Quantity Over Quality: How the Rise in Quality Measures is Not Producing Quality Results.

Over the past decade, quality measures (QMs) have been implemented nationally in order to establish standards aimed at improving the quality of care. With the expansion of their role in the Affordable Care Act and pay-for-performance, QMs have had an increasingly significant impact on clinical practice. However, adverse patient outcomes have resulted from adherence to some previously promulgated performance measures. Several of these QMs with unintended consequences, including the initiation of perioperative beta-blockers in noncardiac surgery and intensive insulin therapy for critically ill patients, were instituted as QMs years before large randomized trials ultimately refuted their use. The future of quality care should emphasize the importance of evidence-based, peer-reviewed measures.

Attitudes on Equal Health Care Access versus Efficient Clinical Decisions across a Not-for-Profit Health Care System.

BACKGROUND: Professional roles within a hospital system may influence attitudes behind clinical decisions. OBJECTIVE: To determine participants' preferences about clinical decisions that either value equal health care access or efficiency. DESIGN: Deidentified survey asking participants to choose between offering a low-cost screening test to a whole population ("equal access") or a more sensitive, expensive test that could be given to only half of the population but resulting in 10% more avoided deaths ("efficient"). Data collection took place from August 18, 2021, to January 24, 2022. Study 1644 was determined to be exempt by Tufts Health Sciences Institutional Review Board (IRB). SETTING: Tufts Medicine Healthcare System. PARTICIPANTS: Approximately 15,000 hospital employees received an e-mail from the Tufts Medicine Senior Vice President of Academic Integration. MEASUREMENTS: Analysis of survey responses with chi-square and 1-sample t tests to determine the proportion who chose each option. Logistic regression models fit to examine relationships between professional role and test choice. RESULTS: A total of 1,346 participants completed the survey (∼9.0% response rate). Overall, approximately equal percentages of respondents chose the "equal access" (48%) and "efficient" option (52%). However, gender, professional role (categorical), and clinical role (dichotomous) were significantly associated with test choice. For example, among those in nonclinical roles, women were more likely than men to choose equal health care access. In multivariable analyses, having clinical roles was significantly associated with 1.73 times the likelihood of choosing equal access (95% confidence interval = 1.33-2.25). LIMITATIONS: Generalizability concerns and survey question wording limit the study results. CONCLUSION: Clinicians were more likely than nonclinicians to choose the equal health care access option, and health care administrators were more likely to choose efficiency. These differing attitudes can affect patient care and health care quality. HIGHLIGHTS: Divergent preferences of valuing equal health care access and efficiency may be in conflict during clinical decision making.In this cross-sectional study that included 1,346 participants, approximately equal percentages of respondents chose the "equal access" (48%) and "efficient" option (52%), a nonsignificant difference. However, gender, professional role (categorical), and clinical role (dichotomous) were significantly associated with test choiceSince clinicians were more likely than nonclinicians to choose the equal health care access option and health care administrators were more likely to choose efficiency, these differing attitudes can affect patient care and health care quality.

Late-afternoon communication and patient planning (CAPP) rounds: an intervention to allow early patient discharges.

OBJECTIVE: Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO). METHODS: We enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention. PROGRAM EVALUATION: Primary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences. RESULTS: Expected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, P < 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, P < 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time. CONCLUSION: Afternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.

CKD classification based on estimated GFR over three years and subsequent cardiac and mortality outcomes: a cohort study.

BACKGROUND: It is unknown whether defining chronic kidney disease (CKD) based on one versus two estimated glomerular filtration rate (eGFR) assessments changes the prognostic importance of reduced eGFR in a community-based population. METHODS: Participants in the Atherosclerosis Risk in Communities Study and the Cardiovascular Health Study were classified into 4 groups based on two eGFR assessments separated by 35.3 +/- 2.5 months: sustained eGFR < 60 mL/min per 1.73 m(2) (1 mL/sec per 1.73 m(2)); eGFR increase (change from below to above 60); eGFR decline (change from above to below 60); and eGFR persistently >or=60. Outcomes assessed in stratified multivariable Cox models included cardiac events and a composite of cardiac events, stroke, and mortality. RESULTS: There were 891 (4.9%) participants with sustained eGFR < 60, 278 (1.5%) with eGFR increase, 972 (5.4%) with eGFR decline, and 15,925 (88.2%) with sustained eGFR > 60. Participants with eGFR sustained < 60 were at highest risk of cardiac and composite events [HR = 1.38 (1.15, 1.65) and 1.58 (1.41, 1.77)], respectively, followed by eGFR decline [HR = 1.20 (1.00, 1.45) and 1.32 (1.17, 1.49)]. Individuals with eGFR increase trended toward increased cardiac risk [HR = 1.25 (0.88, 1.77)] and did not significantly differ from eGFR decline for any outcome. Results were similar when estimating GFR with the CKD-EPI equation. CONCLUSION: Individuals with persistently reduced eGFR are at highest risk of cardiovascular outcomes and mortality, while individuals with an eGFR < 60 mL/min per 1.73 m(2) at any time are at intermediate risk. Use of even a single measurement of eGFR to classify CKD in a community population appears to have prognostic value.

Uric acid and incident kidney disease in the community.

Uric acid may mediate aspects of the relationship between hypertension and kidney disease via renal vasoconstriction and systemic hypertension. To investigate the relationship between uric acid and subsequent reduced kidney function, limited-access data of 13,338 participants with intact kidney function in two community-based cohorts, the Atherosclerosis Risks in Communities and the Cardiovascular Health Study, were pooled. Mean baseline serum uric acid was 5.9 +/- 1.5 mg/dl, mean baseline serum creatinine was 0.9 +/- 0.2 mg/dl, and mean baseline estimated GFR was 90.4 +/- 19.4 ml/min/1.73 m(2). During 8.5 +/- 0.9 yr of follow-up, 712 (5.6%) had incident kidney disease defined by GFR decrease (>or=15 ml/min/1.73 m(2) with final GFR <60 ml/min/1.73 m(2)), while 302 (2.3%) individuals had incident kidney disease defined by creatinine increase (>or=0.4 mg/dl with final serum creatinine >1.4 mg/dl in men and 1.2 mg/dl in women). In GFR- and creatinine-based logistic regression models, baseline uric acid level was associated with increased risk for incident kidney disease (odds ratio 1.07 [95% confidence interval 1.01 to 1.14] and 1.11 [95% confidence interval 1.02 to 1.21] per 1-mg/dl increase in uric acid, respectively), after adjustment for age, gender, race, diabetes, systolic BP, hypertension, cardiovascular disease, left ventricular hypertrophy, smoking, alcohol use, education, lipids, albumin, hematocrit, baseline kidney function and cohort; therefore, elevated serum uric acid level is a modest, independent risk factor for incident kidney disease in the general population.

An in vitro acoustic analysis and comparison of popular stethoscopes.

PURPOSE: To compare the performance of various commercially available stethoscopes using standard acoustic engineering criteria, under recording studio conditions. MATERIALS AND METHODS: Eighteen stethoscopes (11 acoustic, 7 electronic) were analyzed using standard acoustic analysis techniques under professional recording studio conditions. An organic phantom that accurately simulated chest cavity acoustics was developed. Test sounds were played via a microphone embedded within it and auscultated at its surface by the stethoscopes. Recordings were made through each stethoscope's binaurals and/or downloaded (electronic models). Recordings were analyzed using standard studio techniques and software, including assessing ambient noise (AMB) rejection. Frequency ranges were divided into those corresponding to various standard biological sounds (cardiac, respiratory, and gastrointestinal). RESULTS: Loudness and AMB rejection: Overall, electronic stethoscopes, when set to a maximum volume, exhibited greater values of perceived loudness compared to acoustic stethoscopes. Significant variation was seen in AMB rejection capability. Frequency detection: Marked variation was also seen, with some stethoscopes performing better for different ranges (eg, cardiac) vs others (eg, gastrointestinal). CONCLUSION: The acoustic properties of stethoscopes varied considerably in loudness, AMB rejection, and frequency response. Stethoscope choice should take into account clinical conditions to be auscultated and the noise level of the environment.

The relationship between nontraditional risk factors and outcomes in individuals with stage 3 to 4 CKD.

BACKGROUND: Chronic kidney disease is associated with increased risk for cardiovascular disease and mortality. Both traditional and nontraditional cardiovascular disease risk factors may contribute. STUDY DESIGN: Cohort. SETTINGS & PARTICIPANTS: Community-based adult population of the Atherosclerosis Risk in Communities and Cardiovascular Health Studies with estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m(2). PREDICTORS: Nontraditional cardiovascular disease risk factors, including body mass index, diastolic blood pressure, and triglyceride, albumin, uric acid, fibrinogen, C-reactive protein, and hemoglobin levels. OUTCOMES: Composite of myocardial infarction, stroke, and all-cause mortality. Secondary outcomes included individual components of the composite. RESULTS: Of 1,678 individuals with decreased eGFR (mean, 51.1 +/- 8.5 mL/min/1.73 m(2)), 891 (53%) reached the composite end point during a median follow-up of 108 months; 23% had a cardiac event, 45% died, and 14% experienced a stroke. Serum albumin level less than 3.9 g/dL (hazard ratio, 0.68 for every 0.3-g/dL decrease; 95% confidence interval, 0.60 to 0.77), increased serum triglyceride level (hazard ratio, 1.07 for every 50-mg/dL increase; 95% confidence interval, 1.02 to 1.12), C-reactive protein level (hazard ratio, 1.15 per log-unit increase; 95% confidence interval, 1.07 to 1.24), and fibrinogen level (hazard ratio, 1.12 per 50-mg/dL increase; 95% confidence interval, 1.07 to 1.18) independently predicted composite events. Both decreased (<14.5 g/dL) and increased (>14.5 g/dL) hemoglobin levels predicted composite events. Serum albumin level less than 3.9 g/dL and increased serum fibrinogen level independently predicted cardiac events. For serum albumin and hemoglobin levels, the relationship with composite and mortality outcomes was nonlinear (P < 0.001). LIMITATIONS: Single assessment of eGFR. No albuminuria data. CONCLUSIONS: Several nontraditional cardiovascular disease risk factors predict adverse outcomes in individuals with stage 3 to 4 chronic kidney disease. The relationship between risk factors and outcomes is often nonlinear.

Waist-to-hip ratio, body mass index, and subsequent kidney disease and death.

BACKGROUND: Chronic kidney disease (CKD) and obesity are important public health concerns. We examined the association between anthropomorphic measures and incident CKD and mortality. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: Individual patient data pooled from the Atherosclerosis Risk in Communities Study and the Cardiovascular Health Study. PREDICTORS: Waist-to-hip ratio (WHR), body mass index (BMI). OUTCOMES & MEASUREMENTS: Incident CKD defined as serum creatinine level increase greater than 0.4 mg/dL with baseline creatinine level of 1.4 mg/dL or less in men and 1.2 mg/dL or less in women and final creatinine level greater than these levels, and, in separate analyses, estimated glomerular filtration rate (eGFR) decrease of 15 mL/min/1.73 m(2) or greater with baseline eGFR of 60 mL/min/1.73 m(2) or greater and final eGFR less than 60 mL/min/1.73 m(2). Multivariable logistic regression to determine the association between WHR, BMI, and outcomes. Cox models to evaluate a secondary composite outcome of all-cause mortality and incident CKD. RESULTS: Of 13,324 individuals, mean WHR was 0.96 in men and 0.89 in women and mean BMI was 27.2 kg/m(2) in both men and women. During 9.3 years, 300 patients (2.3%) in creatinine-based models and 710 patients (5.5%) in eGFR-based models developed CKD. In creatinine-based models, each SD increase in WHR was associated with increased risk of incident CKD (odds ratio, 1.22; 95% confidence interval [CI], 1.05 to 1.43) and the composite outcome (hazard ratio, 1.12; 95% CI, 1.06 to 1.18), whereas each SD increase in BMI was not associated with CKD (odds ratio, 1.05; 95% CI, 0.93 to 1.20) and appeared protective for the composite outcome (hazard ratio, 0.94; 95% CI, 0.90 to 0.99). Results of eGFR-based models were similar. LIMITATIONS: Single measures of creatinine, no albuminuria data. CONCLUSIONS: WHR, but not BMI, is associated with incident CKD and mortality. Assessment of CKD risk should use WHR rather than BMI as an anthropomorphic measure of obesity.

Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

This chapter about antithrombotic therapy for valvular heart disease is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patient values might lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2008; 133[suppl]:123S-131S). Among the key recommendations in this chapter are the following: for patients with rheumatic mitral valve disease complicated singly or in combination by the presence of atrial fibrillation (AF), previous systemic embolism, or left atrial thrombus, we recommend vitamin K antagonist (VKA) therapy (Grade 1A). For patients with rheumatic mitral valve disease and normal sinus rhythm, without left atrial enlargement, we do not suggest antithrombotic therapy unless a separate indication exists (Grade 2C). For patients with mitral valve prolapse (MVP), not complicated by AF, who have not had systemic embolism, unexplained transient ischemic attacks, or ischemic stroke, we recommend against antithrombotic therapy (Grade 1C). In patients with mitral annular calcification complicated by systemic embolism or ischemic stroke, we recommend antiplatelet agent (APA) therapy (Grade 1B). For patients with isolated calcific aortic valve disease, we suggest against antithrombotic therapy (Grade 2C). But, for those with aortic valve disease who have experienced ischemic stroke, we suggest APA therapy (Grade 2C). For patients with stroke associated with aortic atherosclerotic lesions, we recommend low-dose aspirin (ASA) therapy (Grade 1C). For patients with cryptogenic ischemic stroke and a patent foramen ovale (PFO), we recommend APA therapy (Grade 1A). For patients with mechanical heart valves, we recommend VKA therapy (Grade 1A). For patients with mechanical heart valves and history of vascular disease or who have additional risk factors for thromboembolism, we recommend the addition of low-dose aspirin ASA to VKA therapy (Grade 1B). We suggest ASA not be added to long-term VKA therapy in patients with mechanical heart valves who are at particularly high risk of bleeding (Grade 2C). For patients with bioprosthetic heart valves, we recommend ASA (Grade 1B). For patients with bioprosthetic heart valves and additional risk factors for thromboembolism, we recommend VKA therapy (Grade 1C). For patients with infective endocarditis, we recommend against antithrombotic therapy, unless a separate indication exists (Grade 1B).

Does error and adverse event reporting by physicians and nurses differ?

BACKGROUND: Some hospitals have instituted voluntary electronic error reporting systems (e-ERSs) to gather data on medical errors, adverse events, near misses, or environmental issues in a peer review-protected environment. An e-ERS allows for real-time review, oversight, and intervention and provides insight into hospital processes in need of modification to reduce the likelihood of adverse hospital events. In a descriptive study of a standardized, Web-based reporting system, the reporting practices of physicians and nurses were compared. METHODS: Twenty-nine acute care hospitals and one long-term care organization implemented an e-ERS between August 2000 and December 2005. The reporting system consisted of a secure, Web-based portal available on all hospital computers. Events were classified by the level of impact on the patient using a standard classification scheme. All reports that occurred from August 2000 through January 2006 were analyzed in aggregate analyses. Hospitals and patients were de-identified to study investigators. RESULTS: Some 266,224 events were reported over 7.3 million inpatient days--1 event per 27.5 days. Physicians were the reporters of 1.1% of total events, nurses 45.3%, and other hospital employees 53.6%. Physicians were more likely to be the reporter for events that caused permanent harm, near death, or death of a patient (p < .01). Nurses were more likely to be the reporter for events that caused no or temporary harm (p < .01). DISCUSSION: Physicians reported a narrower spectrum of events than nurses; they were more likely to report as the impact of events on patients increased but less likely to report fatal events. Nurses' reporting remained stable across impact levels. Differences exist between whether nurses and physicians report events; physicians must be encouraged to increase their reporting of adverse events.

Cardiovascular outcomes and all-cause mortality: exploring the interaction between CKD and cardiovascular disease.

BACKGROUND: Chronic kidney disease (CKD) is a risk factor for cardiovascular disease (CVD). Concurrently, CVD may promote CKD, resulting in a vicious cycle. We evaluated this hypothesis by exploring whether CKD and CVD have an additive or synergistic effect on future cardiovascular and mortality outcomes. METHODS: Patients were pooled from 4 community-based studies: Atherosclerosis Risk in Communities, Framingham Heart, Framingham Offspring, and Cardiovascular Health Study. CKD is defined by an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) (<1 mL/s/1.73 m(2)). Baseline CVD included myocardial infarction, angina, stroke, transient ischemic attack, claudication, heart failure, and coronary revascularization. The primary outcome is a composite of cardiac events, stroke, and death. Secondary outcomes included individual components. Multivariable analyses using Cox regression examined differences in study outcomes. The interaction of CKD and CVD was tested. RESULTS: The study population included 26,147 individuals. During 10 years, 4% (n = 2,927) of individuals with no CKD or CVD developed the primary outcome, 33% (n = 518) with only CKD, 37% (n = 1,260) with only CVD, and 66% (n = 459) with both. Both CKD (hazard ratio [HR], 1.26; 95% confidence interval [CI], 1.16 to 1.35; P < 0.0001) and CVD (HR, 1.83; 95% CI, 1.72 to 1.95; P < 0.0001) were independent risk factors for the primary outcome. The interaction term CKD x CVD was not statistically significant (HR, 0.98; 95% CI, 0.85 to 1.13; P = 0.74). Similar results were obtained for secondary outcomes. CONCLUSION: CKD and CVD are both strong independent risk factors for adverse cardiovascular and mortality outcomes in the general population. Although individuals with both risk factors are at extremely high risk, there does not appear to be a synergistic effect of CKD and CVD on outcomes.

Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals.

OBJECTIVE: To describe the rate and types of events reported in acute care hospitals using an electronic error reporting system (e-ERS). DESIGN: Descriptive study of reported events using the same e-ERS between January 1, 2001 and September 30, 2003. SETTING: Twenty-six acute care nonfederal hospitals throughout the U.S. that voluntarily implemented a web-based e-ERS for at least 3 months. PARTICIPANTS: Hospital employees and staff. INTERVENTION: A secure, standardized, commercially available web-based reporting system. RESULTS: Median duration of e-ERS use was 21 months (range 3 to 33 months). A total of 92,547 reports were obtained during 2,547,154 patient-days. Reporting rates varied widely across hospitals (9 to 95 reports per 1,000 inpatient-days; median=35). Registered nurses provided nearly half of the reports; physicians contributed less than 2%. Thirty-four percent of reports were classified as nonmedication-related clinical events, 33% as medication/infusion related, 13% were falls, 13% as administrative, and 6% other. Among 80% of reports that identified level of impact, 53% were events that reached a patient ("patient events"), 13% were near misses that did not reach the patient, and 14% were hospital environment problems. Among 49,341 patient events, 67% caused no harm, 32% temporary harm, 0.8% life threatening or permanent harm, and 0.4% contributed to patient deaths. CONCLUSIONS: An e-ERS provides an accessible venue for reporting medical errors, adverse events, and near misses. The wide variation in reporting rates among hospitals, and very low reporting rates by physicians, requires investigation.

Hematocrit and left ventricular mass: the Framingham Heart study.

OBJECTIVES: The goal of this study was to investigate the relationship between hematocrit (Hct) and left ventricular mass index (LVMI) and LV hypertrophy (LVH) in subjects without known hypertension or cardiovascular disease in the Framingham Heart study. BACKGROUND: Anemia may be an independent risk factor for cardiovascular disease in the general population. One potential explanation for this finding could be an association between Hct with LVMI or LVH. METHODS: Linear and logistic regression analyses were used to evaluate the association between Hct with LVMI and LVH. All analyses were stratified by gender and further according to menopausal status in women. RESULTS: There were 1,376 men and 1,769 women who met the inclusion criteria. The mean Hct and LVMI were 46.5% and 41.9%, and 127.3 and 95.8 g/m, respectively, in men and women. After adjustment for confounders, each 3% lower Hct was associated with a 2.6 g/m higher mean LVMI in men, and a 1.8 g/m higher mean LVMI in postmenopausal women (p < 0.05). There was a significant quadratic relationship between Hct and LVMI in premenopausal women (p < 0.01). Subjects in the lowest quartile of Hct (compared with the rest of the sample) had an adjusted odds ratio of LVH of 2.0 (95% confidence interval [CI] 1.3 to 3.0) in men and 1.4 (95% CI 0.8 to 2.4) in postmenopausal women. CONCLUSIONS: In a sample without known hypertension or cardiovascular disease, a lower Hct is associated with echocardiographically determined LVH in men and a small but significantly higher LVMI in men and postmenopausal women. The clinical importance of these findings remains unknown.

A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes.

OBJECTIVES: We performed a meta-analysis of randomized trials comparing coronary artery bypass graft surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of coronary artery disease, incorporating new trials and examining long-term outcomes. BACKGROUND: Previous meta-analyses of trials comparing CABG with PTCA have reported short- and intermediate-term outcomes, but since then longer term follow-up and newer trials have been published. METHODS: We performed a meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG. RESULTS: We found a 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02), but no significant advantage at one, three, or eight years. In subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. Patients randomized to PTCA had more repeat revascularizations at all time points (risk difference [RD] 24% to 38%, p < 0.001); with stents, this RD was reduced to 15% at one and three years. Stents also resulted in a significant decrease in nonfatal myocardial infarction at three years when compared with CABG. For diabetic patients, CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: Our results suggest that, when compared with PTCA, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about half.

Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community.

OBJECTIVES: The goal of this study was to determine whether the level of kidney function is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD) outcomes in the Atherosclerosis Risk in Communities (ARIC) study, a prospective cohort study of subjects aged 45 to 64 years. BACKGROUND: The level of kidney function is now recognized as a risk factor for ASCVD outcomes in patients at high risk for ASCVD, but it remains unknown whether the level of kidney function is a risk factor for ASCVD outcomes in the community. METHODS: Cox proportional-hazards regression was used to evaluate the association of glomerular filtration rate (GFR) with ASCVD after adjustment for the major ASCVD risk factors in 15,350 subjects. We searched for nonlinear relationships between GFR and ASCVD. RESULTS: During a mean follow-up time of 6.2 years, 965 (6.3%) of subjects had ASCVD events. Subjects with GFR of 15 to 59 ml/min/1.73 m(2) (n = 444, hazard ratio 1.38 [1.02, 1.87]) and 60 to 89 ml/min/1.73 m(2) (n = 7,665, hazard ratio 1.16 [1.00, 1.34]) had an increased adjusted risk of ASCVD compared with subjects with GFR of 90 to 150 ml/min/1.73 m(2). Each 10 ml/min/1.73 m(2) lower GFR was associated with an adjusted hazard ratio of 1.05 (1.02, 1.09), 1.07 (1.01, 1.12), and 1.06 (0.99, 1.13) for ASCVD, de novo ASCVD, and recurrent ASCVD, respectively. A nonlinear model did not fit the data better than a linear model. CONCLUSIONS: The level of GFR is an independent risk factor for ASCVD and de novo ASCVD in the ARIC study.

Prevalence and cost of imaging in inpatient falls: the rising cost of falling.

OBJECTIVE: To quantify the type, prevalence, and cost of imaging following inpatient falls, identify factors associated with post-fall imaging, and determine correlates of positive versus negative imaging. DESIGN: Single-center retrospective cohort study of inpatient falls. Data were collected from the hospital's adverse event reporting system, DrQuality. Age, sex, date, time, and location of fall, clinical service, Morse Fall Scale/fall protocol, admitting diagnosis, and fall-related imaging studies were reviewed. Cost included professional and facilities fees for each study. SETTING: Four hundred and fifteen bed urban academic hospital over 3 years (2008-2010). PATIENTS: All adult inpatient falls during the study period were included. Falls experienced by patients aged <18 years, outpatient and emergency patients, visitors to the hospital, and staff were excluded. MEASUREMENTS AND MAIN RESULTS: Five hundred and thirty inpatient falls occurred during the study period, average patient age 60.7 years (range 20-98). More than half of falls were men (55%) and patients considered at risk of falls (56%). Falls were evenly distributed across morning (33%), evening (34%), and night (33%) shifts. Of 530 falls, 178 (34%) patients were imaged with 262 studies. Twenty percent of patients imaged had at least one positive imaging study attributed to the fall and 82% of studies were negative. Total cost of imaging was $160,897, 63% ($100,700) from head computed tomography (CT). CONCLUSION: Inpatient falls affect patients of both sexes, all ages, occur at any time of day and lead to expensive imaging, mainly from head CTs. Further study should be targeted toward clarifying the indications for head CT after inpatient falls and validating risk models for positive and negative imaging, in order to decrease unnecessary imaging and thereby limit unnecessary cost and radiation exposure.

Enalapril treatment and hospitalization with atrial tachyarrhythmias in patients with left ventricular dysfunction.

BACKGROUND: Experimental and clinical evidence suggests a preventive role for agiotensin-coverting enzyme (ACE) inhibitors on the development of atrial fibrillation. However, the effect of ACE inhibition on hospitalization with atrial tachyarrhythmias in patients with left ventricular (LV) dysfunction is not known. We sought to determine whether enalapril treatment reduced hospitalizations with atrial tachyarrhythmias in patients with LV dysfunction. METHODS: We performed a retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) trial. Hospitalizations with atrial tachyarrhythmias were noted. RESULTS: A total of 192 hospitalizations with atrial tachyarrhythmias occurred in 158 patients during a follow-up period of 34 months. The time to first hospitalization with atrial tachyarrhythmias or death was significantly lower in the enalapril group (P =.005). In a multivariate analysis adjusting for the presence of atrial fibrillation at study entry, enalapril treatment was associated with a reduction in the rate of hospitalization with atrial tachyarrhythmias or death (RR, 0.87; 95% CI, 0.79-0.96; P =.007). The incidence of hospitalization with atrial tachyarrhythmias was 7.9 hospitalizations per 1000 patient-years of follow-up in the enalapril group, compared with 12.4 per 1000 patient-years in the placebo group (RR, 0.64; 95% CI, 0.48-0.85; P =.002). CONCLUSION: Enalapril is associated with a decreased incidence of hospitalization with atrial tachyarrhythmias in patients with LV dysfunction.

Kidney disease as a risk factor for recurrent cardiovascular disease and mortality.

BACKGROUND: Chronic kidney disease (CKD) is highly prevalent in the United States and is an independent risk factor for adverse cardiovascular disease (CVD) and all-cause mortality outcomes in patients with acute coronary syndromes. Few studies have evaluated the effect of CKD on cardiovascular events in a diverse community-based population with underlying CVD. METHODS: Data for subjects with preexisting CVD were pooled from 4 publicly available, community-based, longitudinal studies: Atherosclerosis Risk in Communities, Cardiovascular Health Study, Framingham Heart Study, and Framingham Offspring Study. CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m2 (<1 mL/s/1.73 m2). The primary study outcome was a composite of myocardial infarction (MI), fatal coronary heart disease (CHD), stroke, and all-cause mortality. The secondary outcome included only MI and fatal CHD. RESULTS: A total of 4,278 subjects satisfied inclusion criteria, and 759 subjects (17.7%) had CKD. Mean follow-up was 86 months. The primary and secondary outcomes were observed in 1,703 (39.8%) and 857 subjects (20.0%), respectively. Incidence rates for the primary and secondary outcomes were greater in persons with CKD compared with those without CKD (62.5% versus 34.9% and 30.6% versus 17.8%, respectively). Adjusted hazard ratios for the primary and secondary outcomes were 1.35 (95% confidence interval [CI], 1.21 to 1.52) and 1.32 (95% CI, 1.12 to 1.55), respectively. CONCLUSION: The presence of CKD in a community-based population with preexisting CVD is associated with an increased risk for recurrent CVD outcomes. This increased risk persists after adjustment for traditional CVD risk factors.

Antithrombotic therapy in valvular heart disease--native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

This chapter about antithrombotic therapy in native and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international normalized ratio [INR], 2.5; range, 2.0 to 3.0) [Grade 1C+]. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs at a therapeutic INR, we recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C). In people with mitral valve prolapse (MVP) without history of systemic embolism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexplained TIAs, we recommend long-term aspirin therapy, 50 to 162 mg/d (Grade 1A). For all patients with mechanical prosthetic heart valves, we recommend vitamin K antagonists (Grade 1C+). For patients with a St. Jude Medical (St. Paul, MN) bileaflet valve in the aortic position, we recommend a target INR of 2.5 (range, 2.0 to 3.0) [Grade 1A]. For patients with tilting disk valves and bileaflet mechanical valves in the mitral position, we recommend a target INR of 3.0 (range, 2.5 to 3.5) [Grade 1C+]. For patients with caged ball or caged disk valves, we suggest a target INR of 3.0 (range, 2.5 to 3.5) in combination with aspirin, 75 to 100 mg/d (Grade 2A). For patients with bioprosthetic valves, we recommend vitamin K antagonists with a target INR of 2.5 (range, 2.0 to 3.0) for the first 3 months after valve insertion in the mitral position (Grade 1C+) and in the aortic position (Grade 2C). For patients with bioprosthetic valves who are in sinus rhythm and do not have AF, we recommend long-term (> 3 months) therapy with aspirin, 75 to 100 mg/d (Grade 1C+).