Edward Guadagnoli

Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores.

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994-1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6% (15.1, 20.1)] and smallest for those rated uncertain [8.8% (6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.

Use of alternative medicine by women with early-stage breast cancer.

BACKGROUND We analyzed the use of alternative medicine by women who had received standard therapy for early-stage breast cancer diagnosed between September 1993 and September 1995. METHODS A cohort of 480 patients with newly diagnosed early-stage breast cancer was recruited from a Massachusetts statewide cohort of women participating in a study of how women choose treatment for cancer. Alternative medical treatments, conventional therapies, and health-related quality of life were examined. RESULTS New use of alternative medicine after surgery for breast cancer was common (reported by 28.1 percent of the women); such use was not associated with choices about standard medical therapies after we controlled for clinical and sociodemographic variables. A total of 10.6 percent of the women had used alternative medicine before they were given a diagnosis of breast cancer. Women who initiated the use of alternative medicine after surgery reported a worse quality of life than women who never used alternative medicine. Mental health scores were similar at base line among women who decided to use alternative medicine and those who did not, but three months after surgery the use of alternative medicine was independently associated with depression, fear of recurrence of cancer, lower scores for mental health and sexual satisfaction, and more physical symptoms as well as symptoms of greater intensity. All groups of women reported improving quality of life one year after surgery. CONCLUSIONS Among women with newly diagnosed early-stage breast cancer who had been treated with standard therapies, new use of alternative medicine was a marker of greater psychosocial distress and worse quality of life.

Rates and Outcomes of Primary and Revision Total Hip Replacement in the United States Medicare Population

Background: Information on the epidemiology of primary total hip replacement is limited, and we are not aware of any reports on the epidemiology of revision total hip replacement. The objective of this study was to characterize the rates and immediate postoperative outcomes of primary and revision total hip replacement in persons sixty-five years of age and older residing in the United States.Methods: We used Medicare claims submitted by hospitals, physicians, and outpatient facilities between July 1, 1995, and June 30, 1996, to identify individuals who had undergone elective primary total hip replacement for a reason other than a fracture (61,568 patients) or had had revision total hip replacement (13,483 patients). Annual incidence rates of primary and revision total hip replacement were calculated, and multivariate modeling was used to evaluate the association between patient characteristics and surgical rates. The rates of occurrence of five complications within ninety days postoperatively were also evaluated, and relationships between those outcomes and patient characteristics were assessed with use of multivariate models adjusted for hospital and surgeon volume.Results: The rates of primary total hip replacement were three to six times higher than the rates of revision total hip replacement. Women had higher rates than men, and whites had higher rates than blacks. The rates of primary and revision total hip replacement increased with age until the age of seventy-five to seventy-nine years and then declined. The rates of complications occurring within ninety days after primary total hip replacement were 1.0% for mortality, 0.9% for pulmonary embolus, 0.2% for wound infection, 4.6% for hospital readmission, and 3.1% for hip dislocation. The rates after revision total hip replacement were 2.6%, 0.8%, 0.95%, 10.0%, and 8.4%, respectively. Factors associated with an increased risk of an adverse outcome included increased age, gender (men were at higher risk than women), race (blacks were at higher risk than whites), a medical comorbidity, and a low income.Conclusions: Analysis of United States Medicare population data showed that the rates of total hip replacement increased with age up to the age of seventy-five to seventy-nine years and that blacks had a significantly lower rate of total hip replacement than whites. The overall rates of adverse outcomes were relatively low, but they were significantly higher after revision than after primary total hip replacement.Level of Evidence: Prognostic study, Level II-1 (retrospective study). See p. 2 for complete description of levels of evidence.

Association Between Hospital and Surgeon Procedure Volume and Outcomes of Total Hip Replacement in the United States Medicare Population

Background: The mortality and complication rates of many surgical procedures are inversely related to hospital procedure volume. The objective of this study was to determine whether the volumes of primary and revision total hip replacements performed at hospitals and by surgeons are associated with rates of mortality and complications. Methods: We analyzed claims data of Medicare recipients who underwent elective primary total hip replacement (58,521 procedures) or revision total hip replacement (12,956 procedures) between July 1995 and June 1996. We assessed the relationship between surgeon and hospital procedure volume and mortality, dislocation, deep infection, and pulmonary embolus in the first ninety days postoperatively. Analyses were adjusted for age, gender, arthritis diagnosis, comorbid conditions, and income. Analyses of hospital volume were adjusted for surgeon volume, and analyses of surgeon volume were adjusted for hospital volume. Results: Twelve percent of all primary total hip replacements and 49% of all revisions were performed in centers in which ten or fewer of these procedures were carried out in the Medicare population annually. In addition, 52% of the primary total hip replacements and 77% of the revisions were performed by surgeons who carried out ten or fewer of these procedures annually. Patients treated with primary total hip replacement in hospitals in which more than 100 of the procedures were performed per year had a lower risk of death than those treated with primary replacement in hospitals in which ten or fewer procedures were performed per year (mortality rate, 0.7% compared with 1.3%; adjusted odds ratio, 0.58; 95% confidence interval, 0.38, 0.89). Patients treated with primary total hip replacement by surgeons who performed more than fifty of those procedures in Medicare beneficiaries per year had a lower risk of dislocation than those who were treated by surgeons who performed five or fewer of the procedures per year (dislocation rate, 1.5% compared with 4.2%; adjusted odds ratio, 0.49; 95% confidence interval, 0.34, 0.69). Patients who had revision total hip replacement done by surgeons who performed more than ten such procedures per year had a lower rate of mortality than patients who were treated by surgeons who performed three or fewer of the procedures per year (mortality rate, 1.5% compared with 3.1%; adjusted odds ratio, 0.65; 95% confidence interval, 0.44, 0.96). Conclusions: Patients treated at hospitals and by surgeons with higher annual caseloads of primary and revision total hip replacement had lower rates of mortality and of selected complications. These analyses of Medicare claims are limited by a lack of key clinical information such as operative details and preoperative functional status.

Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement.

Background: The lengths of acute hospital stays following total hip replacement have diminished substantially in recent years. As a result, a greater proportion of complications occurs following discharge. Data on the incidence trends of major complications of total hip replacement would facilitate recognition and management of these adverse events.Methods: We used Medicare claims data on beneficiaries sixty-five years and older who had had elective, primary total hip replacement for a reason other than a fracture (58,521 patients) or had had revision total hip replacement (12,956 patients) between July 1, 1995, and June 30, 1996. We calculated incidence rates of dislocation, pulmonary embolism, and deep hip infection per 10,000 person-weeks for four time-periods following the admission for the surgery (during the index hospitalization, from discharge to four weeks postoperatively, from five to thirteen weeks postoperatively, and from fourteen to twenty-six weeks postoperatively). We then used life-table methods to estimate the cumulative incidence of each complication over the first six postoperative months.Results: Of the patients who had had a primary total hip replacement, 3.9% had a dislocation, 0.9% had a pulmonary embolism, and 0.2% had a deep infection in the first twenty-six postoperative weeks. In the revision total hip replacement cohort, the proportions with dislocation, pulmonary embolism, and deep infection were 14.4%, 0.8%, and 1.1%, respectively. The rates of these adverse outcomes were highest during the index hospitalization, diminished considerably in the period from discharge to four weeks postoperatively, and continued to drop in the periods from five to thirteen and fourteen to twenty-six weeks postoperatively.Conclusions: The incidence rates of dislocation, pulmonary embolism, and deep infection are highest immediately after total hip replacement, but they continue to be elevated throughout the first three postoperative months. With the lengths of hospital stays continuing to diminish, an increasing proportion of complications will occur in outpatients. These findings provide a basis for developing strategies to prevent these complications in the postdischarge management of patients who have had elective total hip replacement.Level of Evidence: Prognostic study, Level II-1 (retrospective study). See p. 2 for complete description of levels of evidence.

Knowledge and Practices of Generalist and Specialist Physicians Regarding Drug Therapy for Acute Myocardial Infarction

BACKGROUND The respective roles of generalist and specialist physicians in the care of patients is currently a matter of debate. Information is limited about the knowledge and practices of generalist and specialist physicians regarding conditions that both groups treat, such as myocardial infarction. METHODS We therefore surveyed 1211 cardiologists, internists, and family practitioners in the states of New York and Texas about four treatments demonstrated by randomized clinical trials to be associated with improved survival after myocardial infarction (thrombolytic therapy, immediate and long-term use of aspirin, and long-term use of beta-blockers) and two treatments for which such evidence is lacking (diltiazem for patients with pulmonary congestion and prophylactic lidocaine). We asked physicians about the effect of each treatment on survival and the likelihood that they would prescribe each class of drugs. RESULTS For the four beneficial treatments, the cardiologists believed more strongly than the internists and family physicians that survival was improved by the treatment, and they were more likely to prescribe these drugs (P < 0.001). For example, 94.1 percent of cardiologists said they were very likely to prescribe thrombolytic agents to treat an acute myocardial infarction, as compared with 82.0 percent of internists and 77.3 percent of family practitioners. Conversely, for the two treatments for which trials showed no evidence of a survival benefit, cardiologists were less likely than internists and family practitioners to think there was such a benefit and less likely to prescribe the drugs (P < 0.001). For example, 4.7 percent of cardiologists reported that they were very likely to use prophylactic lidocaine, as compared with 13.1 percent of internists, and 16.5 percent of family practitioners. When we used logistic regression to adjust for potential confounders, all the differences between the cardiologists and the internists and family practitioners remained significant (P < 0.02). CONCLUSIONS Internists and family practitioners are less aware of or less certain about key advances in the treatment of myocardial infarction than are cardiologists. This finding underscores the need to improve the dissemination of information from clinical trials to generalist physicians, particularly if they are to have an enlarged role in the evolving health care system.

Patterns of Change: Dynamic Typology Applied to Smoking Cessation

Patterns of change occurring in a combined cross-sectional and longitudinal (cross-sequential) analysis of 14 variables were investigated in a two-year study of self-change approaches to smoking cessation. Every six months for five rounds, subjects (N = 544) were assessed on 10 change processes, self-efficacy, temptations to smoke, and their decisions weighing the pros and cons of smoking. Subjects were also assessed on which of the following four stages of change they were in at each round: precontemplation, contemplation, action and maintenance. Dynamic clustering was employed to group subjects on the basis of their patterns of changes in stages over the five rounds. This yielded 14 profile groups (longitudinal typologies) which initially were compared on the 14 variables. Patterns of change on each of the variables became clear when the data were integrated cross-sectionally and longitudinally to form composite developmental profiles. The basic pattern of change processes can best be represented by a mountain metaphor. The change processes followed a general pattern of increasing from precontemplation to contemplation, peaked at a particular stage of change and then declined either to precontemplation levels or to somewhat higher levels if used as relapse prevention strategies. Temptation and the pros of smoking followed a linear pattern of decreasing across the stages, while self-efficacy increased linearly. The patterns of change and the mountain metaphor can be used as an organizing principle for developing models of change. The models can be used to develop therapy programs and self-help programs based on how people change their own problem behavior.

Health and economic impact of surgical site infections diagnosed after hospital discharge.

Although surgical site infections (SSIs) are known to cause substantial illness and costs during the index hospitalization, little information exists about the impact of infections diagnosed after discharge, which constitute the majority of SSIs. In this study, using patient questionnaire and administrative databases, we assessed the clinical outcomes and resource utilization in the 8-week postoperative period associated with SSIs recognized after discharge. SSI recognized after discharge was confirmed in 89 (1.9%) of 4,571 procedures from May 1997 to October 1998. Patients with SSI, but not controls, had a significant decline in SF-12 (Medical Outcomes Study 12-Item Short-Form Health Survey) mental health component scores after surgery (p=0.004). Patients required significantly more outpatient visits, emergency room visits, radiology services, readmissions, and home health aide services than did controls. Average total costs during the 8 weeks after discharge were US

Adherence to National Guidelines for Drug Treatment of Suspected Acute Myocardial Infarction: Evidence for Undertreatment in Women and the Elderly

5,155 for patients with SSI and

Patterns of breast carcinoma treatment in older women: Patient preference and clinical and physician influences

1,773 for controls (p<0.001).