William Corser

Predictors of smoking cessation and relapse after hospitalization for acute coronary syndrome

BACKGROUND A hospital admission for a serious cardiac event offers a unique opportunity for smoking cessation. Understanding the factors that predict and enhance cessation among smoking cardiac inpatients is important for hospital physicians and clinical staff. STUDY OBJECTIVE To determine factors that predict smoking cessation, relapse, or continued smoking among posthospitalized cardiac patients who were smoking at the time of admission. SAMPLE Patients hospitalized with acute coronary syndrome (ACS) were recruited from 5 hospitals in Michigan to participate in a study assessing hospital quality improvement plus at-home health behavior change counseling. MEASUREMENTS Patient interview data were collected shortly after discharge and 3 and 8 months later to describe patient demographics, clinical characteristics, tobacco use, and other behaviors. Multinomial logit regression was used to predict smoking cessation, relapse, and continued smoking. RESULTS Of patients smoking at hospitalization who completed both follow-up interviews, 56.8% (n = 111) were not smoking at 8 months. A significant predictor of successful cessation was higher household income (odds ratio [OR] = 4.72; P = 0.003), while having other smokers in the household decreased the odds of cessation (OR = 0.20; P = 0.001). History of depression increased the odds of relapse (OR = 6.38; P = 0.002) and being a lighter smoker decreased the odds (OR = 0.16; P = 0.026). CONCLUSIONS Although approximately one-half of the smokers in this study reported successful cessation, interventions are still needed to assist all smokers to successfully quit smoking after an ACS hospitalization. Our data suggest targeting follow-up programs to include other family members and using specialized methods for heavy smokers.

Hopelessness and depression in the early recovery period after hospitalization for acute coronary syndrome

PURPOSE Psychosocial factors, such as depression, have been identified as important predictors of morbidity and mortality in individuals with coronary heart disease; however, little research has been done examining hopelessness in this population. This investigation examined the frequency and severity of hopelessness and depression in the early recovery period after hospitalization for acute coronary syndrome (ACS), the relationship between hopelessness and depression, and patient characteristics leading to these 2 variables. METHODS A total of 525 post-ACS patients at 5 hospitals in Michigan were interviewed. Measures included the cognitive expectations factor of the Beck Hopelessness Scale and the Center for Epidemiologic Studies-Depression Scale. RESULTS Hopelessness symptoms were frequent and moderate to severe in 27% of the sample, whereas depression was frequent and moderate to severe in 36% of subjects. Hopelessness was moderately correlated with depression, yet a number of different patient characteristics were predictive of each. Lower educational level predicted hopelessness, but not depression. Patients who had coronary artery bypass surgery or coronary angioplasty were more hopeless, but not more depressed. Female gender predicted depression, but not hopelessness. Hopelessness and depression had a shared variance of 33%. CONCLUSIONS Hopelessness and depression were frequent and moderate to severe in a portion of patients in the early ACS recovery period. An association between hopelessness and depression exists, while different patient characteristics were more strongly associated with each. Longitudinal analysis is needed to examine hopelessness and depression in later phases of the ACS recovery period.

Do self-report and medical record comorbidity data predict longitudinal functional capacity and quality of life health outcomes similarly?

BackgroundThe search for a reliable, valid and cost-effective comorbidity risk adjustment method for outcomes research continues to be a challenge. The most widely used tool, the Charlson Comorbidity Index (CCI) is limited due to frequent missing data in medical records and administrative data. Patient self-report data has the potential to be more complete but has not been widely used. The purpose of this study was to evaluate the performance of the Self-Administered Comorbidity Questionnaire (SCQ) to predict functional capacity, quality of life (QOL) health outcomes compared to CCI medical records data.MethodAn SCQ-score was generated from patient interview, and the CCI score was generated by medical record review for 525 patients hospitalized for Acute Coronary Syndrome (ACS) at baseline, three months and eight months post-discharge. Linear regression models assessed the extent to which there were differences in the ability of comorbidity measures to predict functional capacity (Activity Status Index [ASI] scores) and quality of life (EuroQOL 5D [EQ5D] scores).ResultsThe CCI (R2 = 0.245; p = 0.132) did not predict quality of life scores while the SCQ self-report method (R2 = 0.265; p < 0.0005) predicted the EQ5D scores. However, the CCI was almost as good as the SCQ for predicting the ASI scores at three and six months and performed slightly better in predicting ASI at eight-month follow up (R2 = 0.370; p < 0.0005 vs. R2 = 0.358; p < 0.0005) respectively. Only age, gender, family income and Center for Epidemiologic Studies-Depression (CESD) scores showed significant association with both measures in predicting QOL and functional capacity.ConclusionsAlthough our model R-squares were fairly low, these results show that the self-report SCQ index is a good alternative method to predict QOL health outcomes when compared to a CCI medical record score. Both measures predicted physical functioning similarly. This suggests that patient self-reported comorbidity data can be used for predicting physical functional capacity and QOL and can serve as a reliable risk adjustment measure. Self-report comorbidity data may provide a cost-effective alternative method for risk adjustment in clinical research, health policy and organizational improvement analyses.Trial registrationClinical Trials.gov NCT00416026

Is quality improvement sustainable? Findings of the American college of cardiology's guidelines applied in practice

OBJECTIVE (i) To examine the sustainability of an in-hospital quality improvement (QI) intervention, the American College of Cardiologys Guideline Applied to Practice (GAP) in acute myocardial infarction (AMI). (ii) To determine the predictors of physician adherence to AMI guidelines-recommended medication prescribing. DESIGN Prospective observational study. SETTING Five mid-Michigan community hospitals. PARTICIPANTS 516 AMI patients admitted consecutively 1 year after the GAP intervention. These patients were compared with 499 post-GAP patients. MAIN OUTCOME MEASURES The main outcome was adherence to medication use guidelines. Predictors of medication use were determined using multivariable logistic regression analysis. RESULTS 1 year after GAP implementation, adherence to most medications remained high. We found a significant increase in beta-blocker (BB) use in-hospital (87.9 vs. 72.1%, P < 0.001) whereas cholesterol assessment within 24 h (79.5 vs. 83.6%, P > 0.225) did not change significantly. However, discharge aspirin (83 vs. 90%, P < 0.018) and BB prescriptions (84 vs. 92%, P < 0.016) dropped to preintervention rates. Discharge angiotensin-converting enzyme inhibitor and treatment of patients with low-density lipoprotein of ≥ 100 were unchanged. Predictors of receiving appropriate medications were male gender (for aspirin and BBs) and treatment with percutaneous coronary intervention compared with coronary artery bypass graft. Notably, prescription rates for discharge medications differed significantly by hospital. CONCLUSIONS Early benefits of the Mid-Michigan GAP intervention on guideline use were only partially sustained at 1 year. Differences in guideline adherence by treatment modality and hospital demonstrate challenges for follow-up phases of GAP. Additional strategies to improve sustainability of QI efforts are urgently needed.

A Unique Set of Interactions: The MSU Sustained Partnership Model of Nurse Practitioner Primary Care

Purpose To present a unified conceptual model that identifies the integral processes of nurse practitioner (NP) care delivery and that integrates major structural influences and potential outcomes. The model is further characterized to delineate the unique and “value‐added” nature of NP primary care and to describe how this nature may be correlated with specific clinical outcomes. Data Sources Extensive review of the literature, relevant conceptual models, clinical experiences of the authors, and two sets of qualitative data exploring differences between NP practice and other practices. Conclusions The basis of NP primary care is the unique provider‐client relationship that develops within the primary care setting. This relationship is oriented toward (a) helping clients become empowered to more appropriately manage their own care in a way that will best meet their needs, (b) encouraging mutual decision making, (c) ensuring clients’ continuity of care, and (d) providing a holistic approach to primary care. The major structural influences are NP role components, interdisciplinary practice relationships, budget resources and payer mix, and environmental characteristics. The potential outcomes are increased healthpromoting behaviors, improved utilization of care, higher client satisfaction levels, and improved health status. Implications for Practice NPs can use this model to articulate the unique contribution of NP practice and its interrelationships within the broader primary care setting. Practicing NPs can use this framework to better understand the complexities of their current and future primary care practices. Faculty can utilize the concepts to help guide students’ understanding of their prospective roles as advanced practice nurses. Finally, this conceptual framework can inform research about specific NP processes and related outcomes. A clearly delineated model that accurately depicts structures, processes, and outcomes relevant to NP primary care can strengthen NP education, distinguish NP practice, and advance evidenced‐based research linking NP practice and outcomes.

Contemporary Adult Diabetes Mellitus Management Perceptions

AbstractBackground: Over 180 million people have been diagnosed with diabetes mellitus worldwide, with this number expected to more than double by 2030. Due to the increasing mortality and morbidity associated with this epidemic, the improved primary-care management of diabetes during routine office visits remains an emerging international challenge. Objective: To report the results of a series of exploratory semi-structured group interview sessions with a sample of 44 American adults with type 2 diabetes, concerning their diabetes management perceptions and office-based diabetes care processes. Methods: A total of 44 adults from a Midwest Internal Medicine Clinic were interviewed during 2004 and 2005 before starting a larger, quantitative, shared decision-making intervention study. During group interviews, participants offered their perceptions of their self-management practices, interactions with office clinicians, and diabetes-related health outcomes to date. A total of 178 audio-taped interview comments (across 44 participants) were transcribed and analyzed for core themes and sub-themes. Results: Many participants reported frustrating experiences regarding the relationship between their personal diabetes self-management practices and typical office visit interactions with clinicians. Most participants perceived these diabetes management processes as inherently different from each other. Many participants were intrigued with the proposed shared decision-making management approach of the larger intervention study. Conclusions: Primary-care clinicians should assess how patients may perceive their self-management strategies relate to office-based diabetes care processes. Patients’ self-management beliefs and practices should be routinely evaluated since they frequently affect the nature of key diabetes care office visit decisions. These qualitative results suggest that clinicians should convey the increasing interdependence between their patients’ daily diabetes self-management practices and contemporary office visit decision-making discussions.

Changes in practice patterns affecting in-hospital and post-discharge survival among ACS patients

BackgroundAdherence to clinical practice guidelines for the treatment of specific illnesses may result in unexpected outcomes, given that multiple therapies must often be given to patients with diverse medical conditions. Yet, few studies have presented empirical evidence that quality improvement (QI) programs both change practice by improving adherence to guidelines and improve patient outcomes under the conditions of actual practice. Thus, we focus on patient survival, following hospitalization for acute coronary syndrome in three successive patient cohorts from the same community hospitals, with a quality improvement intervention occurring between cohorts two and three.MethodsThis study is a comparison of three historical cohorts of Acute Coronary Syndrome (ACS) patients in the same five community hospitals in 1994–5, 1997, 2002–3. A quality improvement project, the Guidelines Applied to Practice (GAP), was implemented in these hospitals in 2001.Study participants were recruited from community hospitals located in two Michigan communities during three separate time periods. The cohorts comprise (1) patients enrolled between December 1993 and April 1995 (N = 814), (2) patients enrolled between February 1997 and September 1997 (N = 452), and (3) patients enrolled between January 14, 2002 and April 13, 2003 (N = 710).Mortality data were obtained from Michigans Bureau of Vital Statistics for all three patient cohorts. Predictor variables, obtained from medical record reviews, included demographic information, indicators of disease severity (ejection fraction), co-morbid conditions, hospital treatment information concerning most invasive procedures and the use of ace-inhibitors, beta-blockers and aspirin in the hospital and as discharge recommendations.ResultsAdjusted in-hospital mortality showed a marked improvement with a HR = 0.16 (p < 0.001) comparing 2003 patients in the same hospitals to those 10 years earlier. Large gains in the in-hospital mortality were maintained based on 1-year mortality rates after hospital discharge.ConclusionChanges in practice patterns that follow recommended guidelines can significantly improve care for ACS patients. In-hospital mortality gains were maintained in the year following discharge.

Posthospital Heart-Healthy Behaviors in Adults With Comorbid Diabetes

The purpose of these secondary analyses was to examine relationships between patient factors and patient-provider decision-making style (PDM) on heart-healthy behavior changes in 142 adults with diabetes after hospitalization for an acute coronary syndrome (ACS). A clinical trial randomized adults to either control or a telephone coaching intervention. Generalized estimating equations were used to analyze the relationship between patient factors and PDM style on longitudinal postdischarge changes in three heart-healthy behaviors, avoiding high fat foods, weight loss, and increased physical activity. Neither PDM style nor telephone coaching intervention affected heart-healthy behaviors in this population. Although adults with diabetes preferred collaborative patient-provider decision-making, present levels of provider engagement were not sufficient to support behavior change. Results suggest the need for sustained and tailored nursing interventions to facilitate heart-healthy behavior changes in adults with diabetes after ACS hospitalization.

Association of cardiac drugs with depression after acute coronary syndrome

Background: Depressive adverse effects of major cardiac medications in patients with cardiovascular disease have been suggested. Objective: To investigate the influence of the use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and/or β-blockers on subsequent depressive symptoms in patients hospitalized for acute coronary syndrome. Methods: A sample of 521 patients was followed for 8 months during 1,340 observations. Data were collected from structured telephone interviews and medical record chart reviews. Pooled time series generalized estimating equations regression models were used to evaluate depressive symptom scores, controlling for major clinical and sociodemographic patient characteristics. Results: No significant independent or interactive effects were found linking the use of these medications to subsequent depressive symptoms, despite changes in depressive symptoms over time. Factors that did affect subsequent depression included sociodemographic (eg, increased age, less education) and clinical characteristics (eg, higher composite comorbidity, prior history of depression and/or first myocardial infarction, higher postdischarge pain levels). Conclusions: Our results suggest that potential depressive adverse effects should not be considered a contraindication to the use of recommended cardiac medications. Observed increases in depressive symptoms after an acute cardiac injury will more likely be attributed to other patient characteristics independent of the use of major drug therapy prescribed to prevent further acute cardiac events.

Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): An Overlooked Form of Hypoglycemia in Clinical Practice

Objective Many patients with diabetes opt to fast for lab tests, especially for lipid profiles, thus missing breakfast. In parallel, recent studies and international guidelines have indicated that routine fasting for lipid panels may not be necessary. Missing breakfast while fasting for lab tests may invoke hypoglycemia, if patients are not properly instructed about adjusting diabetes medications on the night before or on the day of the lab test. Our group described this form of hypoglycemia and introduced the term FEEHD to refer to it (fasting-evoked en route hypoglycemia in diabetes). In a recently published small study, we reported a rate of occurrence of FEEHD of 27.1%. The objective of this study was to evaluate the rate of occurrence of FEEHD in another clinic. Methods Patients with diabetes were asked to complete a simple, 2-page survey inquiring about hypoglycemic events while fasting for labs in the preceding 12 months. Results A total of 525 patients completed the surveys out of 572 patients invited (91.8% response rate). A total of 363 patients with complete data were analyzed, with a mean age of 60.6 (SD 12.5) years. A total of 62 (17.1%) patients reported having experienced one or more FEEHD events in the prior 12 months. Of the 269 patients who were at higher risk of FEEHD (on insulin secretagogues or on insulin), 59 (21.9%) reported having experienced FEEHD. Only 33 of FEEHD patients (53%) recalled having contacted their provider regarding the events and only 22 (35%) indicated having received some sort of FEEHD prevention instructions. Conclusion Our study shows a significant rate of occurrence of FEEHD in the real world (a clinical practice). FEEHD is especially dangerous, as patients often commute (drive) to and from the laboratory facility (potential risk of traffic accidents). Given study limitations, further studies are needed to assess prevalence of FEEHD in other settings and in the general populations.