Dong D. Zhang

Cardiac Morbidity of Adjuvant Radiotherapy for Breast Cancer

PURPOSEnAdjuvant breast irradiation has been associated with an increase in cardiac mortality, because left-sided breast radiation can produce cardiac damage. The purpose of this study was to determine whether modern adjuvant radiotherapy is associated with increased risk of cardiac morbidity.nnnPATIENTS AND METHODSnData from the Surveillance, Epidemiology, and End Results-Medicare database were used for women who were diagnosed with nonmetastatic breast cancer from 1986 to 1993, had known disease laterality, underwent breast surgery, and received adjuvant radiotherapy. The Cox proportional-hazards model was used to compare patients with left- versus right-sided breast cancer for the end points of hospitalization with the following discharge diagnoses (International Classification of Diseases, 9th Revision codes): ischemic heart disease (410-414, 36.0, and 36.1), valvular heart disease (394-397, 424, 35), congestive heart failure (428, 402.01, 402.11, 402.91, and 425), and conduction abnormalities (426, 427, 37.7-37.8, and 37.94-37.99).nnnRESULTSnEight thousand three hundred sixty-three patients had left-sided breast cancer, and 7,907 had right-sided breast cancer. Mean follow-up was 9.5 years (range, 0 to 15 years). There were no significant differences in patients with left- versus right-sided cancers for hospitalization for ischemic heart disease (9.9% v 9.7%), valvular heart disease (2.9% v 2.8%), conduction abnormalities (9.7% v 9.6%), or heart failure (9.7% v 9.7%). The adjusted hazard ratio for left- versus right-sided breast cancer was 1.05 (95% CI, 0.94 to 1.16) for ischemic heart disease, 1.07 (95% CI, 0.89 to 1.30) for valvular heart disease, 1.07 (95% CI, 0.96 to 1.19) for conduction abnormalities, and 1.05 (95% CI, 0.95 to 1.17) for heart failure.nnnCONCLUSIONnWith up to 15 years of follow-up there were no significant differences in cardiac morbidity after radiation for left- versus right-sided breast cancer.

Effect of Depression on Diagnosis, Treatment, and Survival of Older Women with Breast Cancer

Objectives: To assess the effect of a prior diagnosis of depression on the diagnosis, treatment, and survival of older women with breast cancer.

Outpatient Follow-up Visit and 30-Day Emergency Department Visit and Readmission in Patients Hospitalized for Chronic Obstructive Pulmonary Disease

BACKGROUNDnReadmissions in patients with chronic obstructive pulmonary disease (COPD) are common and costly. We examined the effect of early follow-up visit with patients primary care physician (PCP) or pulmonologist following acute hospitalization on the 30-day risk of an emergency department (ER) visit and readmission.nnnMETHODSnWe conducted a retrospective cohort study of fee-for-service Medicare beneficiaries with an identifiable PCP who were hospitalized for COPD between 1996 and 2006. Three or more visits to a PCP in the year prior to the hospitalization established a PCP for a patient. We performed a Cox proportional hazard regression with time-dependent covariates to determine the risk of 30-day ER visit and readmission in patients with or without a follow-up visit to their PCP or pulmonologist.nnnRESULTSnOf the 62xa0746 patients admitted for COPD, 66.9% had a follow-up visit with their PCP or pulmonologist within 30 days of discharge. Factors associated with lower likelihood of outpatient follow-up visit were longer length of hospital stay, prior hospitalization for COPD, older age, black race, lower socioeconomic status, and emergency admission. Those receiving care at nonteaching, for-profit, and smaller-sized hospitals were more likely to have a follow-up visit. In a multivariate, time-dependent analysis, patients who had a follow-up visit had a significantly reduced risk of an ER visit (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.83-0.90) and readmission (HR, 0.91; 95% CI, 0.87-0.96).nnnCONCLUSIONnContinuity with patients PCP or pulmonologist after an acute hospitalization may lower rates of ER visits and readmission in patients with COPD.

Clinical significance of falling blood pressure among older adults

We assessed the prevalence of falling blood pressure among older adults and its relationship to subsequent outcomes, using public use data from four sites of the Established Populations for Epidemiologic Studies of the Elderly. Seventeen percent of subjects had a decrease in systolic blood pressure of 20 mm Hg or greater and 22% had a decrease in diastolic blood pressure of 10 mm Hg or greater between year 0 and year 3. Falling systolic and diastolic blood pressure was associated with increased all-cause mortality (OR 1.5, 95% CI 1.3, 1.7), cardiovascular mortality (OR 1.6, 95% CI 1.3, 1.9) and all cardiovascular events (OR 1.4, 95% CI 1.2, 1.6) in the subsequent 3 years (years 4 to 6). Increasing amount of fall in blood pressure was associated with increasing risk of mortality. The magnitude of effect of falling blood pressure on adverse outcomes declined and became nonsignificant after adjusting for comorbidity and functional status at baseline. Thus, falling blood pressure is common among older adults and is a marker for underlying poor health and subsequent mortality.

Neighborhood composition and cancer among Hispanics: tumor stage and size at time of diagnosis.

Background: We have previously reported that cancer incidence for lung, female breast, and colon and rectum for Hispanics decreases with increasing percentage of Hispanics at the census tract. In contrast, cervical cancer incidence increases with increasing percentage of Hispanics at the census tract. Methods: In this study, we investigate the hypothesis that Hispanics living in census tracts with high percentages of Hispanics are diagnosed with more advanced cancer, with respect to tumor size and stage of diagnosis. Data from the Surveillance, Epidemiology, and End Results registry and the U.S. Census Bureau were used to estimate the odds of diagnosis at a “late” stage (II, III, IV) versus “early” stage (I) and breast cancer tumor size among Hispanics as a function of census tract percent Hispanic. Hispanic ethnicity in the Surveillance, Epidemiology, and End Results registry was identified by medical record review and Hispanic surname lists. The study also used income of Hispanics living in the census tract and controlled for age at diagnosis and gender. Results: We found that Hispanics living in neighborhoods with higher density of Hispanic populations were more likely to be diagnosed with late-stage breast, cervical, or colorectal cancer, and to have a larger tumor size of breast cancer. Conclusions: Our findings suggest that the benefits of lower cancer incidence in high tract percent Hispanics are partially offset by poorer access and reduced use of screening in conjunction with lower income, poorer health insurance coverage, and language barriers typical of these communities. (Cancer Epidemiol Biomarkers Prev 2008;17(11):2931–6)

Risk of Continued Institutionalization After Hospitalization in Older Adults

BACKGROUNDnLittle is known about the role of hospitalization as a risk factor for placement into long-term care. We therefore sought to estimate the percentage of long-term care nursing home stays precipitated by a hospitalization and factors associated with risk of nursing home placement after hospitalization.nnnMETHODSnWe studied a retrospective cohort of a 5% sample of Medicare enrollees aged ≥ 66 years. The study included 762,243 patients admitted 1,149,568 times in January-April of 1996-2008, with 3,880,292 nonhospitalized controls. We measured residence in a nursing home 6 months after hospitalization.nnnRESULTSnFrom 1996 through 2008, 5.55% of hospitalized patients resided in a nursing home 6 months later compared with 0.54% of nonhospitalized control patients. Three quarters of new nursing home placements were precipitated by a hospitalization. Independent risk factors for long-term care placement after hospitalization included advanced age (odds ratio [OR] = 3.56 for age 85-94 vs. 66-74 years), female gender (OR = 1.41), dementia (OR = 6.15), and discharge from the hospital to a skilled nursing facility (SNF; OR = 10.83). Having a primary care physician was associated with reduced odds (OR = 0.75). In the adjusted analyses, risk of institutionalization after hospitalization decreased 4% per year from 1996 to 2008. There were very large geographic variations in rates of long-term care after hospitalization, from < 2% in some hospital referral regions to > 13% in others for patients > 75 years in 2007-2008.nnnCONCLUSIONSnMost placements in nursing homes are preceded by a hospitalization followed by discharge to a SNF. Discharge to a SNF is associated with a high risk of subsequent long-term care.

Comanagement of Hospitalized Surgical Patients by Medicine Physicians in the United States

BACKGROUNDnComanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes. We examined the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States.nnnMETHODSnWe conducted a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for 1 of 15 inpatient surgical procedures from 1996 to 2006 (n = 694 806). We also calculated the proportion of Medicare beneficiaries comanaged by medicine physicians (generalist physicians or internal medicine subspecialists) during hospitalization. Comanagement was defined by relevant physicians (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patients were hospitalized.nnnRESULTSnBetween 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by a medicine physician: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). The percentage of patients experiencing comanagement was relatively unchanged from 1996 to 2000 and then increased sharply. The increase was entirely attributable to a surge in comanagement by generalist physicians. In a multivariable multilevel analysis, comanagement by generalist physicians increased 11.4% per year from 2001 to 2006. Patients with advanced age, with more comorbidities, or receiving care in nonteaching, midsize (200-499 beds), or for-profit hospitals were more likely to receive comanagement. All of the growth in comanagement was attributed to increased comanagement by hospitalist physicians.nnnCONCLUSIONSnMedical comanagement of Medicare beneficiaries hospitalized for a surgical procedure is increasing because of the increasing role of hospitalists. To meet this growing need for comanagement, training in internal medicine should include medical management of surgical patients.

The role of the surgeon in whether patients with lymph node-positive colon cancer see a medical oncologist.

Chemotherapy improves survival for patients with stage III colon cancer, but some older patients with lymph node‐positive colon cancer do not see a medical oncologist and, thus, do not receive adjuvant chemotherapy.

Overuse of Preoperative Cardiac Stress Testing in Medicare Patients Undergoing Elective Noncardiac Surgery

Objective:To determine the frequency and predictors of cardiac stress testing before elective noncardiac surgery in Medicare patients with no indications for cardiovascular evaluation. Background:The American College of Cardiology/American Heart Association guidelines indicate that patients without class I (American Heart Association high risk) or class II cardiac conditions (clinical risk factors) should not undergo cardiac stress testing before elective noncardiac, nonvascular surgery. Methods:We used 5% Medicare inpatient claims data (1996–2008) to identify patients aged ≥ 66 years who underwent elective general surgical, urological, or orthopedic procedures (N = 211,202). We examined the use of preoperative stress testing in the subset of patients with no diagnoses consistent with cardiac disease (N = 74,785). Bivariate and multivariate analyses were used to identify predictors of preoperative cardiac stress testing. Results:Of the patients with no cardiac indications for preoperative stress testing, 3.75% (N = 2803) received stress testing in the 2 months before surgery. The rate of preoperative stress testing increased from 1.72% in 1996 to 6.44% in 2007 (P < 0.0001). A multivariate analysis adjusting for patient and hospital characteristics showed a significant increase in preoperative stress testing over time. Female sex [odds ratio (OR) 1.11; 95% CI: 1.02–1.21], presence of other comorbidities [OR 1.22; 95% confidence interval (CI): 1.09–1.35], high-risk procedure (OR 2.42; 95% CI: 2.04–2.89), and larger hospital size (OR 1.17; 95% CI: 1.03–1.32) were positive predictors of stress testing. Patients living in regions with greater Medicare expenditures (OR 1.24; 95% CI: 1.05–1.45) were also more likely to receive stress tests. Conclusions:In a 5% sample of Medicare claims data, 2803 patients underwent preoperative stress testing without any indications. When these results were applied to the entire Medicare population, we estimated that there are over 56,000 patients who underwent unnecessary preoperative stress testing. The rate of testing in patients without cardiac indications has increased significantly over time.

Discharge Setting for Patients with Hip Fracture: Trends from 2001 to 2005

OBJECTIVES: To examine recent trends in discharge disposition after hospitalization for hip fracture.