Steven D. Culler

Patient adherence improves glycemic control

Purpose The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. Methods A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. Results The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P= .0001) and 0.34% lower for each quartile of better medication adherence (P= .0009). Conclusion Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.

Factors related to potentially preventable hospitalizations among the elderly.

OBJECTIVES The authors examine whether the odds of having a hospitalization associated with an ambulatory care sensitive condition can be explained by observed differences in a Medicare beneficiarys predisposing, enabling, and need characteristics. METHODS A multivariate cross-sectional analysis of Medicares administrative inpatient claims data and the Medicare Current Beneficiary Survey was conducted on a nationally representative sample of Medicare beneficiaries. Each Medicare beneficiarys hospital utilization was classified into one of three categories: (1) no hospital admissions; (2) hospitalized, but no hospitalizations for a potentially preventable condition; and (3) at least one potentially preventable hospitalization. RESULTS The results suggest that being older, black, or living either in a core standard metropolitan statistical area (SMSA) county or a rural county significantly increases the odds of a preventable hospitalization, whereas having attended college, or having only Medicare insurance coverage reduces the odds of a preventable hospitalization. Further, those individuals who assess their health status as poor, have had coronary heart disease, a myocardial infarction, or diabetes, and required assistance with two or more of the six basic activities of daily living are at a greater risk of a preventable hospitalization. CONCLUSIONS Policy efforts aimed at reducing the number of preventable hospitalizations among the elderly should address the complex health care delivery needs of those Medicare beneficiaries who have special health care needs because they are very old, black, live in core SMSA or rural counties, have poor overall health status, and have physical limitations. Efforts to reduce the number of Medicare beneficiaries who experience a preventable hospitalization may be cost-effective as these beneficiaries may account for up to 17.4% of Medicares reimbursement for inpatient, outpatient, and physician services in our data set.

Trends in utilization and complications of catheter ablation for atrial fibrillation in Medicare beneficiaries

BACKGROUND Utilization of radiofrequency catheter ablation (RFA) for treatment of atrial fibrillation (AF) is increasing. Data regarding the safety of RFA for AF outside of selected centers of excellence and in older patients are limited. OBJECTIVE The purpose of this study was to quantify utilization of RFA for treatment of AF and rates of adverse events over time in unselected U.S. Medicare patients. METHODS Using Medicare Provider Analysis and Review (MedPAR) files for fiscal years 2001-2006, we developed a coding algorithm to identify AF patients treated with RFA. The number of hospitals performing the procedure, the number of procedures performed, and the frequency of eight RFA complications were determined. The impact of patient characteristics on complication rates was assessed using multivariable logistic regression. RESULTS For fiscal years 2001 to 2006, the number of hospitals performing RFA for AF in Medicare patients increased from 100 to 162, and the annual total procedure volume increased from 315 to 1975 cases. The overall complication rate was 9.1%. Annual complication rates increased from 6.7% in 2001 to 10.1% in 2006 (P for trend = .01), mainly due to an increase in rates of vascular access complications. Increasing patient age was not associated with a higher complication rate. Hospital procedural volume was not associated with the overall risk of complications but was associated with the probability of in-hospital death. CONCLUSION For fiscal years 2001-2006, use of RFA for treatment of AF increased markedly in the Medicare population. Overall complication rates rose during this time, with perforation/tamponade and vascular access complications accounting for the majority of events.

On-Pump Versus Off-Pump Coronary Artery Bypass Surgery in a Matched Sample of Women A Comparison of Outcomes

Background—Women have consistently higher mortality and morbidity than men after coronary artery bypass grafting (CABG). Whether elimination of cardiopulmonary bypass and performance of coronary artery bypass grafting off-pump (OPCAB) have a beneficial effect specifically in women has not been defined. Methods and Results—From January 1998 through March 2002, 21 902 consecutive female patients at 82 hospitals underwent isolated CABG, as reported in an administrative database. Propensity score computer matching was performed based on 13 variables representing patient characteristics and preoperative risk factors to correct for and minimize selection bias. A total of 7376 (3688 pairs) women undergoing CABG surgery were able to be successfully matched. In a propensity score computer-matched cohort, multivariate logistic regression (odds ratio) revealed that women undergoing on-pump surgery had a 73.3% higher mortality (P=0.002) and a 47.2% higher risk of bleeding complications (P=0.019). Conclusions—In a retrospective analysis of women undergoing CABG, computer-matched to minimize selection bias, off-pump surgery led to decreased mortality and morbidity including bleeding complications.

Effect of a Psychoeducational Intervention on Depression, Anxiety, and Health Resource Use in Implantable Cardioverter Defibrillator Patients

Background: Psychological responses have been reported for some patients after the insertion of an implantable cardioverter defibrillator (ICD). This study tested the effects of a psychoeducational intervention on anxiety, depressive symptoms, functional status, and health resource use during the first year after ICD implantation.

Annual direct and indirect health care costs of chronic idiopathic urticaria: a cost analysis of 50 nonimmunosuppressed patients.

OBJECTIVE To estimate annual direct and indirect health care costs in patients with chronic idiopathic urticaria (CIU) managed with conventional therapies. DESIGN A cost analysis consisting of a survey-guided and retrospective medical record review of direct and indirect health care costs from a societal perspective in patients with CIU. SETTING The Johns Hopkins University allergy and dermatology ambulatory clinics. PARTICIPANTS Fifty adults with active CIU were recruited in sequential order. Individuals who were taking corticosteroids or other immunosuppressants in the month before enrollment were excluded from the study. MAIN OUTCOME MEASURES We estimated direct health care costs, which included laboratory, medication, outpatient visit, and emergency department and hospital visit costs. We also estimated indirect costs, which included earnings lost owing to travel to outpatient visits and absences from work owing to CIU-related illness. RESULTS Patients with CIU consumed a mean (SD) of

Outcomes experience with off-pump coronary artery bypass surgery in women.

2047 (

Differences in income between male and female physicians.

1483) annually. Because CIU is primarily an outpatient disease, medication costs alone accounted for 62.5% (

Economic burden of melanoma in the elderly population: population-based analysis of the Surveillance, Epidemiology, and End Results (SEER)--Medicare data.

1280) of the total annual cost. Indirect costs accounted for 15.7% (

The cost-effectiveness of the use of clopidogrel in acute coronary syndromes in five countries based upon the CURE study

322) of the total costs. CONCLUSIONS High medication costs, followed by total indirect costs, result in the largest economic burden among patients with CIU. High medication costs may place low-income patients at risk for suboptimal treatment and increased burden due to poorly controlled disease. Our estimated total health care costs for CIU are comparable to those of other skin diseases such as vitiligo and bullous disease.