Robert J. Goldberg

β-Blocker therapy in acute myocardial infarction: Evidence for underutilization in the elderly

PURPOSE To assess the impact of patient age on the use of beta-blocker therapy in the management of acute myocardial infarction. PATIENTS AND METHODS The population studied consisted of 4,762 patients hospitalized with validated acute myocardial infarction in 16 hospitals in the Worcester, Massachusetts, Standard Metropolitan Statistical Area during the years 1975, 1978, 1981, 1984, 1986, and 1988. Logistic regression analysis was employed to control for relevant demographic and clinical variables in evaluating the independent effect of patient age as a determinant of receipt of beta-blocker therapy during the hospitalization. RESULTS A consistent trend toward reduced use of beta-blocker therapy in older patients was demonstrated. After adjustment for demographic and clinical variables (gender; prior history of angina, hypertension, or diabetes mellitus; myocardial infarction characteristics; complications including congestive heart failure and shock; and use of digoxin and diuretics), odds ratios for receipt of beta-blocker therapy relative to patients less than 55 years of age were 0.61 for those 55 to 64; 0.52 for those 65 to 74; 0.36 for those 75 to 84; and 0.26 for those 85 or older. Analyses performed for each study year demonstrated results consistent with those for the overall study population. CONCLUSION The results of this population-based study suggest that there are substantial opportunities for expanded use of beta-blocker therapy in elderly patients who have sustained an acute myocardial infarction.

Should We Use the IMPACT-Model for the Outcome Prognostication of TBI Patients? A Qualitative Study Assessing Physicians’ Perceptions

Introduction. Shared Decision-Making may facilitate information exchange, deliberation, and effective decision-making, but no decision aids currently exist for difficult decisions in neurocritical care patients. The International Patient Decision Aid Standards, a framework for the creation of high-quality decision aids (DA), recommends the presentation of numeric outcome and risk estimates. Efforts are underway to create a goals-of-care DA in critically-ill traumatic brain injury (ciTBI) patients. To inform its content, we examined physicians’ perceptions, and use of the IMPACT-model, the most widely validated ciTBI outcome model, and explored physicians’ preferences for communicating prognostic information towards families. Methods. We conducted a qualitative study using semi-structured interviews in 20 attending physicians (neurosurgery,neurocritical care,trauma,palliative care) at 7 U.S. academic medical centers. We used performed qualitative content analysis of transcribed interviews to identify major themes. Results. Only 12 physicians (60%) expressed awareness of the IMPACT-model; two stated that they “barely” knew the model. Seven physicians indicated using the model at least some of the time in clinical practice, although none used it exclusively to derive a patient’s prognosis. Four major themes emerged: the IMPACT-model is intended for research but should not be applied to individual patients; mistrust in the IMPACT-model derivation data; the IMPACT-model is helpful in reducing prognostic variability among physicians; concern that statistical models may mislead families about a patient’s prognosis. Discussion: Our study identified significant variability of the awareness, perception, and use of the IMPACT-model among physicians. While many physicians prefer to avoid conveying numeric prognostic estimates with families using the IMPACT-model, several physicians thought that they “ground” them and reduce prognostic variability among physicians. These findings may factor into the creation and implementation of future ciTBI-related DAs.