Richard G. Pinckney

APACHE II Predicts long-term survival in COPD patients admitted to a general medical ward

OBJECTIVE: The Acute Physiology and Chronic Health Evaluation II (APACHE II) was developed to predict intensive-care unit (ICU) resource utilization. This study tested APACHE II’s ability to predict long-term survival of patients with chronic obstructive pulmonary disease (COPD) admitted to general medical floors.DESIGN: We performed a retrospective cohort study of patients admitted for COPD exacerbation outside the ICU. APACHE II scores were calculated by chart review. Mortality was determined by the Social Security Death Index. We tested the association between APACHE II scores and long-term mortality with Cox regression and logistic regression.PATIENTS: The analysis included 92 patients admitted for COPD exacerbation in two Burlington, Vermont hospitals between January 1995 and June 1996.MEASUREMENTS AND MAIN RESULTS: In Cox regression, APACHE II score (hazard ratio [HR] 1.76 for each increase in a 3-level categorization, 95% confidence interval [CI] 1.16 to 2.65) and comorbidity (HR 2.58; 95% CI, 1.36 to 4.88) were associated with long-term mortality (P < .05) in the univariate analysis. After controlling for smoking history, comorbidity, and admission pCO2, APACHE II score was independently associated with long-term mortality (HR 2.19; 95% CI, 1.27 to 3.80). In univariate logistic regression, APACHE II score (odds ratio [OR] 2.31; 95% confidence internal [CI] 1.24 to 4.30) and admission pCO2 (OR 4.18; 95% CI, 1.15 to 15.21) were associated with death at 3 years. After controlling for smoking history, comorbidity, and admission pCO2, APACHE II score was independently associated with death at 3 years (OR 2.62; 95% CI, 1.12 to 6.16).CONCLUSION: APACHE II score may be useful in predicting long-term mortality for COPD patients admitted outside the ICU.

Effect of false-positive mammograms on return for subsequent screening mammography

There has been concern that false-positive mammograms may deter women from future screening mammograms. We sought to determine whether false-positive mammograms affected follow-up for rescreening. We studied a cohort of 41,844 women in the Vermont Mammography Registry. We measured the proportion of women returning for the next screening mammogram for 30 months following an initial screening mammogram, and compared rates of follow-up screening at 18 and 30 months in women with false-positive and true-negative initial mammograms. We adjusted for potential confounders using multivariable logistic regression models. Of the 2469 women aged 50 years or older with false-positive mammograms, 67.2% (n = 1660) returned at 18 months for rescreening, compared with 63.9% (16,948/26,521) of the women with true-negative mammograms (P = 0.001). Similarly, 86.8% (2143/2469) of the women with false-positive mammograms returned at 30 months for rescreening, compared with 84.7% (22,466/26,521) of the women with true-negative mammograms (P = 0.005). After adjusting for age, use of hormone replacement therapy, prior mammography, prior false-positive mammography, and education, women with false-positive mammograms were more likely to return at 18 months (odds ratio [OR] = 1.40; 95% confidence interval [CI]: 1.30 to 1.51) and at 30 months (OR = 1.30; 95% CI: 1.18 to 1.44). Despite previous concerns, false-positive screening mammograms did not discourage women from returning for subsequent screening mammography. However, other deleterious effects of false-positive results still warrant improvements in the accuracy of breast cancer screening.

The effect of medication samples on self-reported prescribing practices: a statewide, cross-sectional survey.

BackgroundThe pharmaceutical industry spends billions of dollars annually to encourage clinicians to prescribe their medications. Small studies have demonstrated that one of the marketing strategies, the distribution of free sample medications, is associated with increased use of brand name medication over generic medication.ObjectivesTo determine the relationship between the presence of drug samples in primary care clinics and prescription of preferred drug treatments.DesignCross-sectional survey.ParticipantsPrimary care prescribers in the state of Vermont.Main MeasurementPrescribers were presented with two clinical vignettes and asked to provide the name of the medication they would prescribe in each case. We compared the responses of prescribers with and without samples in their clinics.Key ResultsTwo hundred six prescribers out of the total population of 631 returned the survey and met the eligibility criteria. Seventy-two percent of prescribers had sample closets in their clinics. Seventy percent of clinicians with samples would prescribe a thiazide diuretic for hypertension compared to 91% in those without samples (P < 0.01). For managing depression 91% of prescribers with samples would have provided a generic medication in a patient with no health insurance, compared to 100% of those without samples in their clinic (P = 0.02).ConclusionsClinicians with samples in their clinics were less likely to prescribe preferred medications for hypertension and depression.

Motivating Smokers in the Hospital Pulmonary Function Laboratory to Quit Smoking by Use of the Lung Age Concept

INTRODUCTION The purpose of this study was to investigate the use of lung age to motivate a quit attempt among smokers presenting to a hospital pulmonary function testing (PFT) laboratory. METHODS Participants were randomized to receive a lung age-based motivational strategy (intervention group) versus standard care (control group). At 1 month, all participants were interviewed by telephone to determine whether they made a quit attempt. RESULTS A total of 67 participants were enrolled, and 51 completed the study. Baseline mean data included age = 52 years, 70% women, 40 pack-years of smoking, FEV(1) = 69% predicted, and lung age = 83 years. The quit attempt rates were not different between the intervention and control groups (32% vs. 24%, respectively, p = .59). There was a near significant interaction between lung age and intervention strategy (p = .089), with quit attempt rates among those with normal lung age of 18% in the intervention group versus 33% in the control group and among those with high (worse) lung age of 39% in the intervention group versus 17% in the control group; p = .38. CONCLUSIONS Using lung age to motivate smokers presenting to the PFT laboratory to quit may succeed in patients with high lung age but may undermine motivation in smokers with normal lung age. Further work is needed to refine the approach to smokers with normal lung age.

Prevalence of food insecurity and utilization of food assistance program: an exploratory survey of a Vermont middle school.

BACKGROUND Access to sufficient food--in terms of both quality and quantity--is especially critical for children. Undernourishment during childhood and adolescence can have health implications, both short and long term. The prevalence of food insecurity was assessed in a sample of Vermont school children, as well as the relationship between food insecurity, participation in school breakfast or lunch, exercise and body mass index (BMI), all with a goal to identify needs to improve effectiveness of current programs. METHODS A cross-sectional, 23-item self-administered survey of students attending a public middle school in Vermont. RESULTS Twenty percent of the children were residing in a food insecure household. No statistically significant differences were observed in terms of age, sex or BMI percentile and food security status. Food insecure (with or without hunger) participants were less likely to eat breakfast at home compared to food secure participants (67.1% vs 81.4%, p = .007). However, such differences were not observed between eating school breakfast or lunch. Sixty-two percent of food insecure (with or without hunger) participants engaged in daily exercise compared to 75.9% food secure participants (p = .014). CONCLUSION Children in food insecure households were less likely to be physically active and to eat breakfast at home. However, the school breakfast program is negating any difference between the 2 groups in terms of eating breakfast at all. We consider this a success given the short- and long-term implications of food insecurity in children. We believe these findings have important implications for schools, policy makers, and programs to reduce food insecurity.

Clinical impact of biopsy method on the quality of surgical management in melanoma

Though guidelines recommend excisional biopsy for diagnosing melanoma, partial biopsy techniques are commonly performed, risking underestimation of Breslow depth and altering surgical management. Biopsy choice patterns by specialty and subsequent impact on surgical management was examined.

Awareness and Perceptions of Vermont’s Prescribed Product Gift Ban and Disclosure Law by Prescribers and Pharmacists:

Purpose: Vermont law strictly regulates the interactions between pharmaceutical manufacturers and health care providers, including gifts, meals, and medication samples. The purpose of this study was to describe providers’ awareness and perceptions of current requirements. Methods: An online survey was completed by Vermont providers, including prescribers and pharmacists. The survey asked providers about their awareness of 15 different legal requirements and about their level of agreement with these requirements. Results: Four hundred and eleven providers completed the survey (61% male, mean age 52 years, and 71% physicians). Awareness of the 15 requirements ranged from 28.4% to 93.8%. Most providers agreed or had no strong opinions. Responses at significance levels of P < .001 were noted in 8 of 15 requirements when perceptions were stratified by providers who had any interactions with pharmaceutical representatives in the past year (N = 227, 55.4%) versus providers who reported no interactions (N = 183; 44.6%). Conclusions: A high proportion of Vermont providers are unaware of the current law. Most agreed or had no strong opinions about the requirements; however, at least a quarter disagreed with banning small gifts and meals. Having any interaction with pharmaceutical representatives changed how providers perceived the requirements. These data may be useful for other states considering similar laws.