David W. Hosmer

A communitywide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease.

BackgroundThe purpose of the study was to examine overall differences and temporal trends therein between men and women regarding the incidence rates, in-hospital and long-term survival after initial acute myocardial infarction (AMI), and out-of-hospital deaths caused by coronary disease Methods and ResultsThis nonconcurrent prospective study was carried out in 16 teaching and community hospitals in Worcester, Mass., in six time periods between 1975 and 1988. A total of 3,148 patients hospitalized with validated initial AMI comprised the study sample. The age-adjusted incidence rates of initial AMI increased between 1975 and 1981 in the two sexes, with a marked decrease thereafter, these rates declined by 26% in men and by 22% in women between 1975 and 1988. The overall unadjusted in-hospital case-fatality rates after initial AMI were significantly higher in women (21.7%) than in men (12.7%). Age- and multivariable-adjusted in-hospital case-fatality rates, however, were not significantly different for men compared with women (multivariate-adjusted OR, 0.90; 95% CI, 0.70, 1.16). No clear trends in in-hospital case-fatality rates were observed in men or women over the periods under study. There were no significant sex differences in the age-adjusted long-term survival rates of discharged hospital survivors of AMI. The multivariate-adjusted risk of total mortality among discharged hospital survivors, however, was significantly increased in men (multivariate-adjusted OR, 1.20; 95% CI, 1.03, 1.39); neither of the sexes experienced an improvement over time in long-term prognosis. The incidence rates of out-of-hospital deaths caused by coronary disease declined by 60%o in men and 69%o in women between 1975 and 1988. ConclusionThe results of this multihospital, community-based study suggest declines in the incidence rates of AMI and out-of-hospital deaths caused by coronary disease in men and women over the period under study (1975–1988). No significant sex differences in in-hospital survival were observed, whereas a poorer long-term survival experience after hospital discharge was observed for men compared with women after controlling for potentially confounding prognostic factors. (Circulation 1993;87:1947-1953)

Medicare treatment differences for blacks and whites.

OBJECTIVESnThis study investigated racial differences in procedure use among elderly Medicare beneficiaries. It is hypothesized that providers do not discriminate inappropriately in treating black and white patients and that the apparent differences in black-white treatment could be attributed to other differences between the two populations.nnnMETHODSnRates of use for selected procedures were examined among two patient groups: (1) the universe of Medicare beneficiaries in 10 states and the District of Columbia and (2) a subset of this sample created by matching beneficiaries on the basis of zip code of residence to neutralize the effects of black-white differences in provider access and regional practice patterns. Because all Medicare beneficiaries have a common core of standard benefits, the importance of financial access differences in accounting for black/white utilization differences is diminished.nnnRESULTSnThree major findings were indicated from this study: (1) area-controlled comparisons find even larger black-white disparities than those shown from uncontrolled comparisons, (2) the disparities are larger in southern states, and (3) the disparities vary substantially with procedure cost.nnnCONCLUSIONSnAlthough no clinical data were analyzed, providers appeared to be giving less intensive treatment to otherwise similar black Medicare beneficiaries.

Predicting fractures in an international cohort using risk factor algorithms without BMD

Clinical risk factors are associated with increased probability of fracture in postmenopausal women. We sought to compare prediction models using self‐reported clinical risk factors, excluding BMD, to predict incident fracture among postmenopausal women. The GLOW study enrolled women aged 55 years or older from 723 primary‐care practices in 10 countries. The population comprised 19,586 women aged 60 years or older who were not receiving antiosteoporosis medication and were followed annually for 2 years. Self‐administered questionnaires were used to collect data on characteristics, fracture risk factors, previous fractures, and health status. The main outcome measure compares the C index for models using the WHO Fracture Risk (FRAX), the Garvan Fracture Risk Calculator (FRC), and a simple model using age and prior fracture. Over 2 years, 880 women reported incident fractures including 69 hip fractures, 468 “major fractures” (as defined by FRAX), and 583 “osteoporotic fractures” (as defined by FRC). Using baseline clinical risk factors, both FRAX and FRC showed a moderate ability to correctly order hip fracture times (C index for hip fracture 0.78 and 0.76, respectively). C indices for “major” and “osteoporotic” fractures showed lower values, at 0.61 and 0.64. Neither algorithm was better than the model based on ageu2009+u2009fracture history alone (C index for hip fracture 0.78). In conclusion, estimation of fracture risk in an international primary‐care population of postmenopausal women can be made using clinical risk factors alone without BMD. However, more sophisticated models incorporating multiple clinical risk factors including falls were not superior to more parsimonious models in predicting future fracture in this population.

Empirically Based Composite Fracture Prediction Model From the Global Longitudinal Study of Osteoporosis in Postmenopausal Women (GLOW)

CONTEXTnSeveral fracture prediction models that combine fractures at different sites into a composite outcome are in current use. However, to the extent individual fracture sites have differing risk factor profiles, model discrimination is impaired.nnnOBJECTIVEnThe objective of the study was to improve model discrimination by developing a 5-year composite fracture prediction model for fracture sites that display similar risk profiles.nnnDESIGNnThis was a prospective, observational cohort study.nnnSETTINGnThe study was conducted at primary care practices in 10 countries.nnnPATIENTSnWomen aged 55 years or older participated in the study.nnnINTERVENTIONnSelf-administered questionnaires collected data on patient characteristics, fracture risk factors, and previous fractures.nnnMAIN OUTCOME MEASUREnThe main outcome is time to first clinical fracture of hip, pelvis, upper leg, clavicle, or spine, each of which exhibits a strong association with advanced age.nnnRESULTSnOf four composite fracture models considered, model discrimination (c index) is highest for an age-related fracture model (c index of 0.75, 47 066 women), and lowest for Fracture Risk Assessment Tool (FRAX) major fracture and a 10-site model (c indices of 0.67 and 0.65). The unadjusted increase in fracture risk for an additional 10 years of age ranges from 80% to 180% for the individual bones in the age-associated model. Five other fracture sites not considered for the age-associated model (upper arm/shoulder, rib, wrist, lower leg, and ankle) have age associations for an additional 10 years of age from a 10% decrease to a 60% increase.nnnCONCLUSIONSnAfter examining results for 10 different bone fracture sites, advanced age appeared the single best possibility for uniting several different sites, resulting in an empirically based composite fracture risk model.

Survival Rates in Trauma Patients Following Health Care Reform in Massachusetts

IMPORTANCEnMassachusetts introduced health care reform (HCR) in 2006, expecting to expand health insurance coverage and improve outcomes. Because traumatic injury is a common acute condition with important health, disability, and economic consequences, examination of the effect of HCR on patients hospitalized following injury may help inform the national HCR debate.nnnOBJECTIVEnTo examine the effect of Massachusetts HCR on survival rates of injured patients.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective cohort study of 1,520,599 patients hospitalized following traumatic injury in Massachusetts or New York during the 10 years (2002-2011) surrounding Massachusetts HCR using data from the State Inpatient Databases. We assessed the effect of HCR on mortality rates using a difference-in-differences approach to control for temporal trends in mortality.nnnINTERVENTIONnHealth care reform in Massachusetts in 2006.nnnMAIN OUTCOME AND MEASUREnSurvival until hospital discharge.nnnRESULTSnDuring the 10-year study period, the rates of uninsured trauma patients in Massachusetts decreased steadily from 14.9% in 2002 to 5.0.% in 2011. In New York, the rates of uninsured trauma patients fell from 14.9% in 2002 to 10.5% in 2011. The risk-adjusted difference-in-difference assessment revealed a transient increase of 604 excess deaths (95% CI, 419-790) in Massachusetts in the 3 years following implementation of HCR.nnnCONCLUSIONS AND RELEVANCEnHealth care reform did not affect health insurance coverage for patients hospitalized following injury but was associated with a transient increase in adjusted mortality rates. Reducing mortality rates for acutely injured patients may require more comprehensive interventions than simply promoting health insurance coverage through legislation.

Comparison of two prognostic models in trauma outcome

The Trauma Audit and Research Network (TARN) in the UK publicly reports hospital performance in the management of trauma. The TARN risk adjustment model uses a fractional polynomial transformation of the Injury Severity Score (ISS) as the measure of anatomical injury severity. The Trauma Mortality Prediction Model (TMPM) is an alternative to ISS; this study compared the anatomical injury components of the TARN model with the TMPM.