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This article has been corrected. The original version (PDF) is appended to this article as a Supplement. Background: Dabigatran (150 mg twice daily) has been associated with lower rates of stroke than warfarin in trials of atrial fibrillation, but large-scale evaluations in clinical practice are limited. Objective: To compare incidence of stroke, bleeding, and myocardial infarction in patients receiving dabigatran versus warfarin in practice. Design: Retrospective cohort. Setting: National U.S. Food and Drug Administration Sentinel network. Patients: Adults with atrial fibrillation initiating dabigatran or warfarin therapy between November 2010 and May 2014. Measurements: Ischemic stroke, intracranial hemorrhage, extracranial bleeding, and myocardial infarction identified from hospital claims among propensity score–matched patients starting treatment with dabigatran or warfarin. Results: Among 25 289 patients starting dabigatran therapy and 25 289 propensity score–matched patients starting warfarin therapy, those receiving dabigatran did not have significantly different rates of ischemic stroke (0.80 vs. 0.94 events per 100 person-years; hazard ratio [HR], 0.92 [95% CI, 0.65 to 1.28]) or extracranial hemorrhage (2.12 vs. 2.63 events per 100 person-years; HR, 0.89 [CI, 0.72 to 1.09]) but were less likely to have intracranial bleeding (0.39 vs. 0.77 events per 100 person-years; HR, 0.51 [CI, 0.33 to 0.79]) and more likely to have myocardial infarction (0.77 vs. 0.43 events per 100 person-years; HR, 1.88 [CI, 1.22 to 2.90]). However, the strength and significance of the association between dabigatran use and myocardial infarction varied in sensitivity analyses and by exposure definition (HR range, 1.13 [CI, 0.78 to 1.64] to 1.43 [CI, 0.99 to 2.08]). Older patients and those with kidney disease had higher gastrointestinal bleeding rates with dabigatran. Limitation: Inability to examine outcomes by dabigatran dose (unacceptable covariate balance between matched patients) or quality of warfarin anticoagulation (few patients receiving warfarin had available international normalized ratio values). Conclusion: In matched adults with atrial fibrillation treated in practice, the incidences of stroke and bleeding with dabigatran versus warfarin were consistent with those seen in trials. The possible relationship between dabigatran and myocardial infarction warrants further investigation. Primary Funding Source: U.S. Food and Drug Administration.

Cardiovascular Risk Assessment: A Systematic Review of Guidelines: Annals of Internal Medicine: Vol 165, No 10

Background: Many guidelines exist for screening and risk assessment for the primary prevention of cardiovascular disease in apparently healthy persons. Purpose: To systematically review current primary prevention guidelines on adult cardiovascular risk assessment and highlight the similarities and differences to aid clinician decision making. Data Sources: Publications in MEDLINE and CINAHL between 3 May 2009 and 30 June 2016 were identified. On 30 June 2016, the Guidelines International Network International Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and Web sites of organizations responsible for guideline development were searched. Study Selection: 2 reviewers screened titles and abstracts to identify guidelines from Western countries containing recommendations for cardiovascular risk assessment for healthy adults. Data Extraction: 2 reviewers independently assessed rigor of guideline development using the Appraisal of Guidelines for Research and Evaluation II instrument, and 1 extracted the recommendations. Data Synthesis: Of the 21 guidelines, 17 showed considerable rigor of development. These recommendations address assessment of total cardiovascular risk (5 guidelines), dysglycemia (7 guidelines), dyslipidemia (2 guidelines), and hypertension (3 guidelines). All but 1 recommendation advocates for screening, and most include prediction models integrating several relatively simple risk factors for either deciding on further screening or guiding subsequent management. No consensus on the strategy for screening, recommended target population, screening tests, or treatment thresholds exists. Limitation: Only guidelines developed by Western national or international medical organizations were included. Conclusion: Considerable discrepancies in cardiovascular screening guidelines still exist, with no consensus on optimum screening strategies or treatment threshold. Primary Funding Source: Barts Charity.

Primary Care Physician Volume and Quality of Diabetes Care: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 166, No 4

Background: A relationship between higher patient volume and both better quality of care and better outcomes has been shown for many acute care conditions. Whether a volume–quality relationship exists for the outpatient management of chronic diseases is uncertain. Objective: To explore the association between primary care physician volume and quality of diabetes care. Design: Cohort study. Setting: The study was conducted using linked population-based health care administrative data in Ontario, Canada. Patients: 1 018 647 adults with diabetes in 2011 who received care from 9014 primary care physicians. Two measures of volume were ascertained for each physician: overall ambulatory volume (representing time available to devote to chronic disease management during patient encounters) and diabetes-specific volume (representing disease-specific expertise). Measurements: Quality of care was measured over a 2-year period using 6 indicators: disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing), prescribing appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins), and adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia). Results: Higher overall ambulatory volume was associated with lower rates of appropriate disease monitoring and medication prescription. In contrast, higher diabetes-specific volume was associated with better quality of care across all 6 indicators. Limitation: Only a select set of quality indicators and potential confounders could be ascertained from available data. Conclusion: Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care. These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care. Health policies or programs to support physicians with a low volume of patients with diabetes may improve care. Primary Funding Source: Canadian Institutes of Health Research.

Continued Statin Prescriptions After Adverse Reactions and Patient Outcomes: A Cohort Study: Annals of Internal Medicine: Vol 167, No 4

Background: Many patients discontinue statin treatment, often after having a possible adverse reaction. The risks and benefits of continued statin therapy after an adverse reaction are not known. Objective: To examine the relationship between continuation of statin therapy (any prescription within 12 months after an adverse reaction) and clinical outcomes. Design: Retrospective cohort study. Setting: Primary care practices affiliated with 2 academic medical centers. Participants: Patients with a presumed adverse reaction to a statin between 2000 and 2011. Measurements: Information on adverse reactions to statins was obtained from structured electronic medical record data or natural-language processing of narrative provider notes. The primary composite outcome was time to a cardiovascular event (myocardial infarction or stroke) or death. Results: Most (81%) of the adverse reactions to statins were identified from the text of electronic provider notes. Among 28 266 study patients, 19 989 (70.7%) continued receiving statin prescriptions after the adverse reaction. Four years after the presumed adverse event, the cumulative incidence of the composite primary outcome was 12.2% for patients with continued statin prescriptions, compared with 13.9% for those without them (difference, 1.7% [95% CI, 0.8% to 2.7%]; P < 0.001). In a secondary analysis of 7604 patients for whom a different statin was prescribed after the adverse reaction, 2014 (26.5%) had a documented adverse reaction to the second statin, but 1696 (84.2%) of those patients continued receiving statin prescriptions. Limitations: The risk for recurrent adverse reactions to statins could not be established for the entire sample. It was also not possible to determine whether patients actually took the statins. Conclusion: Continued statin prescriptions after an adverse reaction were associated with a lower incidence of death and cardiovascular events. Primary Funding Source: Chinese National Key Program of Clinical Science, National Natural Science Foundation of China, and Young Scientific Research Fund of Peking Union Medical College Hospital.

Why Physician Leaders of Health Care Organizations Should Participate in Direct Patient Care

What Stands in the Way of Making Hepatitis B and C Rare Diseases in the United States?

The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study: Annals of Internal Medicine: Vol 166, No 6

Background: Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown. Objective: To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life. Design: Retrospective cohort. Setting: The HRS (Health and Retirement Study). Participants: 5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012. Measurements: Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. Body mass index was modeled as a continuous variable with a quadratic functional form. Results: For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, −9.3 to −4.0 percentage points), hospice duration decreased by 3.8 days (CI, −4.4 to −3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, −6.0 to −0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, −19.6 to −10.9 percentage points), hospice duration decreased by 4.3 days (CI, −5.7 to −2.9 days), and in-home death decreased by 6.3 percentage points (CI, −11.2 to −1.5 percentage points) versus decedents with BMI of 20 kg/m2. Limitation: Baseline data were self-reported, and the interval between reported BMI and time of death varied. Conclusion: Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life. Primary Funding Source: Robert Wood Johnson Foundation Clinical Scholars Program.

Integrated Interventions for Improving Total Worker Health: A Panel Report From the National Institutes of Health Pathways to Prevention Workshop: Total Worker Health—What's Work Got to Do With It?

This National Institutes of Health (NIH) Pathways to Prevention workshop was cosponsored by the NIH Office of Disease Prevention; National Heart, Lung, and Blood Institute; and National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention. A multidisciplinary working group developed the agenda, and an evidence-based practice center prepared an evidence report through a contract with the Agency for Healthcare Research and Quality. During the 1.5-day workshop, experts discussed the body of evidence and participants commented during open discussions. After weighing the data from the evidence report, expert presentations, and public comments, an unbiased, independent panel prepared a draft report that identified research gaps and future research priorities. The report was posted on the NIH Office of Disease Prevention Web site for 5 weeks for public comment. This article highlights 8 recommendations critical for advancing the science of integrated interventions to improve the total health of workers.

Nurses and Industry: Conflict or Collaboration?

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