Comparing methods to identify hip fracture in a nursing home population using Medicare claims.

UNLABELLED: The inpatient principal diagnosis in Medicare claims identified 96% of hip fractures in hospitalized nursing home residents with high rates of confirmation by other claims files. INTRODUCTION: Hip fracture is typically identified in Medicare claims by examining only the principal diagnosis in the inpatient file, but this simple approach might be inadequate for nursing home residents. Our objective was to examine the impact of varied operational definitions for identifying hip fracture hospitalizations in administrative claims data. METHODS: We conducted a retrospective examination of Medicare inpatient and outpatient claims data for dually Medicaid- and Medicare-eligible nursing home residents in 1999 in California, Florida, Missouri, New Jersey, and Pennsylvania (n = 197,514). We determined the number of hip fractures identified in inpatient (Medicare A) diagnoses codes using differing definitions that varied according to whether or not hip fracture was required to be the principal diagnosis and whether or not confirmatory imaging and procedure codes were required to be found in other (Medicare B) claims files. RESULTS: Hip fractures were found in any inpatient diagnosis position in 4,680 subjects, with 4,479 of these found in the principal diagnosis position. With either approach to diagnosis position, confirmatory imaging and procedure codes were identified for 95% of persons hospitalized with hip fracture. CONCLUSION: The principal diagnosis alone will identify 96% of hip fracture diagnoses in hospitalized nursing home residents. Such diagnoses are confirmed at very high rates by other sources of claims data. Researchers may be confident using a simple approach to identifying hip fracture hospitalizations in this population, using inpatient claims alone and interrogating only the principal diagnosis position.

Use and effectiveness of intravenous heparin therapy for treatment of acute myocardial infarction in the elderly.

OBJECTIVES: We sought to determine the use and association with 30-day mortality of intravenous heparin for the treatment of acute myocardial infarction in elderly patients not treated with a reperfusion strategy and without contraindications to anticoagulation. BACKGROUND: The benefit of using full-dose intravenous heparin for the treatment of acute myocardial infarction in the elderly is not known. METHODS: We conducted a retrospective cohort study using hospital medical records of all Medicare beneficiaries admitted to the hospital with an acute myocardial infarction in Alabama, Connecticut, Iowa and Wisconsin from June 1992 through February 1993. RESULTS: Among the 6,935 patients > or = 65 years old who had no absolute chart-documented contraindications to heparin, 3,227 (47%) received early full-dose intravenous heparin therapy. After adjustment for baseline differences in demographic, clinical and treatment factors between patients with and without heparin, the use of heparin (odds ratio 1.02, 95% confidence interval 0.87 to 1.18) was not associated with a significantly better 30-day mortality rate. CONCLUSIONS: Although intravenous heparin was commonly used for treatment of acute myocardial infarction in the elderly, it was not associated with an improved 30-day mortality rate. Although the findings of this observational study must be interpreted with care, they lead us to question whether the prevalent use of intravenous heparin has therapeutic effectiveness in this population.

Validation of a clinical prediction rule for left ventricular ejection fraction after myocardial infarction in patients > or = 65 years old.

We sought to validate a previously described clinical prediction rule for classifying left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI). As part of the Connecticut cohort of the Cooperative Cardiovascular Project (CCP) pilot study, we identified 3,093 Medicare patients who had been admitted to hospitals throughout Connecticut with an AMI in 1992 and 1993. Retrospective chart review and detailed electrocardiogram interpretation were performed. Of the 1,891 patients with an interpretable EF, 1,378 (73%) had > or = 1 of the rule's exclusion criteria. Of the remaining 513 patients, the clinical prediction rule had a positive predictive value of 89% (i.e., 456 of 513 patients had an EF > or = 40%). In a multivariate model, presentation > 6 hours after the onset of chest pain, a history of bypass surgery, and diabetes mellitus were associated with patients in whom the rule did not correctly predict an EF > or = 40%. Excluding patients with these characteristics from the rule increased the positive predictive value from 89% to 93% and excluded an additional 239 patients. The EF could not be predicted among the patients who did not meet the rule's criteria. In conclusion, a previously published clinical prediction rule for the classification of the EF in patients after an AMI correctly classified 8 of every 9 eligible elderly patients as having an EF > or = 40%. Thus, while not performing as well as it did in the original study, our findings support the use of this rule in providing clinicians with an objective method for estimating an EF > or = 40% in a specific subset of elderly patients.

Determinants of appropriate use of angiotensin-converting enzyme inhibitors after acute myocardial infarction in persons > or = 65 years of age.

We sought to determine how often angiotensin-converting enzyme (ACE) inhibitors are prescribed as a discharge medication among eligible patients > or = 65 years old with an acute myocardial infarction; to identify patient characteristics associated with the decision to prescribe ACE inhibitors; and to determine the factors associated with the decision to obtain an evaluation of left ventricular function among patients who have no contraindications to ACE inhibitors. We addressed these aims with an observational study of consecutive elderly Medicare beneficiary survivors of an acute myocardial infarction hospitalized in Alabama, Connecticut, Iowa, and Wisconsin between June 1992 and February 1993. Among the 5,453 patients without a contraindication to ACE inhibitors at discharge, 3,528 (65%) had an evaluation of left ventricular function. Of the 1,228 patients without a contraindication to ACE inhibitors who had a left ventricular ejection fraction < or = 40%, 548 (45%) were prescribed the medication at discharge. In a multivariable analysis, an increased prescribed use of ACE inhibitors at discharge was correlated with several factors, including diabetes mellitus, congestive heart failure, ventricular tachycardia, and loop diuretics as a discharge medication. Patients admitted after the publication of the Survival and Ventricular Enlargement (SAVE) trial were significantly more likely to receive ACE inhibitors, although the absolute improvement in utilization was small in the 6 months after the trial results were published. In conclusion, improving the identification of appropriate patients for ACE inhibitors and increasing the prescription of ACE inhibitors for ideal patients may provide an excellent opportunity to improve care.

Characterization of serum antibody responses to recombinant HIV-1 gp160 vaccine by enzyme immunoassay. NIAID AIDS Vaccine Clinical Trials Network.

An enzyme immunoassay (EIA) was developed to measure serum antibody responses of healthy adult volunteers vaccinated with 40 or 80 micrograms of human immunodeficiency virus type 1 (HIV-1) recombinant gp160 (rgp160) vaccine at 0, 1, 6, and 18 months. This assay, which used purified rgp160 as antigen, was compared with the Biotech/Du Pont HIV-1 Western blot and the Abbott HIV-1 EIA. Of 33 volunteers who received three doses of rgp160 vaccine, seroresponses were detected in 91% by rgp160 EIA, 97% by Western blot, and 30% by HIV-1 EIA. The level of IgG rgp160 EIA antibody (mainly IgG1) peaked after the third immunization; 64% of 33 vaccinees still had detectable antibody by 12 months. The fourth immunization induced anamnestic IgG EIA antibody in 23 of 24 vaccinees, with titers ranging from 1:200 to 1:25,600. Neutralizing antibody was not detected in postvaccination sera by microtiter syncytium formation inhibition assay. Additional testing of sera by EIA indicated that the immune response to the vaccine was directed toward epitopes on both gp120 and gp41. Seroresponses to the immunodominant epitopes on gp41 were infrequent and none were detected to the neutralization epitope in the V3 region of gp120. This highly sensitive EIA is useful for characterizing HIV-1-specific antibody responses induced by an HIV-1 gp160 subunit vaccine.

Curriculum assessment for prevention topics and the population perspective.

BACKGROUND: According to the Association of American Medical College's (AAMC) Senior Questionnaire, medical students spend an inadequate amount of time learning about health promotion, disease prevention, and the population health perspective. OBJECTIVE: Determine the health promotion/disease prevention (HPDP) content of the medical school curriculum at the University of Kansas School of Medicine, using an inventory of knowledge and skills in HPDP and using physician education objectives from Healthy People 2000. METHODS: A 121-item survey to evaluate curriculum content was developed. All course directors evaluated their course by using this instrument. An average of three medical students used this instrument to assess each curriculum lecture and every clinical clerkship day in the required medical school curriculum. A teaching session was defined as spending a minimum of 3-5 minutes teaching an HPDP topic. RESULTS: Of 21 required courses in the medical school curriculum, 11 accounted for the 393 teaching sessions in HPDP. Seventy-five percent (293 sessions) of these dealt with clinical prevention. Quantitative methods received 40 sessions, whereas the health services organization and delivery and the community dimensions of medical practice received 37 and 23 sessions, respectively. Course directors and students disagreed significantly in which HPDP topics were taught in the curriculum. CONCLUSIONS: Clinical prevention was fairly well covered in the medical school curriculum. Quantitative methods, health services organization and delivery, and community dimensions of medical practice were poorly covered. This assessment was used to substantially improve the curriculum. To track and improve curriculum content in all courses, course directors need to know more precise details about the content of their courses, so this detail can be used to better evaluate the overall curriculum.

Warfarin for stroke prevention in octogenarians with atrial fibrillation.

The authors examined warfarin use in elderly patients with atrial fibrillation. Medical records were abstracted from a random sample of Medicare beneficiaries with atrial fibrillation who were discharged from Kansas hospitals. Data were analyzed for warfarin and aspirin use and risk factors for stroke or bleeding in patients 65-79 years of age or 80 years and older. Stroke risk factors other than age and atrial fibrillation were seen in 98% of 142 patients less than 80 years of age and 100% of 141 octogenarians. Warfarin use was similar in the younger and older age groups (50% vs. 45%, respectively; p = ns) and was not associated with the number of stroke or bleeding risk factors. Compared to patients less than 80 years of age, octogenarians were less likely to receive aspirin (38% vs. 27%, respectively; p < 0.05). Anticoagulation rates for high-risk patients with atrial fibrillation were low and poorly explained by stroke or bleeding risks.

Quality improvement at the national level. Lessons from the Cooperative Cardiovascular Project.

Most quality improvement projects address care delivered in one service of a hospital, such as the operating suite or the obstetrics service. Some projects are collaborative efforts involving groups of hospitals with similar interests. Few projects attempt to change care on a population basis (i.e., involving all providers in entire states or the nation as a whole.) The Cooperative Cardiovascular Project (CCP), sponsored by the Health Care Financing Administration, is attempting to improve care for all Medicare patients suffering from acute myocardial infarctions nation-wide. The CCP has been active since 1993 and, in a pilot project, has demonstrated that care can be improved on a population basis (i.e., in four entire states). This article explores the lessons learned from the CCP pilot and from the evolving CCP national experience.

Direct observation of smoking cessation activities in primary care practice.

OBJECTIVE: Our goals were to determine how often family physicians incorporate smoking cessation efforts into routine office visits and to examine the effect of patient, physician, and office characteristics on the frequency of these efforts. STUDY DESIGN: Data was gathered using direct observation of physician-patient encounters, a survey of physicians, and an on-site examination of office systems for supporting smoking cessation. POPULATION: We included patients seen for routine office visits in 38 primary care physician practices. OUTCOMES MEASURED: The frequency of tobacco discussions among all patients, the extent of these discussions among smokers, and the presence of tobacco-related systems and policies in physicians' offices were measured. RESULTS: Tobacco was discussed during 633 of 2963 encounters (21%; range among practices = 0%-90%). Discussion of tobacco was more common in the 58% of practices that had standard forms for recording smoking status (26% vs 16%; P=.01). Tobacco discussions were more common during new patient visits but occurred less often with older patients and among physicians in practice more than 10 years. Of 244 smokers identified, physicians provided assistance with smoking cessation for 38% (range among practices = 0%-100%). Bupropion and nicotine-replacement therapy were discussed with smokers in 31% and 17% of encounters, respectively. Although 68% of offices had smoking cessation materials for patients, few recorded tobacco use in the "vital signs" section of the patient history or assigned smoking-related tasks to nonphysician personnel. CONCLUSIONS: Smoking cessation practices vary widely in primary care offices. Strategies are needed to assist physicians with incorporating systematic approaches to maximize smoking cessation rates.

Impact of intercurrent respiratory infections on lung health in infants born <29 weeks with bronchopulmonary dysplasia.

OBJECTIVE: Assess the impact of intercurrent respiratory infections in infants <29 weeks gestational age (GA). STUDY DESIGN: A retrospective cohort study of 111 infants born <29 weeks GA, controlling for bronchopulmonary dysplasia (BPD) severity and assessing pulmonary health over the first year of life through oxygen, diuretic and inhaled steroid use. RESULT: Regression analysis showed viral infections increased oxygen use (odds ratio (OR) of 15.5 (confidence interval (CI)=3.4, 71.3)). The trend test showed increasing numbers of viral infections were associated with increased oxygen (OR (95% CI)=6.4 (2.3 to 17.4), P=0.0003), diuretic (OR (95% CI)=2.4 (1.1to 5.2), P=0.02) and inhaled steroid use (OR (95% CI)=2.2 (1.003 to 5.2), P=0.049), whereas bacterial infections were not. CONCLUSION: Viral infections caused more long-term pulmonary morbidity/mortality than bacterial infections on premature lung health, even when controlling for BPD.

Hyperglycaemia and mortality of diabetic patients with candidaemia.

AIMS: To determine whether the degree of hyperglycaemia has an impact on in-hospital mortality in diabetic patients with candidaemia. METHODS: A retrospective cohort study of 87 diabetic patients with candidaemia admitted between June 1995 and June 2003 was carried out at two medical centres. Patients were stratified into two groups: those with moderate hyperglycaemia (7 days post-candidaemia mean blood glucose < 13.9 mmol/l) and those with severe hyperglycaemia (7 days post-candidaemia mean blood glucose > or = 13.9 mmol/l). A stepwise logistic regression analysis was performed to determine whether the degree of hyperglycaemia was a significant predictor of mortality. RESULTS: During the follow-up period from admission till discharge, 34 (39.1%) patients had died. Nine (69.2%) of 13 patients with severe hyperglycaemia have died while 25 (33.8%) of 74 patients with moderate hyperglycaemia have died. Multivariate analysis identified three independent determinants of death; Apache II score > or = 23 [OR 8.1, 95% CI (2.6, 25.3), P = 0.0003], mean blood glucose levels 7 days post-candidaemia > or = 13.9 mmol/l [OR 6.8, 95% CI (1.2, 38.2), P = 0.03], and mechanical ventilation [OR 6.5, 95% CI (2.21), P = 0.03]. CONCLUSION: Severe hyperglycaemia is an important marker of increased mortality among hospitalized diabetic patients with candidaemia.

Optimizing beta-blocker use after myocardial infarction.

Although beta-adrenergic blockers can significantly reduce mortality after a myocardial infarction, these agents are prescribed to only a minority of patients. Underutilization of beta blockers may be attributed, in part, to fear of adverse effects, especially in the elderly and in patients with concomitant disorders such as diabetes or heart failure. However, studies have shown that such patients are precisely the ones who derive the greatest benefit from beta blockade. Advancing age or the presence of potentially complicating disease states is usually not a justification for withholding beta-blocker therapy. With use of cardioselective agents and through careful dosing and monitoring, the benefits of beta blockers after myocardial infarction far outweigh the potential risks in most patients.

Acid-base and electrolyte abnormalities due to capreomycin.

We report a patient with tuberculosis treated with a five-drug regimen who experienced severe acid-base and electrolyte abnormalities including hypomagnesemia, hypokalemia, hypocalcemia, and a hypochloremic metabolic alkalosis. These disturbances are believed to be due to treatment with capreomycin, which produced renal magnesium wasting and possible tubular damage. Therefore, we recommend frequent determinations of serum electrolytes, magnesium, and calcium in patients treated with capreomycin.

Gonorrhea prevalence in the Maryland state prisons.

During a 6-month period from July 1 through December 31, 1986, 2,598 consecutive men were screened for gonorrhea upon entry into the Maryland Division of Corrections. Twenty-eight men (1.1%) demonstrated positive cultures for gonorrhea with 27 of them (92%) asymptomatic. This prevalence is substantially lower than other rates reported from prisons and detention centers. Although the role of asymptomatic males as a reservoir for gonorrhea has been well delineated, standard recommendations for screening high-risk male populations such as prison inmates have not been established. These data suggest that screening in some correctional facilities may not be cost-effective given the low prevalence observed. In addition, contact tracing may be delayed by long holding periods in local detention facilities prior to transfer to the state prison system. These data underscore the need for additional analysis to determine the most effective program structure for screening in correctional facilities and detention centers.

Fecal occult blood test use by Kansas medicare beneficiaries.

PURPOSE: The aim of this study was to examine utilization of and trends in fecal occult blood testing (FOBT) among beneficiaries since Medicare began FOBT coverage on January 1, 1998. METHODS: We identified Kansas Medicare beneficiaries ages 65-79. Using Medicare claims, we determined which beneficiaries received FOBT during 1998-1999. We examined demographic variables associated with FOBT and rate changes over time. We linked beneficiaries to primary care practices (PCPs) and examined FOBT variations among 483 PCPs. RESULTS: FOBT use remained unchanged during the study period. Of the 215,322 beneficiaries, 11% received at least one FOBT in 1998 and 11% in 1999; 18% had at least one test during the 2-year period, but only 4% had a test during both years. Caucasians and females had the highest FOBT rates. Although FOBT rates among PCPs ranged from 0 to 71%, only 19% of the practice rates exceeded 10%. CONCLUSIONS: Few beneficiaries obtain annual FOBT and little change in rates has occurred since Medicare reimbursement began. Although FOBT rates vary widely between PCPs, most either do not provide FOBT or do not bill Medicare for FOBT. The FOBT claims rate is much lower than reported in patient surveys and may indicate that Medicare should reexamine its reimbursement policy.

Caretaker compliance with different antibiotic formulations for treatment of childhood pneumonia.

To determine the effect of antibiotic formulations on compliance, 400 children, aged 2 months to 5 years, with a presumptive diagnosis of pneumonia, were randomly assigned to receive one of the following formulations of cotrimoxazole: 1. syrup accompanied by a 10-ml measuring cup; 2. syrup accompanied by a 5-ml measuring spoon; 3. tablets; 4. single-dose sachets of antibiotic powder. A research assistant visited the childs' home on the fourth day of therapy, asked the care-giver about compliance, and observed the care-giver prepare a dose of the medication. The remaining amount of medicine was measured, and when possible (n = 151), a urine specimen was tested for the presence of sulphamethoxazole. All of the care-givers reported giving at least one dose on the first day of therapy. By the fourth day, 82 per cent of those receiving syrup were still taking their medication compared to 71 and 55 per cent of those receiving sachets or tablets, respectively (P < 0.01). Of those who received syrup accompanied by a spoon, 38 per cent under-dosed the medicine by at least 30 per cent. Overall, compliance was highly correlated with the care-giver's report of difficulty in administering the medication. Additional research is needed to understand the obstacles encountered by care-givers in administering sachets and tablets. Meanwhile, the use of antibiotic syrup, accompanied by an appropriately sized measuring cup, appears to offer the greatest probability of medication compliance in the treatment of Egyptian children with pneumonia.

Drug prescribing for patients with changing renal function.

The prevalence and course of renal dysfunction in hospitalized patients and the prescribing of renally eliminated drugs in these patients were studied. All adult inpatients at a large teaching hospital who had a serum creatinine concentration assay performed were screened for renal dysfunction (an estimated creatinine clearance of < 40 mL/min). Renally compromised patients were monitored for changes in renal function. The regimens of selected renally eliminated drugs prescribed for these patients were compared with the manufacturers' recommended dosages for patients with renal compromise. Of the 3800 patients screened, 195 (5%) had renal dysfunction; most of these patients were older than 65 years. Although improvements in renal function were noted in 49 (30%) of the 169 patients with renal dysfunction who were not receiving hemodialysis, elderly patients were less likely to show an improvement in renal function. Of the 60 patients with renal dysfunction for whom a renally eliminated drug was prescribed, 27 (45%) were receiving dosages in excess of the manufacturers' recommendations. Changes in creatinine clearance estimates are common in hospitalized patients with renal impairment. Programs designed to alert physicians to potentially excessive dosages of renally eliminated drugs need to be sensitive to these changes.