Barbara L. Lytle

Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality.

Objectives Social isolation has been linked to poor survival in patients with coronary artery disease (CAD). Few studies have closely examined the psychosocial characteristics of CAD patients who lack social contact. Methods Social isolation was examined as a predictor of mortality in 430 patients with significant CAD. More isolated patients were compared with their less isolated counterparts on factors that might help explain the association between isolation and survival. Results The mortality rate was higher among isolated individuals. Those with three or fewer people in their social support network had a relative risk of 2.43 (p = .001) for cardiac mortality and 2.11 (p = .001) for all-cause mortality, controlling for age and disease severity. Adjustments for income, hostility, and smoking status did not alter the risk due to social isolation. With the exception of lower income, higher hostility ratings, and higher smoking rates, isolated patients did not differ from nonisolated patients on demographic indicators, disease severity, physical functioning, or psychological distress. Isolated patients reported less social support and were less pleased with the way they got along with network members, but they did not report less satisfaction with the amount of social contact received. Conclusions Patients with small social networks had an elevated risk of mortality, but this greater risk was not attributable to confounding with disease severity, demographics, or psychological distress. These findings have implications for mechanisms linking social isolation to mortality and for the application of psychosocial interventions.

Caregiver burden in partners of Vietnam war veterans with posttraumatic stress disorder

Caregiver burden in 58 partners of Vietnam veterans with posttraumatic stress disorder (PTSD) was examined. The relationship between patient PTSD severity and caregiver burden, as well as the effect of several caregiver and patient variables on caregiver psychological status, was evaluated twice, an average of 8 months apart. Patient symptom severity was positively correlated with caregiver burden. Time 1 cross-sectional analysis indicated that greater caregiver burden was associated with greater caregiver psychological distress, dysphoria, and anxiety. Patient symptom severity also contributed to caregiver psychological distress; financial stress contributed to caregiver dysphoria and trait anxiety. Time 2 cross-sectional analyses essentially replicated the Time 1 findings. A third set of analyses examining change scores indicated that changes in caregiver burden for individuals in the sample positively predicted individual changes in caregiver psychological distress, dysphoria, and state anxiety.

Self-Efficacy and Adjustment in Cancer Patients: A Preliminary Report

The relation between cancer self-efficacy and patient cancer adjustment, depression, psychological distress, and behavioral dysfunction in 42 cancer patients was studied in a preliminary investigation. Participants were male cancer outpatients recruited from a Veterans Administration Medical Center who completed a Cancer Self-Efficacy Scale, the Center for Epidemiological Studies-Depression Scale, the Affect Balance Scale, and the Sickness Impact Profile. Correlational analyses indicated that self-efficacy was related to all adjustment measures. Regression analyses revealed that when age, education, time since initial diagnosis, and current disease status were controlled, the relationships between patient self-efficacy expectations and cancer adjustment, psychological distress, negative affect, positive affect, and behavioral dysfunction remained statistically significant. Taken together, the results of the analyses suggested that patient expectancies about control over cancer-related symptoms were related to several important aspects of patient functioning. The results underscored the need for further investigation of this construct in cancer patients.

The NCDR ACTION Registry–GWTG: transforming contemporary acute myocardial infarction clinical care

Aims The NCDR ACTION Registry-GWTG collects detailed in-hospital clinical, process-of-care and outcomes data for patients admitted with acute myocardial infarction (AMI) in the USA. The registry is a national AMI surveillance system that contributes to the scientific enquiry process of AMI care through the facilitation of local and national quality improvement efforts. Interventions No treatments are mandated, participating centres receive routine quality-of-care and outcomes performance feedback reports and access to quality of care tools, such as dosing algorithms and standing orders. Population AMI patients are retrospectively identified. No informed consent is required, as data are anonymised. From January 2007 to date, 147 165 records have been submitted from 383 participating US hospitals. Patients with a primary diagnosis of ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction are eligible for enrolment in the registry. These patients must have ischemic symptoms and electrocardiogram changes, and/or positive cardiac markers within 24 hours of initial presentation. Baseline data Approximately 350 fields encompassing patient demographics, medical history and risk factors, hospital presentation, initial cardiac status, medications and associated doses, reperfusion strategy, procedures, laboratory values, and outcomes. Data are manually entered by study personnel; there are non-financial incentives at the hospital level. Completeness within the registry is noteworthy with most fields at less than 5% missing. Endpoints Main outcome measures include American College of Cardiology/American Heart Association myocardial infarction performance indicators, as well as in-hospital patient outcomes. Data are available for research by application to: http://www.ncdr.com.

National survey of hospital strategies to reduce heart failure readmissions findings from the get with the guidelines-heart failure registry

Background— Reducing 30-day heart failure readmission rates is a national priority. Yet, little is known about how hospitals address the problem and whether hospital-based processes of care are associated with reductions in readmission rates. Methods and Results— We surveyed 100 randomly selected hospitals participating in the Get With the Guidelines-Heart Failure quality improvement program regarding common processes of care aimed at reducing readmissions. We grouped processes into 3 domains (ie, inpatient care, discharge and transitional care, and general quality improvement) and scored hospitals on the basis of survey responses using processes selected a priori. We used linear regression to examine associations between these domain scores and 30-day risk-standardized readmission rates. Of the 100 participating sites, 28% were academic centers and 64% were community hospitals. The median readmission rate among participating sites (24.0%; 95% CI, 22.6%–25.7%) was comparable with the national average (24.6%; 23.5–25.9). Sites varied substantially in care processes used for inpatient care, education, discharge process, care transitions, and quality improvement. Overall, neither inpatient care nor general quality improvement domains were associated with 30-day readmission rates. Hospitals in the lowest readmission rate quartile had modestly higher discharge and transitional care domain scores ( P =0.03). Conclusions— A variety of strategies are used by hospitals in an attempt to improve 30-day readmission rates for patients hospitalized with heart failure. Although more complete discharge and transitional care processes may be modestly associated with lower 30-day readmission rates, most current strategies are not associated with lower readmission rates.Background—Reducing 30-day heart failure readmission rates is a national priority. Yet, little is known about how hospitals address the problem and whether hospital-based processes of care are associated with reductions in readmission rates. Methods and Results—We surveyed 100 randomly selected hospitals participating in the Get With the Guidelines-Heart Failure quality improvement program regarding common processes of care aimed at reducing readmissions. We grouped processes into 3 domains (ie, inpatient care, discharge and transitional care, and general quality improvement) and scored hospitals on the basis of survey responses using processes selected a priori. We used linear regression to examine associations between these domain scores and 30-day risk-standardized readmission rates. Of the 100 participating sites, 28% were academic centers and 64% were community hospitals. The median readmission rate among participating sites (24.0%; 95% CI, 22.6%–25.7%) was comparable with the national average (24.6%; 23.5–25.9). Sites varied substantially in care processes used for inpatient care, education, discharge process, care transitions, and quality improvement. Overall, neither inpatient care nor general quality improvement domains were associated with 30-day readmission rates. Hospitals in the lowest readmission rate quartile had modestly higher discharge and transitional care domain scores (P=0.03). Conclusions—A variety of strategies are used by hospitals in an attempt to improve 30-day readmission rates for patients hospitalized with heart failure. Although more complete discharge and transitional care processes may be modestly associated with lower 30-day readmission rates, most current strategies are not associated with lower readmission rates.

The Impact of a Statewide Pre-Hospital STEMI Strategy to Bypass Hospitals Without Percutaneous Coronary Intervention Capability on Treatment Times

Background— The ultimate treatment goal for ST-segment elevation myocardial infarction (STEMI) is rapid reperfusion via primary percutaneous intervention (PCI). North Carolina has adopted a statewide STEMI referral strategy that advises paramedics to bypass local hospitals and transport STEMI patients directly to a PCI-capable hospital, even if a non-PCI-capable hospital is closer. Methods and Results— We assessed the adherence of emergency medical services to this STEMI protocol, as well as subsequent associations with patient treatment times and outcomes by linking data from the Acute Coronary Treatment and Intervention Outcomes Network Registry®—Get With the Guidelines™ and a statewide emergency medical services data system from June 2008 to September 2010 for all patients with STEMI. Patients were divided into those (1) transported directly to a PCI hospital, thereby bypassing a closer non-PCI hospital and (2) first taken to a closer non-PCI center and later transferred to a PCI hospital. Among 6010 patients with STEMI, 1288 were eligible and included in our study cohort. Of these, 826 (64%) were transported directly to a PCI facility, whereas 462 (36%) were first taken to a non-PCI hospital and later transferred. In a multivariable model, increase in differential driving time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center, whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center. Patients sent directly to a PCI center were more likely to have times between first medical contact and PCI within guideline recommendations. Conclusions— We found that patients who were sent directly to a PCI center had significantly shorter time to reperfusion.

Potential unintended financial consequences of pay-for-performance on the quality of care for minority patients

OBJECTIVES The purpose of this study was to determine whether pay-for-performance (PFP) increases existing racial care disparities. BACKGROUND Medicares PFP program provides financial rewards to hospitals whose care performance ranks in the highest quintile relative to peers and reduces funding to hospitals that rank in the lowest quintile. Pay-for-performance is designed to improve care but may disproportionately penalize hospitals caring for large minority populations. METHODS Using Medicare data, 3449 US hospitals were ranked by performance on PFP process measures for acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and heart failure (HF). These rankings were compared with the percentage of African American (AA) patients in a center. We determined the eligibility for financial bonus (highest quintile ranking) or penalty (lowest quintile) among centers treating large AA populations (> or = 20%) versus not after adjusting for hospital facility (catheterization, percutaneous coronary intervention, surgery), academic status, number of hospital beds, location, patient volume, and region. RESULTS The percentage of AA patients treated by a center was inversely associated with performance for AMI and CAP (P < .01) but not HF (P = .06). Relative to hospitals with < 20% AA, those with > or = 20% AA were less likely eligible for financial bonuses and more likely to face penalties: for AMI, adjusted odds ratio (OR) 0.7 (95% CI 0.5-1.0) and 1.8 (1.4-2.4), respectively; for CAP, OR 0.5 (95% CI 0.3-0.6) and 2.3 (1.8-2.9), respectively; for HF, OR 1.0 (95% CI 0.7-1.2) and 1.2 (0.9-1.5), respectively. CONCLUSIONS Hospitals with large minority populations may be at financial risk under PFP. Thus, PFP may worsen existing racial care disparities.

Smoking withdrawal symptoms in response to a trauma-related stressor among vietnam combat veterans with posttraumatic stress disorder☆

This study investigated the relationship between a trauma-related stressor and smoking withdrawal symptoms in 25 male Vietnam combat veterans with posttraumatic stress disorder (PTSD) using a within-subjects design. All subjects were smokers. The stressor involved a modified Stroop task, in which the veterans color-named either anxiety-related or neutral control words. Anxiety-related words produced more withdrawal symptoms than neutral control words, including increased craving, negative affect symptoms, somatic symptoms, and lack of alertness.

Minnesota multiphasic personality inventory profiles of Vietnam combat veterans with posttraumatic stress disorder and their children

Forty children of 28 fathers who are Vietnam veterans with posttraumatic stress disorder (PTSD) completed the Minnesota Multiphasic Personality Inventory. Each of the fathers had at least one elevated clinical scale. Fathers averaged eight elevated clinical scales, and compared to more recent norms, fathers averaged seven elevated clinical scales. Seventy-eight percent of the children had at least one clinically elevated scale (averaging three elevated clinical scales). Compared to contemporary normal adolescents and adults, 65% of children had at least one clinically elevated scale (still averaging three elevated clinical scales). No consistent MMPI profile patterns emerged within or across the two groups. No gender differences were detected among child MMPI profiles. Forty percent of the children reported illegal drug use, and 35% reported behavior problems. Fifteen percent of children reported previous violent behavior. Eighty-three percent of the children reported elevated Cook-Medley hostility scores as compared to an age-matched national normative sample. Children with higher PK scores were also significantly more likely to report higher Cook-Medley hostility scores. Forty-five percent of children reported significant elevations on the PTSD/PK subscales.

Influence of Racial Disparities in Procedure Use on Functional Status Outcomes Among Patients With Coronary Artery Disease

Background—Although black cardiac patients receive fewer revascularization procedures than whites, it is unclear whether this has a detrimental impact on outcomes. The objective of our study was to compare 6-month functional status and angina outcomes among blacks and whites with documented coronary disease and to assess whether differential use of revascularization procedures affects these outcomes. Methods and Results—We identified a prospective cohort of 1534 white and 337 black patients undergoing cardiac catheterization between August 1998 and April 2001. Health status was assessed at baseline and 6 months with the Short-Form 36 (SF-36) Health Survey and the Seattle Angina Questionnaire (SAQ) Angina Frequency Scale. Compared with whites, blacks received fewer coronary revascularization procedures (52.5% versus 66.0%; P<0.01). By 6 months, blacks had similar mortality (odds ratio, 1.03; 95% CI, 0.57 to 1.9) but worse scores in 5 SF-36 domains (physical, social, role physical, role emotional, and mental health function). Blacks also reported higher rates of angina at 6 months than whites (34.2% versus 24.6%; P<0.01). After adjustment for baseline functional status and clinical and demographic variables, blacks had significantly worse summary physical component scores, summary mental component scores, and SAQ Angina Frequency Scale scores. However, differences in physical component summary scores and SAQ scores between blacks and whites were no longer significant after adjustment for revascularization status. Conclusions—Our study is among the first to document greater symptoms and functional impairment among black cardiac patients relative to whites. Differential use of coronary revascularization may contribute to the poorer functional outcomes observed among black patients with documented coronary disease.