J. Sanford Schwartz

Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial

Objectives: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure.

Outcomes of open cholecystectomy in the elderly: a longitudinal analysis of 21,000 cases in the prelaparoscopic era.

OBJECTIVE We sought to obtain unbiased estimates of open cholecystectomy outcomes in a population-based cohort of elderly patients during the immediate prelaparoscopic era. METHODS Medicare claims data were used to identify 21,131 patients aged 65 years or more who underwent open cholecystectomy in Pennsylvania between 1986 and 1989 and to develop longitudinal histories of hospitalizations and physician services utilization for these patients. Study patients were divided into three groups: simple cholecystectomy, cholecystectomy with intraoperative cholangiography (IOC) alone, and cholecystectomy with common bile duct exploration (CBDE). Outcomes examined included 30- and 90-day postoperative mortality rates and postoperative complications. RESULTS Postoperative mortality rates in all patients was 2.1% at 30 days and 3.6% at 90 days. Patients in the CBDE group had a significantly higher mortality rate than those in the simple cholecystectomy or IOC groups; adjusted for differences in case mix, the mortality rate in the CBDE group was 47% higher at 30 days and 29% higher at 90 days. Rates of retained or recurrent common duct stones, bile duct stricture, and recurrent biliary tract surgery by 42 to 60 months after cholecystectomy were 2.8%, 0.4%, and 1.0%, respectively. CBDE was a strong risk factor for these complications. In contrast, the IOC group had a significantly lower risk of having clinically manifest retained or recurrent common duct stones develop by 42 months after operation. CONCLUSIONS This study provides an unbiased assessment of open cholecystectomy outcomes necessary for future comparisons of open and laparoscopic cholecystectomy in elderly patients. Estimates of the excess mortality rates associated with CBDE provide a benchmark for assessing the outcomes of alternative strategies for managing common duct stones during laparoscopic cholecystectomy. Findings regarding the rates of retained or recurrent common bile duct stones in patients undergoing simple cholecystectomy and IOC challenge widespread beliefs about the limited clinical importance of unsuspected common duct stones, at least in the elderly population, and are relevant to the debate about routine IOC.

Predicting success of intensive dialysis in the treatment of uremic pericarditis.

To identify predictors of the success or failure of daily intensive dialysis in uremic pericarditis, a retrospective examination was made of initial clinical, laboratory, and echocardiographic data in 97 patients using univariate and multivariate statistical analysis. In this group, 67 patients showed response to intensive dialysis, and 30 patients did not (22 required surgery and eight died). By univariate analysis, nine factors correlated with intensive dialysis failure (p less than 0.10): admission temperature over 102 degrees F, rales, admission blood pressure under 100 mm Hg, jugular venous distension, peritoneal dialysis treatment only because of severe hemodynamic instability, white blood cell count over 15,000/mm3, white blood cell count left shift, large effusion by echocardiography, and both anterior and posterior effusion by echocardiography. Echocardiographic left ventricular size and function were not useful predictors of success or failure; there was no difference in response to hemodialysis in patients with pericarditis before dialysis (69 percent) versus patients with pericarditis during a maintenance program (67 percent). By discriminant analysis, a seven-variable function was constructed that divided the patients into three groups: (1) those likely to show response to intensive dialysis (48 patients, predictive value of 98 percent), (2) those with an intermediate (38 percent) chance of showing response to intensive dialysis (30 patients), and (3) those unlikely to show response to intensive dialysis (14 patients, predictive value of 100 percent). When the function was applied prospectively to 12 patients (eight with success and four with failure), all were classified correctly. Thus, discriminant analysis of patients with uremic pericarditis allows improved selection of patients with uremic pericarditis likely to have response to daily intensive dialysis and early consideration of alternative forms of treatment in patients unlikely to show response to intensive dialysis. However, the model should be validated in the particular institution where it is to be used before its application.

Prognostic implications of rest and exercise radionuclide ventriculography in patients with suspected or proven coronary heart disease.

Rest and exercise radionuclide ventriculography were assessed for their value in predicting major cardiac events in patients with chest pain. Of 219 patients who were followed for up to 51 months, 42 had major cardiac events: 12 patients (5.5%) died, 5 (2.2%) sustained nonfatal myocardial infarction, and 25 (11.4%) had coronary arterial bypass grafting. Univariate and multivariate survival analysis revealed that exercise left ventricular ejection fraction was the best predictor for total major events and the resting ejection fraction to be the best predictor for death or nonfatal myocardial infarction. These two variables were strong predictors in the entire group of patients and in subgroups: patients with or without Q-wave infarction, patients with high probability of coronary artery disease and those with abnormal resting left ventricular function. Thus, radionuclide angiography provides important prognostic data that permits the physician to categorize patients with chest pain syndromes with respect to subsequent cardiac events. If validated, this model or a modification of it could identify patients at high risk of subsequent major cardiac events who are candidates for intensive follow up and therapy or further invasive evaluation, as well as patients at low risk of subsequent major cardiac events for whom standard follow up would be appropriate.

Risk factors for low birth weight to adolescent mothers

The medical records of mothers less than age 20 years who delivered infants weighing 2500 g or less (n = 112) and 2500 g or more (n = 465) were reviewed to identify factors associated with low birth weight. Of the 26 medical and sociodemographic variables examined, four entered a logistic regression model to differentiate low from normal birth weight mothers: five or fewer prenatal visits, a history of a prior low birth weight infant, illness during pregnancy, and trauma (surgery or injury) during pregnancy. The relative risks and adjusted odds ratios for low birth weight associated with these variables ranged from 1.99 to 4.31. Five or fewer visits accounted for the largest proportion of low birth weight, with an etiologic fraction of 0.43. The ability of the model to discriminate between low and normal birth weight mothers was modest; its sensitivity/specificity was 0.73/0.57 in the original sample and 0.62/0.49 in a separate validation sample (n = 329). The model clarifies the factors associated with adolescent low birth weight and suggests that intervention efforts should focus on early pregnancy identification and regular prenatal care.

Racial and ethnic variation in health resource use and cost for prostate cancer

Study Type – Health economics (resource use)
Level of Evidence 2b

Will the Medicare Prescription Drug Benefit Eliminate Cost Barriers for Older Adults with Diabetes Mellitus

OBJECTIVES: To determine the proportion of older people with diabetes mellitus (DM) eligible to enroll in the standard Medicare Part D drug benefit who will exceed the initial

Impact of Body Mass Index on the Incidence of Cardiometabolic Risk Factors in Ambulatory Care Settings over 5 Years or More

2,250 coverage limit and to determine the effect of hypoglycemic choice on risk of exceeding the coverage limit.

Abruptly Changing Patterns of Diffusion and Use of Extracorporeal Shock-wave Renal Lithotripsy

OBJECTIVE This study was performed to evaluate the association of body mass index (BMI) with the incidence of cardiometabolic risk factors in ambulatory care electronic medical records (EMRs) over 5 years or more. DESIGN A retrospective cohort of normal versus obese patients. SUBJECTS Subjects>or=18 years were identified between 1996 and 2005. MEASUREMENTS Patients were categorized as either normal weight (18 kg/m227 kg/m2) based on baseline BMI (measured 395 days or more after first EMR activity). Outcomes included development, at least 180 days after the first BMI reading date, of four cardiometabolic risk factors (elevated triglycerides, low high-density lipoprotein cholesterol [HDL-C], hypertension, or type 2 diabetes) determined from ICD-9 code, prescribed drug, or biometric reading. Logistic regression estimated the odds of developing cardiometabolic risk factors, alone and combined for normal versus obese patients forward for at least 5 years. RESULTS Seventy-one percent were female, mean age was 43.5 years, and 37.6% had a baseline BMI>27 kg/m2. Comparing obese versus normal weight patients, adjusted odds ratios for the incidence of elevated triglycerides, hypertension, diabetes, and low HDL-C were 2.1 (95% confidence interval [95% CI] 1.9-2.3), 2.2 (95% CI 2.1-2.4), 2.3 (95% CI 2.0-2.7), and 2.2 (95% CI 2.0-2.4), respectively. Adjusted odds ratios of developing one and all four new risk factors were 1.9 (95% CI 1.8-2.1) and 7.9 (95% CI 5.9-10.5), respectively. CONCLUSION Obese patients are approximately twice as likely to develop cardiometabolic risk factors compared with those having normal weight over 5 or more years.

Understanding Laboratory Test Results: Conditions for Appropriate Use of laboratory Tests

Early diffusion and use of extracorporeal shock-wave lithotripsy (ESWL) was found by a 1986 survey of the first 84 operational renal lithotripters in the United States to be similar to that of other equipment-embodied technologies. Resurvey in 1988 of this cohort of units found that clinical indications for ESWL treatment--stone size and location--expanded greatly. Professional fees for ESWL services remained essentially constant, while technical component charges increased 21.0%. Volume of procedures declined by 19.8% among the most productive units, and by 34.4% among the least productive study units; the previously noted approximate fourfold difference remained unchanged between most and least productive units. ESWL patterns of diffusion were comparable to other equipment-embodied diagnostic technology (magnetic resonance imaging [MRI] and computed tomography [CT]) during the first few years of clinical availability. ESWL growth slowed sooner than that of CT and MRI following their introduction into clinical practice, declining in the fourth to fifth year of use following rapid expansion in the first 2 years of availability. While clinical indications for both ESWL and imaging technologies expanded over time, CT and MRI experienced continued growth beyond that of ESWL at the same points of their respective life cycles. In the market areas of the 84 study units, the use of ESWL declined even with expanded indications for treatment, perhaps due to faster expansion of number of units than growth of clinical indications for treatment.