Hospitals' compliance with prophylaxis guidelines for venous thromboembolism.

PURPOSE: A study was conducted to evaluate compliance with the Sixth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy guidelines for the prevention of venous thromboembolism (VTE) in hospitals. METHODS: Using the HealthFacts database, hospitalized patients, age 40 years or more, with medical conditions at risk for VTE (surgical, trauma, and acute spinal injury patients) were identified. Hospital admissions on or after January 1, 2001, and concluded by March 31, 2005, were included if they met any of the following conditions as defined in the ACCP Consensus Conference on Antithrombotic Therapy guidelines: patients at risk of VTE medical conditions, major orthopedic surgery, general surgery, gynecological surgery, urologic surgery, trauma, neurosurgery, and acute spinal cord injury. Hospitalizations were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The primary objective was to examine whether patients received one of the indicated anticoagulants at the proper dosage and during the relevant hospital days as determined in the ACCP guidelines. Rates of compliance were assessed, and the reasons for guideline noncompliance were also determined. RESULTS: The overall compliance rate with ACCP guidelines was 13.3% (ranging from 2.8% for neurosurgery to 52.4% for orthopedic surgery) in the 123,304 hospital admissions that were reviewed. Only 15.3% of patients with at-risk medical conditions received prophylaxis in accordance with ACCP guidelines. Potential reasons for guideline noncompliance among selected conditions included the omission of prophylaxis, inadequate prophylaxis duration, and the wrong type of anticoagulant. CONCLUSION: A retrospective study found low rates of compliance with guidelines for thromboprophylaxis.

Development and validation of a preference weight multiattribute health outcome measure for rheumatoid arthritis.

OBJECTIVE: To develop and validate multiattribute measures for patients with rheumatoid arthritis (RA) to report health states and estimate preference weights. METHODS: Survey materials were mailed to 748 patients. Factor analysis, an item response theory-based model, and an internal consistency test were used to identify attributes and evaluate items. Two multiattribute preference weight functions (MAPWF) were constructed. Construct validity of the new measures was then tested. RESULTS: Four hundred eighty-seven patients returned the survey; 24 items on 6 health attributes were selected to form the new outcomes measure. Two MAPWF were derived with preference weights measured with time tradeoff and visual analog scales as dependent variables. All validity test results were statistically significant. CONCLUSION: Our results reveal that the new measures are reliable and valid in assessing health states and associated preference weights of patients with RA.

Revalidation of the original Cedars-Sinai health-related quality of life in rheumatoid arthritis questionnaire.

OBJECTIVE: To assess the psychometric characteristics of the original 33-item Cedars-Sinai Health-Related Quality of Life in Rheumatoid Arthritis Questionnaire (O-CSHQ-RA) and 11-item CSHQ-RA Short Form (SF) using a representative population of patients with rheumatoid arthritis (RA) from 55 sites across the United States. METHODS: Data were from a 24-week multicenter, open-label, single-arm study of 312 RA patients receiving anakinra. Cronbach's alpha coefficient was used to indicate the internal consistency. Test-retest reliability was assessed by establishing the intraclass correlation coefficient (ICC) for screening and baseline visit responses. Convergent validity was tested with the Pearson correlation coefficient. Analysis of variance was performed to determine discriminant validity. A Wilcoxon signed-rank test and analysis of covariance were used to assess the responsiveness. A discriminant function was generated to determine the clinically meaningful change. RESULTS: Test-retest reliability was demonstrated for both versions of the CSHQ-RA, with ICC ranging from 0.82 to 0.94. Cronbach's alpha coefficients were > or = 0.9, indicating good internal consistency. Pearson correlations between health-related quality of life instruments and CSHQ-RA measures ranged from -0.33 to -0.73 and 0.39 to 0.76, demonstrating good convergent validity. Scores on both versions of the CSHQ-RA differed significantly (p < 0.0001) for patients with different levels of physical disability as measured by the Stanford Health Assessment Questionnaire. Both instruments were responsive to differences in patient health as measured by the general health question (p < 0.0001). Clinically meaningful changes were calculated for all 5 domains of the O-CSHQ-RA (6.9-14.0) and the overall O-CSHQ-RA SF (12.7). CONCLUSION: These results support the validity and reliability of both the original CSHQ-RA and the 11-item CSHQ-RA SF when tested in a representative patient population.

Mortality differences among organisms causing septicemia in hemodialysis patients.

Septicemia is a serious problem in hemodialysis patients because it can lead to life-threatening complications and a persistently elevated risk of death. Most analyses have not examined whether there are differences in mortality risk among the organisms that cause these episodes of septicemia. This study was a retrospective cohort analysis of first septicemia hospitalizations during the first year of hemodialysis. Time to death (both in-hospital and within 12 weeks post-discharge) was compared among the different septicemia-causing organisms based on discharge diagnoses in Medicare billing data from 1996 to 2001. The effect of various complications on mortality risk was also evaluated. There were 22,130 septicemia hospitalizations identified. The most common organism identified was Staphylococcus aureus (27%), with no other organism having an incidence >10%. The overall unadjusted death rate from admission through 12 weeks of follow-up was 34%. During the first hospitalization, the death rate was 14%, and during the 12-week period after the hospitalization it was 20%. In adjusted analyses, S. aureus was associated with a 20% higher risk of death both during the in-hospital period and the 12-week post-discharge period, when compared with all other specified organisms. Hospitalizations complicated by meningitis, stroke, or endocarditis were also associated with increased risk of mortality, independent of the organism causing septicemia. Septicemia hospitalizations are associated with a high mortality rate--both during the initial hospitalization and after discharge. Meningitis, stroke, and endocarditis represent particularly serious complications. Overall, septicemia hospitalizations (especially for S. aureus) are serious events, and patients would benefit from better treatment and prevention.

PTH and the risks for hip, vertebral, and pelvic fractures among patients on dialysis.

BACKGROUND: Few investigations have described fracture risk and its relation to disorders in calcium (Ca), phosphorus (P), and parathyroid hormone (PTH) metabolism in the end-stage renal disease population. METHODS: Laboratory values for Ca, P, and PTH were obtained from Dialysis Morbidity and Mortality Study (DMMS) Waves 1 to 4. Additional data available from the US Renal Data System were used to determine the incidence and associated costs of hip, vertebral, and pelvic fractures in 9,007 patients with nonmissing laboratory values and Medicare as primary payor. Cox proportional hazards and Poisson models were used to analyze time to first fracture and numbers of fractures, respectively. RESULTS: There was no association between Ca or P values and risk for fracture; risks for vertebral and hip fractures and PTH concentrations were U shaped and weakly significant using Poisson regression (P = 0.03). The age- and sex-adjusted mortality rate after fracture was 2.7 times greater (580/1,000 person-years) than for general dialysis patients from the DMMS (217/1,000 person-years). Mean total episodic costs of hip, vertebral, and pelvic fractures were 20,810 dollars +/- 16,743 dollars (SD), 17,063 dollars +/- 26,201 dollars, and 14,475 dollars +/- 19,209 dollars, respectively. CONCLUSION: Using data from the DMMS, there were no associations between Ca and P concentrations and risk for fracture. Risks for hip and vertebral fracture were associated weakly with PTH concentration, with the lowest risk observed around a PTH concentration of 300 pg/mL (ng/L). Fractures were associated with high subsequent mortality and costs. Prospective studies are needed to determine whether therapies that maintain PTH concentrations within or near the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative range will result in fewer complications of disordered mineral metabolism.

Septicemia in patients with ESRD is associated with decreased hematocrit and increased use of erythropoietin.

Septicemia, a common complication in chronic dialysis patients, may be an important factor in erythropoietin (EPO) hyporesponsiveness, because it is a form of inflammation. The quantitative impact of septicemia on EPO requirements has not been studied. The purpose of this study was to analyze patterns of EPO use and levels of anemia among patients who had ESRD and were hospitalized with septicemia. Using United States Renal Data System data, septicemia admissions were identified in patients with first ESRD service from 1996 to 2001. Mean EPO dosage and hematocrit (Hct) level were analyzed from 2 mo before until 3 mo after admission and compared with patients who were hospitalized with acute myocardial infarction (AMI) and patients with no hospitalizations. A total of 4640 hospitalized patients were included in the analysis: 3975 for septicemia and 665 for AMI. In both groups, mean Hct declined significantly in the month of admission and increased in the second month after admission. At all time points, both groups had significantly lower Hct levels compared with the nonhospitalized group. Mean EPO dosage increased, most rapidly in the month after admission. EPO use was highest in the septicemia group. Hospitalization with septicemia is associated with worsening anemia and increasing EPO use. This also was observed for patients who were hospitalized with AMI, suggesting that acute intercurrent illness plays an important role in EPO hyporesponsiveness. Strategies to prevent septicemia are important not only to decrease clinical morbidity but also to conserve EPO usage and thus contain the costs of care for this complex patient population.

Measuring preference weights for American college of rheumatology response criteria for patients with rheumatoid arthritis.

OBJECTIVE: To estimate weights for health states comprising American College of Rheumatology (ACR) response and different levels of adverse events associated with rheumatoid arthritis (RA) treatments. METHODS: A survey was mailed to 748 patients with RA from southern California. In addition to several questionnaires commonly used for patients with RA, patients were instructed to evaluate 10 hypothetical health states, in which they could have an ACR response and/or adverse events due to new treatments, with a visual analog scale (VAS). Patients also evaluated their current health with a VAS question and a time tradeoff (TTO) question. Linear extrapolation was used to derive 6 more health states. The Pearson correlation coefficient was used to validate VAS and TTO results. RESULTS: A total of 487 (65%) patients returned the survey. Among the 10 health states evaluated with VAS directly, the health state in which a patient has ACR70 with no adverse events had the highest VAS weight (0.84), followed by the one having an ACR50 response with no adverse events (0.80). Correlation coefficients ranged from 0.63 for the correlation between VAS and physical component summary to -0.18 between TTO and pain and tender joint count; the correlation coefficients were all statistically significant, indicating there was convergent validity of the VAS and that VAS functioned differently from TTO in how it measured weights. CONCLUSION: VAS weights for 16 ACR response health states of patients with RA were derived. These weights could be used for cost-utility analyses of interventions for patients with RA.

Clinical and economic outcomes of Staphylococcus aureus septicemia in ESRD patients receiving hemodialysis.

BACKGROUND: Serious infections are a common problem in patients with end-stage renal disease (ESRD). The purpose of this study is to identify clinical and economic consequences of hospitalizations for septicemia caused by Staphylococcus aureus in hemodialysis patients with ESRD. METHODS: We conducted a retrospective analysis of data obtained from the US Renal Data System to determine lengths of stay and Medicare paid costs for index hospitalizations and episodes of care for patients with ESRD hospitalized with septicemia caused by S aureus. Factors associated with hospital length of stay and Medicare paid costs were examined in multivariate analysis. RESULTS: A total of 11,572 patient admissions with septicemia caused by S aureus were included; 20.7% of patients developed 1 or more complications. Average length of stay for the index admission was 13.0 days, and 11.8% of patients were readmitted within 12 weeks for care related to S aureus. Average Medicare cost for the index admission was 17,307 dollars. Average episodic cost of care, including the index hospitalization, outpatient visits, and readmissions related to S aureus during the subsequent 12 weeks, was 20,067 dollars. S aureus--related complications were associated with greater episodic costs of care: no complications, 18,476 dollars; one complication, 25,804 dollars (P < 0.05 versus no complications); and 2 or more complications, 32,102 dollars (P < 0.05 versus no complications). In multivariate analysis, complications resulted in increased mean lengths of stay of 4 to 7 days, and complications were among the strongest predictors of total episodic costs. CONCLUSION: Patients with septicemia caused by S aureus had costly and lengthy hospitalizations, which frequently were associated with clinically and economically important complications, including hospital readmissions.

Erythropoiesis-stimulating protein therapy and the decline of renal function: a retrospective analysis of patients with chronic kidney disease.

BACKGROUND/AIMS: Previous studies have hinted at possible associations between anemia and progression of renal disease. The study objective was to determine whether treatment with erythropoiesis-stimulating proteins (ESPs) can curb the rate of decline in renal function in predialysis patients with chronic kidney disease (CKD). METHODS: Observational, before/after analysis using electronic medical records from the Veterans Administration (VA). Included patients had at least two measurements of serum creatinine levels before and after ESP treatment initiation. The Cockcroft-Gault formula was used to derive estimates of glomerular filtration rate (GFR). Rate of renal function decline prior to and following initiation of therapy were compared. RESULTS: One hundred and twenty two patients with renal impairment levels of Stage 3 (moderate) or Stage 4 (severe) at ESP treatment initiation were identified. Over 80% of patients initiated therapy with either Grade 1 or Grade 2 anemia. The rate of renal function decline was calculated as the slope of the least-squares linear regression line of the inverse serum creatinine over time during the pre-treatment initiation and post-treatment initiation time periods. Overall, patients experienced a slowing in the rate of renal function decline after treatment was initiated (mean pretreatment initiation rate of -0.094 dL/mg/yr versus mean post-treatment initiation rate of -0.057 dL/mg/yr). CONCLUSION: Renal function declined at a slower rate following ESP initiation. Results are consistent with prior studies indicating delayed dialysis initiation in patients treated with ESPs. Analyses were limited by the observational study design and lack of information regarding some potential confounders. Longer-term, prospective trials are needed to determine whether ESPs slow progression of renal disease and the potential magnitude of such an effect.

Coerced treatment for methamphetamine abuse: differential patient characteristics and outcomes.

Policymakers have responded to the increase in the prevalence of methamphetamine (MA) use and the associated social costs (such as crime and child abuse and neglect) by mandating a growing number of MA users to substance abuse treatment via the criminal justice system (CJS) and/or child protective service (CPS) agencies. However, empirical evidence remains sparse about treatment outcomes specifically for MA users who report that their treatment admission occurred under such pressures. This analysis uses natural history interview data from 350 clients treated for MA use in Los Angeles County to examine clients' self-reported CJS/CPS pressure to enter treatment, comparing background and treatment characteristics and selected treatment outcomes across groups defined by existence of such perceived pressure and source of pressure. Approximately half the clients reported legal pressure to enter the index (used for sampling) treatment episode. Those reporting pressure were younger, less likely to have received residential treatment, and had longer treatment episodes than those not reporting pressure. Outcomes (treatment completion, relapse within 6 months, time to relapse, and percentage of days with MA use in 24 months following treatment) did not differ significantly in simple comparisons between the pressured and nonpressured groups; however, when client and treatment characteristics were controlled, the short term outcome of relapse within 6 months was worse for those reporting legal pressure. Outcomes did not differ by source of pressure.

Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction.

BACKGROUND: The role of angiotensin-receptor blockers (ARBs) in treating patients with chronic heart failure and high-risk acute myocardial infarction (MI) has been controversial, and recent clinical trials provide more information on this topic. PURPOSE: To quantify the effect of ARBs when compared with placebo (with and without background angiotensin-converting enzyme [ACE] inhibitors) and ACE inhibitors on all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and high-risk acute MI. DATA SOURCES: Data from original research published through 13 November 2003. STUDY SELECTION: Predefined criteria were used to identify 24 trials. DATA EXTRACTION: 2 reviewers independently collected information on study characteristics and data on all-cause mortality and heart failure hospitalization. DATA SYNTHESIS: 24 trials involving 38 080 patients were included. Analysis of chronic heart failure trials revealed that 1) ARBs were associated with reduced all-cause mortality (odds ratio [OR], 0.83 [95% CI, 0.69 to 1.00]) and heart failure hospitalizations (OR, 0.64 [CI, 0.53 to 0.78]) as compared with placebo; 2) for ARBs versus ACE inhibitors, all-cause mortality (OR, 1.06 [CI, 0.90 to 1.26]) and heart failure hospitalization (OR, 0.95 [CI, 0.80 to 1.13]) did not differ; 3) and for combinations of ARBs plus ACE inhibitors versus ACE inhibitors alone, all-cause mortality was not reduced (OR, 0.97 [CI, 0.87 to 1.08]) but heart failure hospitalizations were reduced (OR, 0.77 [CI, 0.69 to 0.87]). For patients with high-risk acute MI, 2 randomized trials compared ARBs with ACE inhibitors but did not reveal differences in all-cause mortality or heart failure hospitalization. LIMITATIONS: Comparative economic data between ARBs and ACE inhibitors are lacking. CONCLUSIONS: Because ACE inhibitors and ARBs do not differ in efficacy for reducing all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and in patients with high-risk acute MI, ARBs should be regarded as suitable alternatives to ACE inhibitors.