Vincent S. Fan

Health status predicts long-term outcome in outpatients with coronary disease

Background—Although patient-reported health status measures have been used as end points in clinical trials, they are rarely used in other settings. Demonstrating that they independently predict mortality and hospitalizations among outpatients with coronary disease could emphasize their clinical value. Methods and Results—This study evaluated the prognostic utility of the Seattle Angina Questionnaire (SAQ), a disease-specific health status measure for patients with coronary artery disease. Patients were enrolled in a prospective cohort study from 6 Veterans Affairs General Internal Medicine Clinics. All patients reporting coronary artery disease who completed a SAQ and had 1 year of follow-up were analyzed (n=5558). SAQ predictor variables were the physical limitation, angina stability, angina frequency, and quality-of-life scores. The primary outcome was 1-year all-cause mortality, and a secondary outcome was hospitalization for acute coronary syndrome (ACS). Lower SAQ scores were associated with increased risks of mortality and ACS admissions. Prognostic models controlling for demographic and clinical characteristics demonstrated significant independent mortality risk with lower SAQ physical limitation scores; odds ratios for mild, moderate, and severe limitation were 1.5, 2.0, and 4.0 versus minimal limitation (P <0.001). Odds ratios for mild, moderate, and severe angina frequency were 0.8, 1.2, and 1.6 (P =0.078). The odds ratios for ACS admission among those with mild, moderate, and severe angina frequency were 1.4, 2.0, and 2.2, respectively (P =0.016). Conclusions—SAQ scores are independently associated with 1-year mortality and ACS among outpatients with coronary disease and may serve a valuable role in the risk stratification of such patients.

A Comprehensive Care Management Program to Prevent Chronic Obstructive Pulmonary Disease Hospitalizations: A Randomized, Controlled Trial

BACKGROUND Improving a patients ability to self-monitor and manage changes in chronic obstructive pulmonary disease (COPD) symptoms may improve outcomes. OBJECTIVE To determine the efficacy of a comprehensive care management program (CCMP) in reducing the risk for COPD hospitalization. DESIGN A randomized, controlled trial comparing CCMP with guideline-based usual care. (ClinicalTrials.gov registration number: NCT00395083) SETTING: 20 Veterans Affairs hospital-based outpatient clinics. PARTICIPANTS Patients hospitalized for COPD in the past year. INTERVENTION The CCMP included COPD education during 4 individual sessions and 1 group session, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management. Patients in both the intervention and usual care groups received a COPD informational booklet; their primary care providers received a copy of COPD guidelines and were advised to manage their patients according to these guidelines. Patients were randomly assigned, stratifying by site based on random, permuted blocks of variable size. MEASUREMENTS The primary outcome was time to first COPD hospitalization. Staff blinded to study group performed telephone-based assessment of COPD exacerbations and hospitalizations, and all hospitalizations were blindly adjudicated. Secondary outcomes included non-COPD health care use, all-cause mortality, health-related quality of life, patient satisfaction, disease knowledge, and self-efficacy. RESULTS Of the eligible patients, 209 were randomly assigned to the intervention group and 217 to the usual care group. Citing serious safety concerns, the data monitoring committee terminated the intervention before the trials planned completion after 426 (44%) of the planned total of 960 patients were enrolled. Mean follow-up was 250 days. When the study was stopped, the 1-year cumulative incidence of COPD-related hospitalization was 27% in the intervention group and 24% in the usual care group (hazard ratio, 1.13 [95% CI, 0.70 to 1.80]; P= 0.62). There were 28 deaths from all causes in the intervention group versus 10 in the usual care group (hazard ratio, 3.00 [CI, 1.46 to 6.17]; P= 0.003). Cause could be assigned in 27 (71%) deaths. Deaths due to COPD accounted for the largest difference: 10 in the intervention group versus 3 in the usual care group (hazard ratio, 3.60 [CI, 0.99 to 13.08]; P= 0.053). LIMITATIONS Available data could not fully explain the excess mortality in the intervention group. Ability to assess the quality of the educational sessions provided by the case managers was limited. CONCLUSION A CCMP in patients with severe COPD had not decreased COPD-related hospitalizations when the trial was stopped prematurely. The CCMP was associated with unanticipated excess mortality, results that differ markedly from similar previous trials. A data monitoring committee should be considered in the design of clinical trials involving behavioral interventions.

Continuity of care and other determinants of patient satisfaction with primary care

AbstractOBJECTIVE: The patient-clinician relationship is a central feature of primary care, and recent developments in the delivery of health care have tended to limit continuity of care. The objective of this study was to evaluate the extent to which continuity of care and other factors are related to patient satisfaction. DESIGN: Cross-sectional, mailed questionnaire study. SETTING: Primary care clinics at 7 Veterans Affairs medical centers. PATIENTS/PARTICIPANTS: Patients (N=21,689) participating in the Ambulatory Care Quality Improvement Project who returned the baseline Seattle Outpatient Satisfaction Questionnaire (SOSQ). MEASUREMENTS AND MAIN RESULTS: We evaluated the association between self-reported continuity and satisfaction, after adjusting for characteristics of patients, clinics, and providers. The humanistic scale of the SOSQ measures patient satisfaction with communication skills and humanistic qualities of providers, whereas the organizational scale measures satisfaction with delivery of health care services. The mean adjusted humanistic score for patients who reported always seeing the same provider was 17.3 (95% confidence interval [CI], 15.5 to 19.1) points higher than for those who rarely saw the same provider. Similarly, the mean adjusted organizational score was 16.3 (95% CI, 14.5 to 18.1) points higher for patients who always saw the same provider compared to rarely. Demographic factors, socioeconomic status, health status, clinic site, and patient utilization of services were all associated with both the adjusted humanistic and organizational scores of the SOSQ. CONCLUSIONS: Self-reported continuity of care is strongly associated with higher patient satisfaction. This suggests that improving continuity of care may improve patient satisfaction with providers as well as with their health care organization.

Validation of case-mix measures derived from self-reports of diagnoses and health

Self-reported chronic diseases and health status are associated with resource use. However, few data exist regarding their ability to predict mortality or hospitalizations. We sought to determine whether self-reported chronic medical conditions and the SF-36 could be used individually or in combination to assess co-morbidity in the outpatient setting. The study was designed as a prospective cohort study. Patients were enrolled in the primary care clinics at seven Veterans Affairs (VA) medical centers participating in the Ambulatory Care Quality Improvement Project (ACQUIP). 10,947 patients, > or = 50 years of age, enrolled in general internal medicine clinics who returned both a baseline health inventory checklist and the baseline SF-36 who were followed for a mean of 722.5 (+/-84.3) days. The primary outcome was all-cause mortality, with a secondary outcome of hospitalization within the VA system. Using a Cox proportional hazards model in a development set of 5,469 patients, a co-morbidity index [Seattle Index of Co-morbidity (SIC)] was constructed using information about age, smoking status and seven of 25 self-reported medical conditions that were associated with increased mortality. In the validation set of 5,478 patients, the SIC was predictive of both mortality and hospitalizations within the VA system. A separate model was constructed in which only age and the PCS and MCS scores of the SF-36 were entered to predict mortality. The SF-36 component scores and the SIC had comparable discriminatory ability (AUC for discrimination of death within 2 y 0.71 for both models). When combined, the SIC and SF-36 together had improved discrimination for mortality (AUC = 0.74, p-value for difference in AUC < 0.005). A new outpatient co-morbidity score developed using self-identified chronic medical conditions on a baseline health inventory checklist was predictive of 2-y mortality and hospitalization within the VA system in general internal medicine patients.

Health care expenditure prediction with a single item, self-rated health measure.

Background:Prediction models that identify populations at risk for high health expenditures can guide the management and allocation of financial resources. Objective:To compare the ability for identifying individuals at risk for high health expenditures between the single-item assessment of general self-rated health (GSRH), “In general, would you say your health is Excellent, Very Good, Good, Fair, or Poor?,” and 3 more complex measures. Study Design:We used data from a prospective cohort, representative of the US civilian noninstitutionalized population, to compare the predictive ability of GSRH to: (1) the Short Form-12, (2) the Seattle Index of Comorbidity, and (3) the Diagnostic Cost-Related Groups/Hierarchal Condition Categories Relative-Risk Score. The outcomes were total, pharmacy, and office-based annualized expenditures in the top quintile, decile, and fifth percentile and any inpatient expenditures. Data Source:Medical Expenditure Panel Survey panels 8 (2003–2004, n = 7948) and 9 (2004–2005, n = 7921). Results:The GSRH model predicted the top quintile of expenditures, as well as the SF-12, Seattle Index of Comorbidity, though not as well as the Diagnostic Cost-Related Groups/Hierarchal Condition Categories Relative-Risk Score: total expenditures [area under the curve (AUC): 0.79, 0.80, 0.74, and 0.84, respectively], pharmacy expenditures (AUC: 0.83, 0.83, 0.76, and 0.87, respectively), and office-based expenditures (AUC: 0.73, 0.74, 0.68, and 0.78, respectively), as well as any hospital inpatient expenditures (AUC: 0.74, 0.76, 0.72, and 0.78, respectively). Results were similar for the decile and fifth percentile expenditure cut-points. Conclusions:A simple model of GSRH and age robustly stratifies populations and predicts future health expenditures generally as well as more complex models.

Bidirectional Relationship between Cognitive Function and Pneumonia

RATIONALE Relationships between chronic health conditions and acute infections remain poorly understood. Preclinical studies suggest crosstalk between nervous and immune systems. OBJECTIVES To determine bidirectional relationships between cognition and pneumonia. METHODS We conducted longitudinal analyses of a population-based cohort over 10 years. We determined whether changes in cognition increase risk of pneumonia hospitalization by trajectory analyses and joint modeling. We then determined whether pneumonia hospitalization increased risk of subsequent dementia using a Cox model with pneumonia as a time-varying covariate. MEASUREMENTS AND MAIN RESULTS Of the 5,888 participants, 639 (10.9%) were hospitalized with pneumonia at least once. Most participants had normal cognition before pneumonia. Three cognition trajectories were identified: no, minimal, and severe rapid decline. A greater proportion of participants hospitalized with pneumonia were on trajectories of minimal or severe decline before occurrence of pneumonia compared with those never hospitalized with pneumonia (proportion with no, minimal, and severe decline were 67.1%, 22.8%, and 10.0% vs. 76.0%, 19.3%, and 4.6% for participants with and without pneumonia, respectively; P < 0.001). Small subclinical changes in cognition increased risk of pneumonia, even in those with normal cognition and physical function before pneumonia (β = -0.02; P < 0.001). Participants with pneumonia were subsequently at an increased risk of dementia (hazard ratio, 2.24 [95% confidence interval, 1.62-3.11]; P = 0.01). Associations were independent of demographics, health behaviors, other chronic conditions, and physical function. Bidirectional relationship did not vary based on severity of disease, and similar associations were noted for those with severe sepsis and other infections. CONCLUSIONS A bidirectional relationship exists between pneumonia and cognition and may explain how a single episode of infection in well-appearing older individuals accelerates decline in chronic health conditions and loss of functional independence.

Costs of pulmonary rehabilitation and predictors of adherence in the National Emphysema Treatment Trial.

This study reports the costs associated with rehabilitation among participants in the National Emphysema Treatment Trial (NETT), and evaluates factors associated with adherence to rehabilitation. Pulmonary rehabilitation is recommended for moderate-to-severe COPD and required by the Centers for Medicare and Medicaid Services (CMS) prior to lung volume reduction surgery (LVRS). Between January 1998 and July 2002, 1,218 subjects with emphysema and severe airflow limitation (FEV1 ≤ 45% predicted) were randomized. Primary outcome measures were designated as mortality and maximal exercise capacity 2 years after randomization. Pre-randomization, estimated mean total cost per patient of rehabilitation was

Anxiety is associated with diminished exercise performance and quality of life in severe emphysema: A cross-sectional study

2,218 (SD

Physiologic variables and functional status independently predict COPD hospitalizations and emergency department visits in patients with severe COPD

314; 2006 dollars) for the medical group and

Polymorphic variation in surfactant protein B is associated with COPD exacerbations

2,187 (SD