplasty, with no significant differences by race/ethnicity observed for either procedure. Conclusion Although absolute risks of complication are low, our findings indicate that, after adjustment, black patients have significantly higher rates of infection-related and non–infection-related complications following knee arthroplasty, compared with white patients. In addition, adjusted rates of infection-related complications after knee arthroplasty are higher in Hispanic patients than in white patients. Such differences between ethnic groups are not seen following hip arthroplasty. These groups do not appear to differ significantly in terms of post-arthroplasty mortality rates.

How does depression influence diabetes medication adherence in older patients

Abstract: Objective Using various measures (electronic monitoring, patient/provider report, pharmacy data), the authors assessed the association between depression and diabetes medication adherence among older patients with Type 2 diabetes. Methods Patients completed a baseline survey on depression (Patient Health Questionnaire) and were given electronic monitoring caps (EMCs) to use with their oral hypoglycemic medication. At the time of the patient baseline survey, providers completed a survey on their patients' overall medication adherence. Upon returning the caps after 30 days, patients completed a survey on their overall medication adherence. EMC adherence was defined as percent of days out of 30 with correct number of doses. Using pharmacy refill data from the patient baseline through 1 year later, they defined adherence as the percentage of days with adequate medication, based on days' supply across refill periods. Results Of 203 patients (mean age: 67 years), 10% (N = 19) were depressed. Depressed patients were less likely to self-report good adherence and had a lower median percentage of days with adequate medication coverage (on the basis of pharmacy refill data). After adjustment for alcohol use, cognitive impairment, age, and other medication use, depression was still negatively associated with adequate adherence, according to patient report and pharmacy data. Depression showed no associated with adherence on the basis of provider or EMC data. Conclusions Depression was independently associated with inadequate medication adherence on the basis of patient self-report and pharmacy data.

The role of race and genetics in health disparities research.

Abstract: Over the past decade, 2 powerful scientific movements in the United States, population genetics and health disparities research, have re-ignited a contentious debate on the complex relationships between genes, race, and disease.1–3 The debate is fueled by the Human Genome Project, the increased technological capacity to map the entire human genome (the library of DNA building blocks), and the concerted national efforts to reduce racial disparities in health and health care. Many scientists believe that an understanding of the unique patterns of genes across patient populations defined by race will help identify populations at risk of developing particular diseases and ultimately enable the medical profession to tailor preventive medicine and therapies to those most likely to respond.4 A central premise of this field of investigation is that race is an inherent biological characteristic that accurately reflects human ancestry and the flow of common threads of genetic material in biologically distinct populations over time and geography. Health disparities research focuses on understanding the complex associations between race, health, and health care. Stimulated by the Healthy People 2010 initiative5 and an Institute of Medicine report documenting inequities in medical treatment among racial minorities,6 many health services, social sciences, and public health investigators have come to view race as a social and cultural construct, not a biological construct to be used in studies of race and human illness. Differences of opinion on the appropriate way to apply the construct of race in biomedical and health services research raise 3 important questions for medical and public health practitioners, scientists, policymakers, and funding agencies committed to advancing both biomedical and health disparities research agendas: What are the arguments for and against using a biological definition of race in medical research? What is the best way to articulate a comprehensive health disparities research agenda? What are the current and future roles of genetics in advancing the health disparities research agenda?

Algorithm for assessing patients' adherence to oral hypoglycemic medication.

Abstract: Clinically useful and accurate medication adherence measures are necessary for optimal diabetes mellitus management in routine practice. While electronic monitoring caps (EMCs) have been considered state-of-the-art in measuring medication adherence,[1–][1],[4][2] their use is limited because they

Effect of Increasing the Intensity of Implementing Pneumonia Guidelines

Abstract: The authors implemented a guideline for deciding whether to manage community-acquired pneumonia in the hospital or at home. Guideline implementation strategies were low, moderate, and high intensit...

Implementation of an inpatient management and discharge strategy for patients with community-acquired pneumonia.

Abstract: OBJECTIVE To assess the effectiveness and safety of implementing an inpatient management and discharge strategy based on empiric antibiotic therapy with ceftriaxone sodium and a guideline to promote timely discharge for clinically stable patients hospitalized with community-acquired pneumonia. STUDY DESIGN A cluster randomized controlled clinical trial with 30 days of patient follow-up at 8 teaching hospitals and 17 nonteaching hospitals nationwide. METHODS Participants included 240 intervention patients and 209 control patients admitted by 85 physician groups between December 1998 and December 1999. Within each hospital, defined physician practice groups were randomized to the intervention arm (physician notification coupled with ceftriaxone sodium as empiric therapy) or control arm (neither component). Physicians in the intervention arm were notified when their patients met guideline criteria for clinical stability; physicians in the control arm were not contacted. RESULTS The median length of stay was 4 days in both study arms. The observed reduction in costs associated with the intervention was not statistically significant when cost outliers were excluded. Mortality, serious adverse event, and rehospitalization rates did not differ significantly across study arms. CONCLUSIONS Implementation of an inpatient management strategy based on physician reminders coupled with empiric use of ceftriaxone sodium did not reduce length of stay or associated medical care costs for patients hospitalized with community-acquired pneumonia. These negative findings are most likely due to insufficient potency of the intervention, inadequate guideline implementation, or imbalances in baseline patient characteristics.

Effect of both elevated troponin-I and peripheral white blood cell count on prognosis in patients with suspected myocardial injury.

Abstract: We found a high white blood cell count (>11,000/mul) to be of additive prognostic value to high troponin-I levels in predicting risk of recurrent nonfatal myocardial infarctions and all-cause mortality in patients who present with acute coronary syndromes and non-ST-elevation myocardial infarctions. A high troponin-I level or white blood cell count increased the odds ratio of an event to 2.2 (95% confidence interval 1.0 to 4.73, p = 0.05), but high values for the 2 markers increased the odds ratio to 4.5 (95% confidence interval 1.42 to 14.21, p = 0.01).