Marie J. Cowan

Psychosocial treatment within sex by ethnicity subgroups in the Enhancing Recovery in Coronary Heart Disease clinical trial.

Objective: Intervening in depression and/or low perceived social support within 28 days after myocardial infarction (MI) in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial did not increase event-free survival. The purpose of the present investigation was to conduct post hoc analyses on sex and ethnic minority subgroups to assess whether any treatment subgroup is at reduced or increased risk of greater morbidity/mortality. Methods: The 2481 patients with MI (973 white men, 424 minority men, 674 white women, 410 minority women) who had major or minor depression and/or low perceived social support were randomly allocated to usual medical care or cognitive behavior therapy. Total mortality or recurrent nonfatal MI (ENRICHD primary endpoint) and cardiac mortality or recurrent nonfatal MI (secondary endpoint) were analyzed as composite endpoints by group for time to first event using Cox proportional hazards regression. Results: There was a trend in the direction of treatment efficacy for white men for the primary endpoint (hazard ratio [HR], 0.80; 95% confidence interval, 0.61–1.05; p = .10) and a significant (p < .006, Bonferroni corrected) effect for the secondary endpoint (HR, 0.63; 95% CI, 0.46–0.87; p = .004). In contrast, the HRs for each of the other three subgroups were nonsignificant. The magnitude of differences in treatment effects between white men and the other subgroups remained significant for the secondary endpoint (p =.04) after adjustment for age, education, living alone, antidepressant use, comorbidity score, cardiac catheterization, ejection fraction, history of hypertension, and major depression. Conclusions: White men, but not other subgroups, may have benefited from the ENRICHD intervention, suggesting that future studies need to attend to issues of treatment design and delivery that may have prevented benefit among sex and ethnic subgroups other than white men.

Predictors of Treatment Response for Depression and Inadequate Social Support – The ENRICHD Randomized Clinical Trial

Objective: To determine whether the ‘dose’ of treatment exposure, delivery of specific components of cognitive behavior therapy (CBT), patient adherence and/or use of antidepressants predict favorable depression and social support outcomes after 6 months of cognitive behavioral treatment. Methods: Secondary analyses of the intervention arm of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial involving persons with acute myocardial infarction (MI): n = 641 for the depression outcomes and n = 523 for the social support outcomes. The outcome measures were, for depression: the Beck Depression Inventory (BDI) and Hamilton Rating Scale for Depression (HAM-D); for social support: the ENRICHD Social Support Instrument (ESSI) and Perceived Social Support Scale (PSSS). Results: Better depression outcomes (measured by the BDI) were receiving a high number of depression-specific intervention components, p < 0.01, and completing a high proportion of homework assignments, p < 0.02. Better depression outcomes (measured by the HAM-D) were receiving a high number of the social communication and assertiveness components of the intervention, p < 0.01, and completing a high proportion of homework assignments, p < 0.01. Better social support outcomes (measured by the ESSI and PSSS) were predicted by membership in a racial or ethnic minority group, p < 0.02 and p < 0.01, respectively; and by completing a higher number of homework assignments, p < 0.01 and p < 0.05, respectively. Delivery of the social communication and assertiveness components of the intervention was an independent predictor of a worse social support outcome, p < 0.01 (measured by the PSSS). Conclusions: The standard components of CBT for depression are useful in treating comorbid depression in post-MI patients. Working on communication skills may help to improve depression but not necessarily social support outcomes in this patient population, while adherence to cognitive-behavioral homework assignments is important for both outcomes. Other components of the ENRICHD intervention that were designed to improve social support had no discernible effects on outcomes. Intervention refinements may be needed in order to achieve better results in future post-MI clinical trials. A greater emphasis on CBT homework adherence could improve both depression and social support outcomes.

An Alternative Approach to Reducing the Costs of Patient Care? A Controlled Trial of the Multi-Disciplinary Doctor-Nurse Practitioner (MDNP) Model:

Objective. Hospitals adapt to changing market conditions by exploring new care models that allow them to maintain high quality while containing costs. The authors examined the net cost savings associated with care management by teams of physicians and nurse practitioners, along with daily multidisciplinary rounds and postdischarge patient follow-up. Methods. One thousand two hundred and seven general medicine inpatients in an academic medical center were randomized to the intervention versus usual care. Intervention costs were compared to the difference in nonintervention costs, estimated by comparing changes between preadmission and postadmission in regression-adjusted costs for intervention versus usual care patients. Intervention costs were calculated by assigning hourly costs to the time spent by different providers on the intervention. Patient costs during the index hospital stay were estimated from administrative records and during the 4-month follow-up by weighting selfreported utilization by unit costs. Results. Intervention costs were

Relation of depression, natural killer cell function, and infections after coronary artery bypass in women.

1187 per patient and associated with a significant

Estimation of myocardial infarct size by digital computer analysis of the VCG

3331 reduction in nonintervention costs. About

Clinical depression in women after cardiac surgery.

1947 of the savings were realized during the initial hospital stay, with the remainder attributable to reductions in postdischarge service use. After adjustment for possible attrition bias, a reasonable estimate of the cost offset was

Heart rate variability and 24-hour minimum heart rate.

2165, for a net cost savings of

Comparative accuracy of computerized spatial vectorcardiography and standard electrocardiography for detection of myocardial infarction.

978 per patient. Because health outcomes were comparable for the 2 groups, the intervention was cost-effective. Conclusions. Wider adoption of multidisciplinary interventions in similar settings might be considered. The savings previously reported with hospitalist models may also be achievable with other models that focus on efficient inpatient care and appropriate postdischarge care.

Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial.

Background: After hospital discharge for coronary artery bypass grafting (CABG), infection is a common cause of morbidity. Although depression has been associated with immune dysfunction, its role in post-CABG infection is unknown. Aims: The purpose of this study was to: 1) compare natural killer cell cytotoxicity (NKCC) and post-hospitalization infections in depressed and non-depressed women after CABG; and 2) test whether NKCC mediated the relationship between post-discharge depression and infections. Methods: Sixty-seven women recovering from CABG were assessed for depression prior to hospital discharge and followed for six months. Major depression was identified by a structured clinical interview. Infections were identified by patient report using the Modified Health Review and by medical chart audit. Results: Compared to non-depressed women after CABG, women with major depression had reduced NKCC, more all-cause infections, and more self-reported illnesses. Although NKCC did not mediate the relationship between depression and wound (i.e. incisional) infections after CABG, it did mediate the relationship between depression and non-wound infections, including pneumonias and upper respiratory infections. Conclusions: For the first six months after CABG, women with major depression are at increased risk for infections. Natural killer cell cytotoxicity may be related to this phenomenon, particularly to non-wound infections.

Effect of a Multidisciplinary Intervention on Communication and Collaboration Among Physicians and Nurses

This study described the linear relationship of the myocardial infarct size, measured postmortem, to the integral of the sequential vector spatial magnitudes analyzed at 400 samples per second during the initial period of abnormal depolarization (IAD) in 25 patients with myocardial infarction (MI) and ten controls. The equation for the fitted regression line was: %MI = -0.35 + 3.33 IAD; r = .90; p less than .001. The duration of abnormal depolarization was determined by two computer algorithms: first, using the classical method of pathological Q wave duration, whenever possible; and a new method of measurement of an abnormally slow rate of rise of vector spatial magnitude with time (dm/dt), when there were no Q waves in the Frank orthogonal lead input signals. There was not a significant difference in the mean values of IAD of the MI group or the control group calculated by the two algorithms.