Getting to Lower Systolic Blood Pressure: Beyond Antihypertensive Therapy

Length of Storage of Red Blood Cells and Patient Survival After Blood Transfusion: A Binational Cohort Study: Annals of Internal Medicine: Vol 166, No 4

Background: Possible negative effects, including increased mortality, among persons who receive stored red blood cells (RBCs) have recently garnered considerable attention. Despite many studies, including 4 randomized trials, no consensus exists. Objective: To study the association between the length of RBC storage and mortality in a large population-based cohort of patients who received transfusions, allowing detection of small yet clinically significant effects. Design: Binational cohort study. Setting: All transfusion recipients in Sweden and Denmark. Patients: 854 862 adult patients who received transfusions from 2003 to 2012. Measurements: Patients were followed from first blood transfusion. Relative and absolute risks for death in 30 days or 1 year in relation to length of RBC storage were assessed by using 3 independent analytic approaches. All analyses were conducted by using Cox proportional hazards regression. Results: Regardless of the analytic approach, no association was found between the length of RBC storage and mortality. The difference in 30-day cumulative mortality between patients receiving blood stored for 30 to 42 days and those receiving blood stored for 10 to 19 days was −0.2% (95% CI, −0.5% to 0.1%). Even among patients who received more than 6 units of RBCs stored for 30 days or longer, the hazard ratio of death was 1.00 (CI, 0.96 to 1.05) compared with those who received no such units. Limitation: Observational study; risk of confounding by indication. Conclusion: Consistent with previous randomized trials, this study found no association between the length of storage of transfused RBCs and patient mortality. Results were homogeneous, with differences in absolute mortality consistently less than 1% among the most extreme exposure categories. These findings suggest that the current practice of storing RBCs for up to 42 days does not need to be changed. Primary Funding Source: The Swedish Research Council, Swedish Heart–Lung Foundation, Swedish Society for Medical Research, Strategic Research Program in Epidemiology at Karolinska Institutet, and Danish Council for Independent Research.

Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study: Annals of Internal Medicine: Vol 166, No 9

Background: Inpatient hyperglycemia is common and is linked to adverse patient outcomes. New methods to improve glycemic control are needed. Objective: To determine whether a virtual glucose management service (vGMS) is associated with improved inpatient glycemic control. Design: Cross-sectional analyses of three 12-month periods (pre-vGMS, transition, and vGMS) between 1 June 2012 and 31 May 2015. Setting: 3 University of California, San Francisco, hospitals. Patients: All nonobstetric adult inpatients who underwent point-of-care glucose testing. Intervention: Hospitalized adult patients with 2 or more glucose values of 12.5 mmol/L or greater (≥225 mg/dL) (hyperglycemic) and/or a glucose level less than 3.9 mmol/L (<70 mg/dL) (hypoglycemic) in the previous 24 hours were identified using a daily glucose report. Based on review of the insulin/glucose chart in the electronic medical record, recommendations for insulin changes were entered in a vGMS note, which could be seen by all clinicians. Measurements: Proportion of patient-days classified as hyperglycemic, hypoglycemic, and at-goal (all measurements ≥3.9 and ≤10 mmol/L [≥70 and ≤180 mg/dL] during the pre-vGMS, transition, and vGMS periods). Results: The proportion of hyperglycemic patients decreased by 39%, from 6.6 per 100 patient-days in the pre-vGMS period to 4.0 per 100 patient-days in the vGMS period (difference, −2.5 [95% CI, −2.7 to −2.4]). The hypoglycemic proportion in the vGMS period was 36% lower than in the pre-vGMS period (difference, −0.28 [CI, −0.35 to −0.22]). Forty severe hypoglycemic events (<2.2 mmol/L [<40 mg/dL]) occurred during the pre-vGMS period compared with 15 during the vGMS period. Limitation: Information was not collected on patients' concurrent illnesses and treatment or physicians' responses to the vGMS notes. Conclusion: Implementation of the vGMS was associated with decreases in hyperglycemia and hypoglycemia. Primary Funding Source: National Institutes of Health, the Wilsey Family Foundation, and the UCSF Clinical & Translational Science Institute.

Weight History and All-Cause and Cause-Specific Mortality in Three Prospective Cohort Studies

Background: The relationship between body mass index (BMI) and mortality is controversial. Objective: To investigate the relationship between maximum BMI over 16 years and subsequent mortality. Design: 3 prospective cohort studies. Setting: Nurses' Health Study I and II and Health Professionals Follow-Up Study. Participants: 225 072 men and women with 32 571 deaths observed over a mean of 12.3 years of follow-up. Measurements: Maximum BMI over 16 years of weight history and all-cause and cause-specific mortality. Results: Maximum BMIs in the overweight (25.0 to 29.9 kg/m2) (multivariate hazard ratio [HR], 1.06 [95% CI, 1.03 to 1.08]), obese I (30.0 to 34.9 kg/m2) (HR, 1.24 [CI, 1.20 to 1.29]), and obese II (≥35.0 kg/m2) (HR, 1.73 [CI, 1.66 to 1.80]) categories were associated with increases in risk for all-cause death. The pattern of excess risk with a maximum BMI above normal weight was maintained across strata defined by smoking status, sex, and age, but the excess was greatest among those younger than 70 years and never-smokers. In contrast, a significant inverse association between overweight and mortality (HR, 0.96 [CI, 0.94 to 0.99]) was observed when BMI was defined using a single baseline measurement. Maximum overweight was also associated with increased cause-specific mortality, including death from cardiovascular disease and coronary heart disease. Limitation: Residual confounding and misclassification. Conclusion: The paradoxical association between overweight and mortality is reversed in analyses incorporating weight history. Maximum BMI may be a useful metric to minimize reverse causation bias associated with a single baseline BMI assessment. Primary Funding Source: National Institutes of Health.

Advanced Practice Clinicians and Physicians in Primary Care: Still More Questions than Answers

Coverage and Access for Americans With Chronic Disease Under the Affordable Care Act: A Quasi-Experimental Study: Annals of Internal Medicine: Vol 166, No 7

Background: Half of Americans have at least 1 chronic disease. Many in this group, particularly racial/ethnic minorities, lacked insurance coverage and access to care before the Patient Protection and Affordable Care Act (ACA) was enacted. Objective: To determine whether the ACA has had an effect on insurance coverage, access to care, and racial/ethnic disparities among adults with chronic disease. Design: Quasi-experimental policy intervention. Setting: Nationally representative, noninstitutionalized sample in the United States. Patients: 606 277 adults aged 18 to 64 years with a chronic disease. Intervention: Implementation of ACA provisions on 1 January 2014. Measurements: Self-reported insurance coverage, having a checkup, having a personal physician, and not having to forgo a needed physician visit because of cost. Results: After the ACA was implemented, insurance coverage increased by 4.9 percentage points (95% CI, 4.4 to 5.4), not having to forgo a physician visit increased by 2.4 percentage points (CI, 1.9 to 2.9), and having a checkup increased by 2.7 percentage points (CI, 2.2 to 3.4). Having a personal physician did not change (0.3 percentage points [CI, −0.2 to 0.8]). All outcomes varied considerably by state, and coverage increased more in states that expanded Medicaid. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 1 in 5 black and 1 in 3 Hispanic persons with a chronic disease continued to lack coverage and access to care after ACA implementation. Limitation: The study examined data from only the first year of the ACA's major coverage expansion provisions. Conclusion: Although the ACA increased coverage and access for persons with chronic disease, substantial gaps remain, particularly for minorities and those in Medicaid nonexpansion states. Primary Funding Source: None.

Patient, Provider, and Combined Interventions for Managing Osteoarthritis in Primary Care: A Cluster Randomized Trial: Annals of Internal Medicine: Vol 166, No 6

Background: A single-site study showed that a combined patient and provider intervention improved outcomes for patients with knee osteoarthritis, but it did not assess separate effects of the interventions. Objective: To examine whether patient-based, provider-based, and patient–provider interventions improve osteoarthritis outcomes. Design: Cluster randomized trial with assignment to patient, provider, and patient–provider interventions or usual care. (ClinicalTrials.gov: NCT01435109) Setting: 10 Duke University Health System community-based primary care clinics. Participants: 537 outpatients with symptomatic hip or knee osteoarthritis. Intervention: The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved electronic delivery of patient-specific osteoarthritis treatment recommendations to providers. Measurements: The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months. Secondary outcomes were objective physical function (Short Physical Performance Battery) and depressive symptoms (Patient Health Questionnaire). Linear mixed models assessed the difference in improvement among groups. Results: No difference was observed in WOMAC score changes from baseline to 12 months in the patient (−1.5 [95% CI, −5.1 to 2.0]; P = 0.40), provider (2.5 [CI, −0.9 to 5.9]; P = 0.152), or patient–provider (−0.7 [CI, −4.2 to 2.8]; P = 0.69) intervention groups compared with usual care. All groups had improvements in WOMAC scores at 12 months (range, −3.7 to −7.7). In addition, no differences were seen in objective physical function or depressive symptoms at 12 months in any of the intervention groups compared with usual care. Limitations: The study involved 1 health care network. Data on provider referrals were not collected. Conclusion: Contrary to a previous study of a combined patient and provider intervention for osteoarthritis in a Department of Veterans Affairs medical center, this study found no statistically significant improvements in the osteoarthritis intervention groups compared with usual care. Primary Funding Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Racial and Ethnic Disparities in Interval Colorectal Cancer Incidence: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 166, No 12

Background: Interval colorectal cancer (CRC) accounts for 3% to 8% of all cases of CRC in the United States. Data on interval CRC by race/ethnicity are scant. Objective: To examine whether risk for interval CRC among Medicare patients differs by race/ethnicity and whether this potential variation is accounted for by differences in the quality of colonoscopy, as measured by physicians' polyp detection rate (PDR). Design: Population-based cohort study. Setting: Medicare program. Participants: Patients aged 66 to 75 years who received colonoscopy between 2002 and 2011 and were followed through 2013. Measurements: Kaplan–Meier curves and adjusted Cox models were used to estimate cumulative probabilities and hazard ratios (HRs) of interval CRC, defined as a CRC diagnosis 6 to 59 months after colonoscopy. Results: There were 2735 cases of interval CRC identified over 235 146 person-years of follow-up. A higher proportion of black persons (52.8%) than white persons (46.2%) received colonoscopy from physicians with a lower PDR. This rate was significantly associated with interval CRC risk. The probability of interval CRC by the end of follow-up was 7.1% in black persons and 5.8% in white persons. Compared with white persons, black persons had significantly higher risk for interval CRC (HR, 1.31 [95% CI, 1.13 to 1.51]); the disparity was more pronounced for cancer of the rectum (HR, 1.70 [CI, 1.25 to 2.31]) and distal colon (HR, 1.45 [CI, 1.00 to 2.11]) than for cancer of the proximal colon (HR, 1.17 [CI, 0.96 to 1.42]). Adjustment for PDR did not alter HRs by race/ethnicity, but differences between black persons and white persons were greater among physicians with higher PDRs. Limitation: Colonoscopy and polypectomy were identified by using billing codes. Conclusion: Among elderly Medicare enrollees, the risk for interval CRC was higher in black persons than in white persons; the difference was more pronounced for cancer of the distal colon and rectum and for physicians with higher PDRs. Primary Funding Source: American Cancer Society.

Antibiotic Prescribing for Nonbacterial Acute Upper Respiratory Infections in Elderly Persons

Background: Reducing inappropriate antibiotic prescribing for acute upper respiratory tract infections (AURIs) requires a better understanding of the factors associated with this practice. Objective: To determine the prevalence of antibiotic prescribing for nonbacterial AURIs and whether prescribing rates varied by physician characteristics. Design: Retrospective analysis of linked administrative health care data. Setting: Primary care physician practices in Ontario, Canada (January–December 2012). Patients: Patients aged 66 years or older with nonbacterial AURIs. Patients with cancer or immunosuppressive conditions and residents of long-term care homes were excluded. Measurements: Antibiotic prescriptions for physician-diagnosed AURIs. A multivariable logistic regression model with generalized estimating equations was used to examine whether prescribing rates varied by physician characteristics, accounting for clustering of patients among physicians and adjusting for patient-level covariates. Results: The cohort included 8990 primary care physicians and 185 014 patients who presented with a nonbacterial AURI, including the common cold (53.4%), acute bronchitis (31.3%), acute sinusitis (13.6%), or acute laryngitis (1.6%). Forty-six percent of patients received an antibiotic prescription; most prescriptions were for broad-spectrum agents (69.9% [95% CI, 69.6% to 70.2%]). Patients were more likely to receive prescriptions from mid- and late-career physicians than early-career physicians (rate difference, 5.1 percentage points [CI, 3.9 to 6.4 percentage points] and 4.6 percentage points [CI, 3.3 to 5.8 percentage points], respectively), from physicians trained outside of Canada or the United States (3.6 percentage points [CI, 2.5 to 4.6 percentage points]), and from physicians who saw 25 to 44 patients per day or 45 or more patients per day than those who saw fewer than 25 patients per day (3.1 percentage points [CI, 2.1 to 4.0 percentage points] and 4.1 percentage points [CI, 2.7 to 5.5 percentage points], respectively). Limitation: Physician rationale for prescribing was unknown. Conclusion: In this low-risk elderly cohort, 46% of patients with a nonbacterial AURI were prescribed antibiotics. Patients were more likely to receive prescriptions from mid- or late-career physicians with high patient volumes and from physicians who were trained outside of Canada or the United States. Primary Funding Source: Ontario Ministry of Health and Long-term Care, Academic Medical Organization of Southwestern Ontario, Schulich School of Medicine and Dentistry, Western University, and Lawson Health Research Institute.

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.