Edward F. Ellerbeck

Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries Patterns of Use and Outcomes

BACKGROUND Although aspirin is an effective, inexpensive, and safe treatment of acute myocardial infarction, the frequency of use of aspirin in actual medical practice is not known. Elderly patients, a group with low rates of utilization of effective therapies such as thrombolytic therapy, also may be at risk of not receiving aspirin for acute myocardial infarction. To address this issue, we sought to determine the current pattern of aspirin use and to assess its effectiveness in a large, population-based sample of elderly patients hospitalized with acute myocardial infarction. METHODS AND RESULTS As part of the Cooperative Cardiovascular Project Pilot, a Health Care Financing Administration initiative to improve quality of care for Medicare beneficiaries, we abstracted hospital medical records of Medicare beneficiaries who were hospitalized in Alabama, Connecticut, Iowa, or Wisconsin from June 1992 through February 1993. Among the 10,018 patients > or = 65 years old who had no absolute contraindications to aspirin, 6140 patients (61%) received aspirin within the first 2 days of hospitalization. Patients who were older, had more comorbidity, presented without chest pain, and had high-risk characteristics such as heart failure and shock were less likely to receive aspirin. The use of aspirin was significantly associated with a lower mortality (OR, 0.78; 95% CI, 0.70 to 0.89) after adjustment for potential confounders. CONCLUSIONS About one third of elderly patients with acute myocardial infarction who had no contraindications to aspirin therapy did not receive it within the first 2 days of hospitalization. The elderly patients with the highest risk of death were the least likely to receive aspirin. After adjustment for differences between the treatment groups, the use of aspirin was associated with 22% lower odds of 30-day mortality. The increased use of aspirin for patients with acute myocardial infarction is an excellent opportunity to improve the delivery of care to elderly patients.

Combined Anticoagulant–Antiplatelet Use and Major Bleeding Events in Elderly Atrial Fibrillation Patients

Background and Purpose— Bleeding risks from combined antiplatelet-warfarin therapy have not been well-described in clinical practice. We examined antiplatelet therapy among warfarin users and the impact on major bleeding rates. Methods— Retrospective cohort analysis of persons discharged on warfarin after an atrial fibrillation admission using data from Medicares National Stroke Project. Data included Medicare claims, enrollment information, and medical record abstracted data. Logistic regression and Cox proportional hazards models were used to predict concurrent antiplatelet use and hospitalization with a major acute bleed within 90 days after discharge from the index AF admission. Results— 10 093 warfarin patients met inclusion criteria with a mean age of 77 years; 19.4% received antiplatelet therapy. Antiplatelet use was less common among women, older persons, and persons with cancer, terminal diagnoses, dementia, and bleeding history. Persons with coronary disease were more likely to receive an antiplatelet agent. Antiplatelets increased major bleeding rates from 1.3% to 1.9% (P=0.052). In the multivariate analysis, factors associated with bleeding events included age (OR, 1.03; 95% CI, 1.002 to 1.05), anemia (OR, 2.52; 95% CI, 1.64 to 3.88), a history of bleeding (OR, 2.40; 95% CI, 1.71 to 3.38), and concurrent antiplatelet therapy (OR, 1.53; 95% CI, 1.05 to 2.22). Conclusions— Although concerns about increased bleeding risk with combined warfarin-antiplatelet therapy are not unfounded, the risk of bleeding is moderately increased. The decision to use concurrent antiplatelet therapy appears to be tempered by cardiac and bleeding risk factors.

Impact of Geographic Barriers on the Utilization of Mammograms by Older Rural Women

OBJECTIVES: To examine whether geographic proximity to mammography facilities influences mammogram utilization.

Determinants of Appropriate Use of Angiotensin-Converting Enzyme Inhibitors After Acute Myocardial Infarction in Persons ≥65 Years of Age

We sought to determine how often angiotensin-converting enzyme (ACE) inhibitors are prescribed as a discharge medication among eligible patients > or = 65 years old with an acute myocardial infarction; to identify patient characteristics associated with the decision to prescribe ACE inhibitors; and to determine the factors associated with the decision to obtain an evaluation of left ventricular function among patients who have no contraindications to ACE inhibitors. We addressed these aims with an observational study of consecutive elderly Medicare beneficiary survivors of an acute myocardial infarction hospitalized in Alabama, Connecticut, Iowa, and Wisconsin between June 1992 and February 1993. Among the 5,453 patients without a contraindication to ACE inhibitors at discharge, 3,528 (65%) had an evaluation of left ventricular function. Of the 1,228 patients without a contraindication to ACE inhibitors who had a left ventricular ejection fraction < or = 40%, 548 (45%) were prescribed the medication at discharge. In a multivariable analysis, an increased prescribed use of ACE inhibitors at discharge was correlated with several factors, including diabetes mellitus, congestive heart failure, ventricular tachycardia, and loop diuretics as a discharge medication. Patients admitted after the publication of the Survival and Ventricular Enlargement (SAVE) trial were significantly more likely to receive ACE inhibitors, although the absolute improvement in utilization was small in the 6 months after the trial results were published. In conclusion, improving the identification of appropriate patients for ACE inhibitors and increasing the prescription of ACE inhibitors for ideal patients may provide an excellent opportunity to improve care.

Group Versus Individual Phone-Based Obesity Treatment for Rural Women

Rural women have among the highest rates of obesity and sedentary lifestyle, yet few studies have examined strategies for delivering state-of-the-art obesity treatment to hard-to-reach rural areas. The purpose of this pilot trial was to examine the impact and cost-effectiveness of a 6-month behavioral weight loss program delivered to rural women by phone either one-on-one with a counselor or to a group via conference call. Thirty-four rural women (mean BMI=34.4, SD=4.6) were randomized to group phone-based treatment or individual phone-based treatment. Completers analysis showed that weight loss was greater in the group condition (mean=14.9 kg=, SD=4.4) compared to the individual condition (mean=9.5 kg, SD=5.2; p=.03). Among the total sample, 62% of participants in the group condition achieved the 10% weight loss goal compared to 50% in the individual condition, and group treatment was found to be more cost-effective. Future research is warranted to examine the benefits of group phone-based treatment for long-term management of obesity among rural populations.

Factors Influencing Infant Visits to Emergency Departments

Objectives. To follow the 1995 birth cohort of infants, born in the State of Missouri, through their first birthday to: 1) examine their rates of visits to emergency departments (EDs), 2) identify predictors of any ED visit, 3) examine rates of nonurgent ED visits, and 4) identify predictors of nonurgent visits. Methods. This was a retrospective population cohort study. Using deterministic linkage procedures, 2 databases at the Missouri Department of Health (DOH; (the patient abstract database and the birth registry database) were linked by DOH personnel. International Classification of Diseases, Ninth Revision-Clinical Modification codes for ED visits were classified as emergent, urgent, or nonurgent by 2 researchers. Eight newborn characteristics were chosen for analysis. Negative binomial regression was used to examine the rates and predictors of both total and nonurgent ED visits. Results. There were 935 total ED visits and 153 nonurgent ED visits per 1000 infant years. The average number of visits was .94, with 59% of infants having no visits, 21% having 1 ED visit, and 20% having 2 or more visits. Factors associated with increases in both total and nonurgent ED visits were Medicaid, self-pay, black race, rural region, presence of birth defects, and a nursery stay of >2 days. Significant interactions were found between Medicaid and race and Medicaid and rural regions on rates of ED use and nonurgent use. The highest rate of ED use, 1.8 per person year, was seen in white, rural infants on Medicaid, and the lowest rate (.4 per person year) was seen in urban white infants not on Medicaid. The highest rates of nonurgent use, .3 per person year, were among urban and rural Medicaid infants of both races and among black infants on commercial insurance. The lowest nonurgent rate, .04 per person year, was seen in white urban infants on commercial insurance. Conclusion. Infants in the State of Missouri have high rates of ED visits. Nonurgent visits are only a small portion of ED visits and cannot explain large variations in ED usage. Increased ED use by Medicaid patients may reflect continuing difficulties in accessing primary care.

The prevalence of and factors associated with chronic atrial fibrillation in Medicare/Medicaid-eligible dialysis patients

Atrial fibrillation is an important comorbidity with substantial therapeutic implications in dialysis patients but its prevalence varies in different studies. We used a database that includes patients in the United States on hemodialysis who were eligible for government assistance with prescription drugs. We then used ICD-9 codes from billing claims in this database to identify patients with chronic atrial fibrillation. Multivariable logistic regression was used to determine adjusted prevalence odds ratios for associated factors. Of 63,884 individuals, the prevalence of chronic atrial fibrillation was 7%. The factors of age over 60 years, male, Caucasian, body mass index over 25 kg/m(2), coronary artery disease, and heart failure were all significantly associated with chronic atrial fibrillation. Prevalence rates, particularly in younger patients, were far higher than those reported in an age group-matched nondialysis population. Thus, given its clinical impact, future efforts are needed to examine risk factors for adverse outcomes in chronic atrial fibrillation, and to identify appropriate management strategies for this disorder, as well as opportunities for quality improvement in this vulnerable population.

Effect of varying levels of disease management on smoking cessation: a randomized trial.

Context Smoking cessation is difficult and may require repeated or intensive interventions. Contribution In this multicenter trial, 750 primary care patients who smoked at least 10 cigarettes per day were randomly assigned to pharmacotherapy (nicotine patch or bupropion), pharmacotherapy supplemented with up to 2 calls from trained counselors, or pharmacotherapy supplemented with up to 6 counseling calls. Utilization of the interventions, which were offered every 6 months for 2 years, declined over time. Smoking abstinence rates at 2 years were 23%, 24%, and 28% in the 3 groups. Caution Pharmacotherapy was free. Smoking abstinence was self-reported. The Editors Cigarette smoking is a chronic illness characterized by repeated cycles of quit attempts and relapse. Most models for addressing smoking cessation are based on single, short-term interventions lasting only a few weeks or months (1). Although most smokers will not quit after a single intervention, few studies have addressed the chronic nature of nicotine dependence by providing systematic, repetitive treatment opportunities (1). Providing treatment only to smokers who are already prepared to quit further limits the reach of current smoking cessation interventions (2). New models of chronic disease care might provide an alternative approach for expanding the reach and effectiveness of smoking cessation efforts (3). Physicians are in direct contact with approximately 70% of smokers each year (4, 5). Their potential role in promoting smoking cessation has been well delineated and incorporated into current clinical practice guidelines (1). With the development of new, more effective prescription pharmacotherapy for smoking cessation, the role of primary care practices in promoting smoking cessation is now more important than ever. Unfortunately, only half of the smokers who see their physicians are asked about their smoking (6), and even fewer receive advice from their health care provider to quit or receive pharmacotherapy or follow-up (4, 7). Smoking cessation counseling competes with other pressing clinical tasks, and beyond brief advice, many physicians feel they are too busy to routinely and repeatedly counsel participants who smoke (810). To assist primary care physicians in the treatment of rural smokers, we developed KanQuit, a smoking cessation program based on the chronic care model (4), which integrates principles of disease management into the treatment of smokers seen in rural primary care. Our objective was to enroll smokers, regardless of their willingness to quit, into a disease registry and compare cessation rates among smokers who received pharmacotherapy alone or combined with either moderate-intensity or high-intensity disease management that includes counseling and provider feedback. Methods Design Overview We did a randomized, single-blind trial of varying levels of disease management for smoking cessation. We recruited participants who smoked more than 10 cigarettes per day from rural primary care clinics across Kansas and randomly assigned them to receive pharmacotherapy alone, pharmacotherapy supplemented by 1 to 2 counseling calls every 6 months (moderate-intensity disease management), or pharmacotherapy supplemented by up to 6 counseling calls every 6 months (high-intensity disease management). For recipients of moderate-intensity and high-intensity disease management, we faxed periodic progress reports to their physician. We offered all participants free pharmacotherapy (either bupropion or transdermal nicotine patch) every 6 months. We enrolled participants from June 2004 to October 2005 and followed them for 24 months, completing follow-up in December 2007. All participants provided written informed consent. The University of Kansas Medical Centers Human Subjects Committee approved the study. Setting and Participants We conducted our study in 50 rural primary care practices in the Kansas Physicians Engaged in Prevention Research network (11). As part of a rural primary care research experience, trained medical students systematically screened participants, identified smokers, and recruited them for this study, regardless of their interest in quitting (12). We considered smokers eligible if they had a primary care physician who participated in this study; were older than 18 years; smoked more than 10 cigarettes per day for at least 1 year and for at least 25 of the past 30 days; spoke English; and had a telephone. We excluded smokers if they were pregnant or planned to become pregnant, planned to move out of the study area, had signs of dementia or mental illness that would preclude participation, or lived with a smoker already enrolled in the study. Of the 1827 smokers we screened, 61% met criteria for study entry (Figure 1). Of these, we enrolled 67%. Figure 1. Study flow diagram. HDM = high-intensity disease management; MDM = moderate-intensity disease management; PM = pharmacotherapy management. Randomization and Interventions Participant Randomization Randomization occurred at the participant level. A computer-generated random-number table was used to generate allocation cards in blocks of 24, with allocation equally distributed across treatment groups. To conceal allocation, we placed these cards in sequentially numbered, opaque, sealed envelopes. After research assistants verified participant eligibility and completed the baseline assessment, the project director opened the next sequential sealed envelope and determined the participants treatment allocation. One of 9 counselors trained in smoking cessation and motivational interviewing (12) conducted all interventions from a single central site. We assigned participants to counselors without regard to practice site. Pharmacotherapy At baseline, all smokers received a health education mailing that consisted of a welcome letter, information about the use of bupropion and the nicotine patch for smoking cessation, and copies of You Can Quit Smoking: Consumer Guide (13) and When Smokers QuitThe Health Benefits Over Time (14). At baseline and at 6, 12, and 18 months, participants received a mailed offer for free pharmacotherapy that consisted of either a 6-week course of a nicotine patch (21 mg/d) or a 7-week course of sustained-release bupropion (150 mg twice daily). Participants interested in using either medication could return a postage-paid postcard or call a toll-free number. We screened all participants who requested pharmacotherapy for potential contraindications (15). Participants with absolute contraindications for a given drug were ineligible to receive that drug but were offered the option of receiving the other drug. Participants with contraindications to both drugs were not eligible to receive medication from the study but could participate in all other aspects of the intervention. For participants who requested bupropion and those with relative contraindications to the nicotine patch, research staff faxed a prescription request to their primary care physicians. This prescription request delineated any relative contraindications or potential drug interactions. For these participants, their physicians made the final assessment of the appropriateness of the bupropion or the patch. For participants without contraindications to the nicotine patch or on receipt of a faxed, signed prescription, the bupropion or patches were mailed to the participant along with instructions for use. Disease Management In addition to pharmacotherapy, the moderate-intensity and high-intensity disease management groups received educational support, telephone counseling, and periodic progress reports with counseling suggestions faxed to their physician. Every 6 months, they received a KanQuit newsletter that addressed tips on quitting smoking, talking with their physician about smoking, and using pharmacotherapy for cessation. The newsletters were personalized to include study updates, counselor photographs, physician feature stories, and testimonials of participants who had quit smoking. We offered participants assigned to moderate-intensity disease management up to 2 telephone-based counseling sessions every 6 months (1 session to promote a quit attempt and 1 additional follow-up session for those who made a quit attempt). We offered participants assigned to high-intensity disease management up to 6 counseling calls every 6 months to either promote quitting or prevent relapse. We scheduled calls at the participants convenience, and they varied according to the participants quit plan but followed a rough schedule of calls at 1, 3, 6, 9, and 16 weeks after the onset of each 6-month treatment cycle. Counselors used motivational interviewing techniques and followed a semistructured protocol to promote a cessation attempt or, for abstinent smokers, to encourage relapse prevention. During counseling calls, case managers reminded participants about the availability of pharmacotherapy and, for interested participants, provided immediate support for acquiring either the nicotine patch or bupropion, as described previously. We faxed personalized progress reports with suggestions for interventions to the participants physician after the first counseling call (both moderate-intensity and high-intensity disease management participants) and after the last counseling call (high-intensity disease management participants only) during each 6-month cycle. We faxed additional progress reports to the participants physician whenever the moderate-intensity or high-intensity disease management participant set a quit date. Outcomes, Measurements, and Follow-up Research assistants who were blinded to treatment group assignment conducted assessments by telephone at baseline and at 6, 12, 18, and 24 months. Primary Outcome The primary outcome measure was self-reported 7-day abstinence at 24 months, defined as not having smoked a cigarette during the previous 7 days. Although self-reported abstinence has been co

Mobile Technology for Obesity Prevention: A Randomized Pilot Study in Racial- and Ethnic-Minority Girls

BACKGROUND Mobile technologies have wide-scale reach and disseminability, but no known studies have examined mobile technologies as a stand-alone tool to improve obesity-related behaviors of at-risk youth. PURPOSE To test a 12-week mobile technology intervention for use and estimate effect sizes for a fully powered trial. METHODS Fifty-one low-income, racial/ethnic-minority girls aged 9-14 years were randomized to a mobile technology (n=26) or control (n=25) condition. Both conditions lasted 12 weeks and targeted fruits/vegetables (FVs; Weeks 1-4); sugar-sweetened beverages (SSBs; Weeks 5-8), and screen time (Weeks 9-12). The mobile intervention prompted real-time goal setting and self-monitoring and provided tips, feedback, and positive reinforcement related to the target behaviors. Controls received the same content in a written manual but no prompting. Outcomes included device utilization and effect size estimates of FVs, SSBs, screen time, and BMI. Data were collected and analyzed in 2011-2012. RESULTS Mobile technology girls used the program on 63% of days and exhibited trends toward increased FVs (+0.88, p=0.08) and decreased SSBs (-0.33, p=0.09). The adjusted difference between groups of 1.0 servings of FVs (p=0.13) and 0.35 servings of SSBs (p=0.25) indicated small to moderate effects of the intervention (Cohens d=0.44 and -0.34, respectively). No differences were observed for screen time or BMI. CONCLUSIONS A stand-alone mobile app may produce small to moderate effects for FVs and SSBs. Given the extensive reach of mobile devices, this pilot study demonstrates the need for larger-scale testing of similar programs to address obesity-related behaviors in high-risk youth.

Use and effectiveness of intravenous heparin therapy for treatment of acute myocardial infarction in the elderly

OBJECTIVES We sought to determine the use and association with 30-day mortality of intravenous heparin for the treatment of acute myocardial infarction in elderly patients not treated with a reperfusion strategy and without contraindications to anticoagulation. BACKGROUND The benefit of using full-dose intravenous heparin for the treatment of acute myocardial infarction in the elderly is not known. METHODS We conducted a retrospective cohort study using hospital medical records of all Medicare beneficiaries admitted to the hospital with an acute myocardial infarction in Alabama, Connecticut, Iowa and Wisconsin from June 1992 through February 1993. RESULTS Among the 6,935 patients > or = 65 years old who had no absolute chart-documented contraindications to heparin, 3,227 (47%) received early full-dose intravenous heparin therapy. After adjustment for baseline differences in demographic, clinical and treatment factors between patients with and without heparin, the use of heparin (odds ratio 1.02, 95% confidence interval 0.87 to 1.18) was not associated with a significantly better 30-day mortality rate. CONCLUSIONS Although intravenous heparin was commonly used for treatment of acute myocardial infarction in the elderly, it was not associated with an improved 30-day mortality rate. Although the findings of this observational study must be interpreted with care, they lead us to question whether the prevalent use of intravenous heparin has therapeutic effectiveness in this population.