Jeffrey Newman

PREDICTORS OF REHOSPITALIZATION FOR SYMPTOMATIC VENOUS THROMBOEMBOLISM AFTER TOTAL HIP ARTHROPLASTY

Background Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic thromboembolic events are not well defined. Methods Using administrative data from the California Medicare records for 1993 through 1996, we identified 297 patients 65 years of age or older who were rehospitalized for thromboembolism within three months after total hip arthroplasty. We compared demographic, surgical, and medical variables potentially associated with the development of thromboembolism in these patients and 592 unmatched controls. Results A total of 89.6 percent of patients with thromboembolism and 93.8 percent of control patients were treated with pneumatic compression, warfarin, enoxaparin, or unfractionated heparin, alone or in combination. In addition, 22.2 percent and 29.7 percent, respectively, received warfarin after discharge. A body-mass index (the weight in ...

Hospital Usage of Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage

Background and Purpose— Do-not-resuscitate (DNR) orders are commonly used after severe stroke. We hypothesized that there is significant variability in how these orders are applied after intracerebral hemorrhage and that this influences outcome. Methods— From a database of all admissions to nonfederal hospitals in California, discharge abstracts were obtained for all patients with a primary diagnosis of intracerebral hemorrhage who were admitted through the emergency department during 1999 and 2000. Characteristics included whether DNR orders were written within the first 24 hours of hospitalization. Case-mix–adjusted hospital DNR use was calculated for each hospital by comparing the actual number of DNR cases with the number predicted from a multivariable model. Outcome (in-hospital death) was evaluated in a separate multivariable model adjusted for individual and hospital characteristics. Results— A total of 8233 patients were treated in 234 hospitals. The percentage of patients with DNR orders varied from 0% to 70% across hospitals. Being treated in a hospital that used DNR orders 10% more often than another hospital with a similar case mix increased a patient’s odds of dying during hospitalization by 13% (P <0.001). Patients treated in the quartile of hospitals with the highest adjusted DNR use were more likely to die, and this was not just because of individual patient DNR status. Conclusions— In-hospital mortality after intracerebral hemorrhage is significantly influenced by the rate at which treating hospitals use DNR orders, even after adjusting for case mix. This is not due solely to individual patient DNR status, but rather some other aspect of overall care.

Incidence of end-stage renal disease in Type 2 (non-insulin-dependent) diabetes mellitus in pima indians

SummaryThe incidence of end-stage renal disease was determined in the Pima Indians of the Gila River Indian Community in Arizona, a population with a high prevalence of Type 2 (non-insulin-dependent) diabetes mellitus. Between 1975 and 1986, from a study population of 5059 subjects, end-stage renal disease occurred in 80 persons, 76 (95%) of whom had Type 2 diabetes. A review of the cases with end-stage renal disease indicated that among the diabetic subjects only two cases could be attributed to nondiabetic renal disease; all other cases were attributable to diabetic nephropathy. In diabetic Pima Indians the incidence rate of end-stage renal disease did not change during the study period, was similar in men and women, and was not effected by age at diagnosis of diabetes or by attained age, but did increase significantly with hypertension (p<0.05). The incidence of end-stage renal disease attributed to diabetic nephropathy increased from 0 cases/1000 person-years at 0–5 years to 40.8 cases/1000 person-years at ≥ 20 years duration of diabetes. In these subjects with Type 2 diabetes, the incidence rate of end-stage renal disease was similar to that in subjects with Type 1 (insulin-dependent) diabetes who were followed at the Joslin Clinic in Boston, Massachusetts when those with similar duration of diabetes were compared.

Survey of Physician Practice Behaviors Related to Diabetes Mellitus in the U.S.: Physician adherence to consensus recommendations

OBJECTIVE To summarize the frequency of physician adherence to consensus recommendations for prevention of diabetic complications. RESEARCH DESIGN AND METHODS Survey data from a nationwide stratified probability sample of primary-care physicians were analyzed. Adherence to recommendations were reported by physician specialty, age-group, and type of diabetes treated. RESULTS Adherence was high for eye exams, blood pressure measurements, neurological and circulatory exams, and laboratory procedures using blood. Adherence was low for examination of the teeth and gums, examination of the feet, and laboratory procedures involving the collection of urine. Internists generally had the highest adherence rates and pediatricians the lowest. Reported adherence decreased with physician age. Adherence was higher for the management of individuals with IDDM than for those with NIDDM. CONCLUSIONS Recommendations for the care of diabetic individuals need to be more widely implemented. Recommendations targeted specifically to pediatricians may be necessary.

Trends in Diabetes and Diabetic Complications, 1980–1987

OBJECTIVE Although diabetes is a major source of morbidity and mortality in the United States, only recently has a unified national surveillance system begun to monitor trends in diabetes and diabetic complications. RESEARCH DESIGN AND METHODS We established a diabetes surveillance system using data for 1980–1987 from vital records, the National Health Interview Survey, the National Hospital Discharge Survey, and the Health Care Financing Administrations records to examine trends in the prevalence and incidence of diabetes, diabetes mortality, hospitalizations, and diabetic complications. RESULTS From 1980 through 1987, the number of individuals known to have diabetes increased by 1 million—to 6.82 million. Age-standardized prevalence for diabetes increased 9% during this period, from 25.4 to 27.6/1000 U.S. residents (P = 0.03). The incidence of diabetes increased among women (P = 0.003), particularly among those > 65 yr old (P = 0.02). Age-standardized mortality rates (for diabetes as either an underlying or contributing cause) per 100,000 individuals with diabetes declined 12%, from 2350 to 2066. Annual mortality rates from stroke (as an underlying cause and diabetes as a contributing cause) and diabetic ketoacidosis declined 29% (P = 0.003) and 22% (P < 0.001), respectively. During these 8 yr, hospitalization rates for major CVD and stroke (as the primary diagnoses and diabetes as a secondary diagnosis) increased 34% (P = 0.006) and 38% (P = 0.01), respectively. Also during this period, hospitalization rates increased 21% for diabetic ketoacidosis (P = 0.01) and 29% for lower-extremity amputations (P = 0.06). From 1982 through 1986, treatment for end-stage renal disease related to diabetes increased > 10% each year (P < 0.001). The prevalence of diagnosed diabetes was nearly twice as high in blacks as in whites (P = 0.04). Blacks also had increased rates of lower-extremity amputation (P = 0.02), diabetic ketoacidosis (P < 0.001), and end-stage renal disease (P = 0.01). CONCLUSIONS Diabetes surveillance data will be useful in planning, targeting, and evaluating public health efforts designed to prevent and control diabetes and its complications.

Is screening mammography effective in elderly women

PURPOSE Screening mammography is effective in reducing breast cancer mortality in women between the ages of 50 and 69 years. We sought to determine whether older women who undergo screening mammography have a decreased risk of metastatic breast cancer. SUBJECTS AND METHODS We studied 690,993 women aged 66 to 79 years who were California Medicare beneficiaries from January 1992 to December 1993, and who chose the fee-for-service plan. Health Care Financing Administration part B billing records were used to determine the use of screening mammography. The extent of breast cancer (in situ, local, regional, or metastatic) was ascertained for the 6,767 women who were diagnosed with the disease in 1993, using data from the California State Cancer Registry. For each type (extent) of breast cancer, the relative risk (RR) and 95% confidence (CI) of developing breast cancer was estimated by dividing the risk of its development in screened women by the risk in women who were not screened. RESULTS A total of 46% of women had mammography during the 2-year study period. In situ, local, and regional breast cancer were more likely to be detected among women who underwent screening mammography. For example, the relative risk of detecting local breast cancer in screened women was 3.3 (95% CI: 3.1 to 3.5). The risk of detecting metastatic breast cancer, on the other hand, was significantly reduced among women aged 66 to 79 years who underwent screening mammography (RR = 0.57, 95% CI: 0.45 to 0.72). CONCLUSION Screening mammography is associated with a decreased risk of detecting metastatic breast cancer among elderly women. Public health recommendations need to weigh the benefit of screening elderly women against the cost and potential harm from screening and treating early lesions that may have no effect on mortality.

Risk factors for coronary heart disease mortality among persons with diabetes

Although coronary heart disease is a leading cause of morbidity and mortality among persons with diabetes, the risk factors for coronary heart disease have not been well established for this population. The authors performed a case-control analysis by using data from two large population-based surveys. Cases of persons who died of coronary heart disease were identified from the 1986 National Mortality Followback Survey, and controls were taken from behavioral risk factor surveys conducted in 35 states in 1988. Diabetic women younger than 55 years with no other risk factors for coronary heart disease had a 16-fold higher risk of dying from coronary heart disease than did women without diabetes. About one-third of younger women who died of coronary heart disease had diabetes. Diabetic men less than 45 years old with no other risk factors for coronary heart disease had an eightfold higher risk of coronary heart disease mortality. Among older white men and women, diabetes increased the risk of mortality from coronary heart disease about twofold. In younger diabetics, current cigarette smoking was associated with a 50% increase in risk, and high blood pressure increased the risk more than threefold. In the older age group, risk factors for coronary heart disease mortality were similar among those with and those without diabetes: Cigarette smoking and high blood pressure each were associated with about a twofold increase in risk. Diabetes is a particularly strong risk factor for mortality from coronary heart disease in young adults. Smoking and blood pressure control represent major opportunities to reduce the risk of coronary heart disease among persons with diabetes.

Assessing dual-role staff-interpreter linguistic competency in an integrated healthcare system

BackgroundInterpreter services for medical care increase physician–patient communication and safety, yet a “formal certification” process to demonstrate interpreter competence does not exist. Testing and training is left to individual health care facilities nationwide. Bilingual staff are often used to interpret, without any assessment of their skills. Assessing interpreters’ linguistic competence and setting standards for testing is a priority.ObjectiveTo assess dual-role staff interpreter linguistic competence in an integrated health care system to determine skill qualification to work as medical interpreters.DesignDual-role staff interpreters voluntarily completed a linguistic competency assessment using a test developed by a language school to measure comprehension, completeness, and vocabulary through written and oral assessment in English and the second language. Pass levels were predetermined by school as not passing, basic (limited ability to read, write, and speak English and the second language) and medical interpreter level. Five staff-interpreter focus groups discussed experiences as interpreters and with language test.ResultsA total of 840 dual-role staff interpreters were tested for Spanish (75%), Chinese (12%), and Russian (5%) language competence. Most dual-role interpreters serve as administrative assistants (39%), medical assistants (27%), and clinical staff (17%). Two percent did not pass, 21% passed at basic level, 77% passed at medical interpreter level. Staff that passed at the basic level was prone to interpretation errors, including omissions and word confusion. Focus groups revealed acceptance of exam process and feelings of increased validation in interpreter role.ConclusionsWe found that about 1 in 5 dual-role staff interpreters at a large health care organization had insufficient bilingual skills to serve as interpreters in a medical encounter. Health care organizations that depend on dual-role staff interpreters should consider assessing staff English and second language skills.

End state renal disease among native Americans, 1983-86

We used data reported to Medicare from 1983 through 1986 to determine the incidence of end-stage renal disease (ESRD) among Native Americans and Whites in the United States. The 1,075 Native American cases represented an annual incidence, age-adjusted to the White population, of 269 per million, 2.8 times the rate for Whites. Fifty-six percent of Native American cases and 27 percent of the White cases were attributed to diabetes, indicating that ESRD is a major problem. Diabetes control provides the greatest opportunity for prevention.

Mammography screening among California Medicare beneficiaries: 1993–1994

BACKGROUND Over half of all breast cancer deaths occur among women 65 years of age or older. However, mammography screening decreases with increasing age, despite better survival rates for tumors detected early. METHODS Health Care Financing Administration data from 1993 and 1994, and 1990 United States Census data were used to assess the impact of race, age, Medicaid coverage, and community-level socioeconomic indices on mammography screening for over 800,000 California Medicare beneficiaries. RESULTS Women who were African American, older, or had Medicaid coverage were significantly less likely to have a biennial mammogram than their counterparts. Women living in areas with fewer college educated residents, with a higher proportion of Mexican or Asian residents had lower use of mammography. However, African-American and Caucasian women with Medicaid coverage had equally low mammography rates (AOR = 1.01, 95% CI .97-1.04), while African-American women with and without Medicaid had similarly low mammography rates (AOR = .96, 95% CI .92-1.01). CONCLUSIONS Despite dual coverage, Medicare beneficiaries enrolled in Medicaid had few mammograms. African-American Medicare beneficiaries, with and without Medicaid, had low mammography rates. Intervention efforts should be targeted toward these women.