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1.
Lancet ; 394(10204): 1169-1180, 2019 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-31484629

RESUMO

BACKGROUND: Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. METHODS: The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). FINDINGS: Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8-3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74-0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, pinteraction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78-1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75-1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48-2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36-3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74-1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75-0·95, p=0·005, in contrast to patients without PCI where it did not, pinteraction=0·012. Benefit was present irrespective of time from most recent PCI. INTERPRETATION: In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk. FUNDING: AstraZeneca.


Assuntos
Doença da Artéria Coronariana/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Ticagrelor/uso terapêutico , Idoso , Aspirina/uso terapêutico , Doenças Cardiovasculares/mortalidade , Angiografia Coronária , Ponte de Artéria Coronária , Doença da Artéria Coronariana/complicações , Estenose Coronária/diagnóstico por imagem , Diabetes Mellitus Tipo 2/complicações , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Humanos , Hipoglicemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Intervenção Coronária Percutânea , Prevenção Secundária , Acidente Vascular Cerebral/epidemiologia
2.
Am J Manag Care ; 22(7): e249-57, 2016 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-27442308

RESUMO

OBJECTIVES: To examine the effect of the Affordable Care Act (ACA) on changes in premiums for subscribers of nongrandfathered, nongroup insurance plans that were "cancelled." STUDY DESIGN: Retrospective multivariate analyses. METHODS: Changes in annual premiums post ACA were evaluated across subgroups of subscriber and health plan characteristics. Data was derived from databases containing information on premiums, plan benefit, and demographics for subscribers aged 18 to 64 years within Kaiser Permanente of the Mid-Atlantic States. A linear regression model was used to examine the independent association between subscriber and health plan characteristics on the relative change in premiums. RESULTS: In 2013, 4169 nongroup subscribers were enrolled in plans that were cancelled as a result of the ACA. The median pre-ACA premium was $3240 (range = $780-$39,492), which increased by a median of 21.3% (range = -77.4% to 193.6%), or $685 (range = -$27,464 to $8676), post ACA in 2014. Premiums increased more for high-deductible plans (median = 63.7%) than standard-deductible plans (median = 8.4%). Due to shifts in the age curve, premiums decreased for more than half of women aged 18 to 44 years, but increased by 35.2% for women aged 55 to 64 years. Premiums fell by 15.5% for subscribers who did not pass standard medical underwriting due to preexisting conditions. CONCLUSIONS: Changes in premiums in the nongroup market post ACA, varied substantially across subgroups, primarily due to differences in the amount of coverage, changes in rating criteria, shifts in the age curve, and anticipated differences in risk selection and composition of the risk pool. Given the extent of this variation, it would be incorrect to conclude the ACA as being uniformly beneficial or detrimental to subscribers of these cancelled plans.


Assuntos
Trocas de Seguro de Saúde/tendências , Cobertura do Seguro/tendências , Seguro Saúde/tendências , Patient Protection and Affordable Care Act , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Modelos Econométricos , Estudos Retrospectivos , Estados Unidos
3.
J Urol ; 195(1): 33-40, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26341576

RESUMO

PURPOSE: Platinum based chemotherapy is widely used for bladder cancer but is associated with vascular toxicity, especially thromboembolism. We evaluated the short-term (less than 1 year) and intermediate-term (2 to 5 years) vascular toxicity of platinum agents in older patients with bladder cancer. MATERIALS AND METHODS: We identified Medicare beneficiaries 66 to 94 years old diagnosed with stage II-III bladder cancer from 1998 to 2007 in the SEER-Medicare database. We measured the association between platinum based chemotherapy and vascular events (thromboembolic and nonthromboembolic) using Cox proportional hazard regression models. RESULTS: The sample included 5,057 patients, of whom 21.3% received platinum based chemotherapy. Patients receiving platinum based chemotherapy were more likely to be younger and male with less comorbidity than those not receiving any chemotherapy. During the first year after diagnosis the patients who received platinum based chemotherapy had a higher risk of a thromboembolic event (19.8% vs 11.6%, AHR 1.43, 95% CI 1.17-1.75) compared to those who did not receive chemotherapy. The likelihood of having a thromboembolic outcome was similar whether platinum chemotherapy was cisplatin based (21.1%, AHR 1.56, 95% CI 1.22-2.00) or carboplatin based (18.9%, AHR 1.35, 95% CI 1.07-1.71). During years 2 to 5 after diagnosis there was no significant association between platinum chemotherapy and the risk of thromboembolic events. The risk of nonthromboembolic vascular events was not increased with platinum chemotherapy in either period. CONCLUSIONS: Patients receiving platinum based chemotherapy were at higher risk for thromboembolism but not other vascular events, particularly in the first year after diagnosis. This risk of thromboembolism is similar for cisplatin and carboplatin.


Assuntos
Antineoplásicos/efeitos adversos , Carboplatina/efeitos adversos , Cisplatino/efeitos adversos , Neoplasias da Bexiga Urinária/tratamento farmacológico , Doenças Vasculares/induzido quimicamente , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Risco , Tromboembolia/induzido quimicamente
5.
Am Heart J ; 169(1): 78-85.e4, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25497251

RESUMO

BACKGROUND: Stroke is a common and important adverse event after acute myocardial infarction (AMI) in the elderly. It is unclear whether the risk of stroke after AMI has changed with improvements in treatments and outcomes for AMI in the last decade. METHODS: To assess trends in risk of stroke after AMI, we used a national sample of Medicare data to identify Fee-for-Service patients (n = 2,305,441) aged ≥65 years who were discharged alive after hospitalization for AMI from 1999 to 2010. RESULTS: We identified 57,848 subsequent hospitalizations for ischemic stroke and 4,412 hospitalizations for hemorrhagic stroke within 1 year after AMI. The 1-year rate of ischemic stroke decreased from 3.4% (95% CI 3.3%-3.4%) to 2.6% (2.5%-2.7%; P < .001). The risk-adjusted annual decline was 3% (hazard ratio, 0.97; [0.97-0.98]) and was similar across all age and sex-race groups. The rate of hemorrhagic stroke remained stable at 0.2% and did not differ by subgroups. The 30-day mortality for patients admitted with ischemic stroke after AMI decreased from 19.9% (18.8%-20.9%) to 18.3% (17.1%-19.6%) and from 48.3% (43.0%-53.6%) to 45.7% (40.3%-51.2%) for those admitted with hemorrhagic stroke. We observed a decrease in 1-year mortality from 37.8% (36.5%-39.1%) to 35.3% (33.8%-36.8%) for ischemic stroke and from 66.6% (61.4%-71.5%) to 60.6% (55.1%-65.9%) for hemorrhagic stroke. CONCLUSIONS: From 1999 to 2010, the 1-year risk for ischemic stroke after AMI declined, whereas the risk of hemorrhagic stroke remained unchanged. However, 30-day and 1-year mortality continued to be high.


Assuntos
Hemorragia Cerebral/epidemiologia , Medicare , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Hemorragia Cerebral/mortalidade , Feminino , Hospitalização/tendências , Humanos , Masculino , Infarto do Miocárdio/terapia , Acidente Vascular Cerebral/mortalidade , Estados Unidos
6.
Circulation ; 130(19): 1730-48, 2014 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-25366837

RESUMO

Education, justification, and optimization are the cornerstones to enhancing the radiation safety of medical imaging. Education regarding the benefits and risks of imaging and the principles of radiation safety is required for all clinicians in order for them to be able to use imaging optimally. Empowering patients with knowledge of the benefits and risks of imaging will facilitate their meaningful participation in decisions related to their health care, which is necessary to achieve patient-centered care. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. Finally, the continually expanding repertoire of techniques that allow high-quality imaging with lower radiation exposure should be used when available to achieve safer imaging. The implementation of these strategies in practice is necessary to achieve high-quality, patient-centered imaging and will require a shared effort and investment by all stakeholders, including physicians, patients, national scientific and educational organizations, politicians, and industry.


Assuntos
American Heart Association , Cardiologia/normas , Doenças Cardiovasculares/diagnóstico por imagem , Doses de Radiação , Lesões por Radiação/prevenção & controle , Cardiologia/educação , Educação Médica/normas , Humanos , Radiografia , Estados Unidos
7.
Am J Manag Care ; 20(8): 659-65, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25295680

RESUMO

OBJECTIVES: CHARISMA was a landmark randomized clinical trial that failed to demonstrate a benefit of dual antiplatelet therapy (DAPT) over aspirin alone for preventing cardiovascular events. However, subgroup analyses of the trial found fewer major adverse cardiovascular events (MACEs) for patients with established cardiovascular disease but more MACEs for patients with multiple risk factors without established cardiovascular disease. Our objective was to examine DAPT use in contemporary clinical practice after publication of CHARISMA results. STUDY DESIGN: Retrospective analysis of a large clinical registry of outpatient cardiovascular visits to over 1000 physicians that collected data on patient clinical history, symptoms, vital signs, and medications. METHODS: Clinical characteristics and prescription rates of aspirin and clopidogrel were compared for patients with established cardiovascular disease and for patients with only multiple cardiovascular risk factors. Prescription of DAPT by calendar quarter was evaluated from 2008 to 2011 using multivariable Poisson regression models. RESULTS: Of 167,839 patients with established cardiovascular disease, 20.5% were prescribed both aspirin and clopidogrel. Of 20,478 patients with multiple risk factors but no known cardiovascular disease, 3.5% were prescribed both aspirin and clopidogrel. Across 14 calendar quarters, prescription rates of DAPT did not change significantly for patients with established CVD but decreased for patients with multiple risk factors with an incidence rate ratio of 0.77. CONCLUSIONS: Use of DAPT is modest in patients with established cardiovascular disease, for whom the CHARISMA trial suggested decreased MACEs, and prescription rates have remained stable over time. Use of DAPT in patients with multiple risk factors only, for whom CHARISMA suggested that DAPT may lead to increased MACE, was low and decreased over time.


Assuntos
Doenças Cardiovasculares/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Aspirina/administração & dosagem , Aspirina/uso terapêutico , Clopidogrel , Quimioterapia Combinada , Feminino , Humanos , Masculino , Inibidores da Agregação de Plaquetas/administração & dosagem , Estudos Retrospectivos , Fatores de Risco , Prevenção Secundária/métodos , Prevenção Secundária/estatística & dados numéricos , Ticlopidina/administração & dosagem , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico
10.
J Am Heart Assoc ; 3(5): e001197, 2014 Sep 23.
Artigo em Inglês | MEDLINE | ID: mdl-25249298

RESUMO

BACKGROUND: There are few data characterizing temporal changes in hospitalization for recurrent acute myocardial infarction (AMI) after AMI. METHODS AND RESULTS: Using a national sample of 2 305 441 Medicare beneficiaries hospitalized for AMI from 1999 to 2010, we evaluated changes in the incidence of 1-year recurrent AMI hospitalization and mortality using Cox proportional hazards models. The observed recurrent AMI hospitalization rate declined from 12.1% (95% CI 11.9 to 12.2) in 1999 to 8.9% (95% CI 8.8 to 9.1) in 2010, a relative decline of 26.4%. The observed recurrent AMI hospitalization rate declined by a relative 27.7% in whites, from 11.9% (95% CI 11.8 to 12.1) to 8.6% (95% CI 8.5 to 8.8) versus a relative decline in blacks of 13.6% from 13.2% (95% CI 12.6 to 13.8) to 11.4% (95% CI 10.9 to 12.0). The risk-adjusted rate of annual decline in recurrent AMI hospitalizations was 4.1% (HR 0.959; 95% CI 0.958 to 0.961), and whites experienced a higher rate of decline (HR 0.957, 95% CI 0.956 to 0.959) than blacks (HR 0.974, 95% CI 0.970 to 0.979).The overall, observed 1-year mortality rate after hospitalization for recurrent AMI declined from 32.4% in 1999 to 29.7% in 2010, a relative decline of 8.3% (P<0.05). In adjusted analyses, 1-year mortality after recurrent AMI hospitalization declined 1.8% per year (HR, 0.982; 95% CI 0.980 to 0.985). CONCLUSIONS: In a national sample of Medicare beneficiaries hospitalized for AMI from 1999 to 2010, hospitalization for recurrent AMI decreased, as did subsequent mortality, albeit to a lesser extent. The risk of recurrent AMI hospitalization declined less in black patients than in whites, increasing observed racial disparities by the end of the study period.


Assuntos
Causas de Morte , Mortalidade Hospitalar/tendências , Hospitalização/estatística & dados numéricos , Medicare/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Hospitalização/tendências , Humanos , Masculino , Medicare/economia , Infarto do Miocárdio/diagnóstico , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Taxa de Sobrevida , Fatores de Tempo , Estados Unidos
11.
Breast Cancer Res Treat ; 146(2): 411-9, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24951268

RESUMO

To evaluate how often trastuzumab therapy is ended early (i.e., early discontinuation) and how cardiovascular events and early discontinuation affect survival among older women with breast cancer. A population-based cohort of female Medicare beneficiaries with stage I-III breast cancer in 2005-2009 who received trastuzumab was assembled and followed through 2011. Completed trastuzumab treatment was defined as ≥11 months of continuous trastuzumab treatments with no delay between trastuzumab treatments >45 days. We identified trastuzumab-associated cardiovascular events as those occurring within 45 days before or after the last trastuzumab treatment. Using Cox proportional hazard models, we examined the association between early discontinuation of trastuzumab and cardiovascular events on all-cause mortality. Our cohort consisted of 585 women (mean age: 71.6 years). Approximately 41 % of women discontinued trastuzumab therapy early. Patients with early discontinuation of trastuzumab were more likely to have heart failure /cardiomyopathy, atrial fibrillation, and other cardiovascular events than women who completed trastuzumab. Cardiovascular events were strongly associated with an increased risk of all-cause mortality [adjusted hazard ratio (AHR) 3.54; 95 % confidence interval (CI) 1.87 to 6.68]. Women with early discontinuation of trastuzumab had a non-significant increase in risk of all-cause mortality (AHR: 1.74; 95 % CI 0.94 to 3.23), compared to women who completed trastuzumab. Early trastuzumab discontinuation was common among older patients, and often associated with adverse cardiovascular events. Development of cardiovascular events was associated with a higher mortality risk than early trastuzumab discontinuation, implying that reducing cardiovascular complications from trastuzumab therapy could likely have a substantive impact on overall survival in this population.


Assuntos
Neoplasias da Mama/epidemiologia , Doenças Cardiovasculares/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados/uso terapêutico , Antineoplásicos/uso terapêutico , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/mortalidade , Doenças Cardiovasculares/mortalidade , Causas de Morte , Estudos de Coortes , Comorbidade , Feminino , Humanos , Razão de Chances , Avaliação de Resultados da Assistência ao Paciente , Fatores de Risco , Programa de SEER , Trastuzumab , Estados Unidos/epidemiologia
12.
J Am Med Inform Assoc ; 21(4): 596-601, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24821738

RESUMO

The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings.


Assuntos
Redes Comunitárias/organização & administração , Redes de Comunicação de Computadores , Registros Eletrônicos de Saúde/organização & administração , Assistência Centrada no Paciente , Assistência Ambulatorial/organização & administração , Humanos , Disseminação de Informação , Registro Médico Coordenado , Estados Unidos
13.
J Am Heart Assoc ; 3(1): e000472, 2014 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-24584736

RESUMO

BACKGROUND: Adjuvant trastuzumab improves survival for women with human epidermal growth factor receptor 2-positive breast cancer, but increases risk for heart failure (HF) and cardiomyopathy (CM). However, clinical trials may underestimate HF/CM risk because they enroll younger subjects with fewer cardiac risk factors. We sought to develop a clinical risk score that identifies older women with breast cancer who are at higher risk of HF or CM after trastuzumab. METHODS AND RESULTS: Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified women with breast cancer who received adjuvant trastuzumab. Using a split-sample design, we used a proportional hazards model to identify candidate predictors of HF/CM in a derivation cohort. A risk score was constructed using regression coefficients, and HF/CM rates were calculated in the validation cohort. The sample consisted of 1664 older women (mean age 73.6 years) with 3-year HF/CM rate of 19.1%. A risk score consisting of age, adjuvant chemotherapy, coronary artery disease, atrial fibrillation or flutter, diabetes mellitus, hypertension, and renal failure was able to classify HF/CM risk into low (0 to 3 points), medium (4 to 5 points), and high (≥6 points) risk strata with 3-year rates of 16.2%, 26.0%, and 39.5%, respectively. CONCLUSIONS: A 7-factor risk score was able to stratify 3-year risk of HF/CM after trastuzumab between the lowest and highest risk groups by more than 2-fold in a Medicare population. These findings will inform future research aimed at further developing a clinical risk score for HF/CM for breast cancer patients of all ages.


Assuntos
Insuficiência Cardíaca , Medição de Risco , Feminino , Humanos
14.
J Card Fail ; 20(2): 65-90, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24556531
15.
J Nucl Cardiol ; 21(1): 192-220, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24374980

RESUMO

The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1-9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.


Assuntos
Cardiologia/normas , Angiografia Coronária/normas , Isquemia Miocárdica/terapia , Adulto , Idoso , Algoritmos , American Heart Association , Tomada de Decisões , Exercício , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Segurança do Paciente , Medição de Risco , Sociedades Médicas , Resultado do Tratamento , Estados Unidos
16.
Circulation ; 128(24): 2577-84, 2013 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-24190958

RESUMO

BACKGROUND: Previous studies have reported conflicting findings regarding how the incidence of heart failure (HF) after acute myocardial infarction (AMI) has changed over time, and data on contemporary national trends are sparse. METHODS AND RESULTS: Using a complete national sample of 2 789 943 AMI hospitalizations of Medicare fee-for-service beneficiaries from 1998 through 2010, we evaluated annual changes in the incidence of subsequent HF hospitalization and mortality using Poisson and survival analysis models. The number of patients hospitalized for HF within 1 year after AMI declined modestly from 16.1 per 100 person-years in 1998 to 14.2 per 100 person years in 2010 (P<0.001). After adjusting for demographic factors, a relative 14.6% decline for HF hospitalizations after AMI was observed over the study period (incidence risk ratio, 0.854; 95% confidence interval, 0.809-0.901). Unadjusted 1-year mortality following HF hospitalization after AMI was 44.4% in 1998, which decreased to 43.2% in 2004 to 2005, but then increased to 45.5% by 2010. After adjusting for demographic factors and clinical comorbidities, this represented a 2.4% relative annual decline (hazard ratio, 0.976; 95% confidence interval, 0.974-0.978) from 1998 to 2007, but a 5.1% relative annual increase from 2007 to 2010 (hazard ratio, 1.051; 95% confidence interval, 1.039-1.064). CONCLUSIONS: In a national sample of Medicare beneficiaries, HF hospitalization after AMI decreased from 1998 to 2010, which may indicate improvements in the management of AMI. In contrast, survival after HF following AMI remains poor, and has worsened from 2007 to 2010, demonstrating that challenges still remain for the treatment of this high-risk condition after AMI.


Assuntos
Insuficiência Cardíaca/etiologia , Hospitalização/estatística & dados numéricos , Hospitalização/tendências , Medicare/estatística & dados numéricos , Medicare/tendências , Infarto do Miocárdio/complicações , Idoso , Idoso de 80 Anos ou mais , Gerenciamento Clínico , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/tendências , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Humanos , Incidência , Masculino , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Estados Unidos/epidemiologia
17.
Catheter Cardiovasc Interv ; 82(7): 1091-105, 2013 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-23703793

RESUMO

OBJECTIVES: Identifying the distributions and determinants of fluoroscopy time for invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI). BACKGROUND: ICA and PCI are significant contributors to radiation exposure from medical imaging in the US. Fluoroscopy time is a potentially modifiable determinant of radiation exposure for these procedures, but has not been well characterized in contemporary practice. METHODS: We evaluated the distribution of fluoroscopy time in patients undergoing ICA and/or PCI in the CathPCI Registry(®) , stratifying patients by numerous clinical scenarios. Hierarchical models were used to determine patient, procedure, operator and hospital-level factors associated with fluoroscopy time for these procedures. RESULTS: Our study included a total of 3,295,348 ICA and PCI procedures performed by 9,600 operators from January 2005 through June 2009. There was wide variation in fluoroscopy times for these procedures with median [IQR] fluoroscopy times of 2.6 [1.7-4.5] minutes for ICA, 6.7 [4.2-10.8] minutes for ICA in patients with prior coronary artery bypass grafting (CABG), 10.1 [6.0-17.4] minutes for PCI, 10.7 [7.0-16.9] minutes for PCI with ICA, and 16.0 [10.6-24.0] minutes for PCI and ICA in patients with prior CABG. Prolonged fluoroscopy times (>30 minutes) were rare for ICA, but occurred in 6.7% of PCIs and 14.7% of PCIs in patients with prior CABG. After accounting for patient characteristics and procedure complexity, operator and hospital-level factors explained nearly 20% of the variation in fluoroscopy time. CONCLUSIONS: Fluoroscopy times vary widely during ICA and PCI with operator and hospital-level factors contributing substantially to these differences. A better understanding of potentially modifiable sources of this variation will elucidate opportunities for enhancing the radiation safety of these procedures.


Assuntos
Angiografia Coronária , Intervenção Coronária Percutânea , Radiografia Intervencionista , Adulto , Idoso , Competência Clínica , Angiografia Coronária/efeitos adversos , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Intervenção Coronária Percutânea/efeitos adversos , Valor Preditivo dos Testes , Doses de Radiação , Lesões por Radiação/etiologia , Lesões por Radiação/prevenção & controle , Radiografia Intervencionista/efeitos adversos , Radiografia Intervencionista/métodos , Sistema de Registros , Fatores de Risco , Fatores de Tempo
18.
J Am Coll Cardiol ; 61(10): 1078-88, 2013 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-23473413

RESUMO

OBJECTIVES: This study sought to analyze recent trends over time in heart failure (HF) hospital stay rates, length of stay (LOS), and in-hospital mortality by age groups with a large national dataset of U.S. hospital discharges. BACKGROUND: Heart failure hospital stay rates, LOS, and mortality have fallen over the past decade for older Medicare beneficiaries, but whether this holds true for younger adults is unknown. METHODS: From the National Inpatient Sample, we calculated HF hospital stay rates, LOS, and in-hospital mortality from 2001 to 2009 with survey data analysis techniques. RESULTS: Hospital stays (n = 1,686,089) with a primary discharge diagnosis of HF were identified from National Inpatient Sample data between 2001 and 2009. The overall national hospital stay rate decreased from 633 to 463 hospital stays/100,000 persons, (-26.9%, p-for-trend <0.001). However, statistically significant declines (p < 0.001) were only observed for patients 55 to 64 years of age (-36.5%) 65 to 74 years (-37.4%), and ≥ 75 years (-28.3%) but not for patients 18 to 44 years of age (-12.8%, p = 0.57) or 45 to 55 years (-16.2%, p = 0.04). Statistically significant declines in LOS were only observed for patients 65 years of age and older. Overall in-hospital mortality fell from 4.5% to 3.3%, a relative decline of -27.4%, (p-for-trend <0.001), but patients 18 to 44 years of age did not exhibit a significant decline (-8.1%, p-for-trend = 0.18). In secondary analyses significant declines in HF hospital stay rate over time were observed for white men, white women, and black women but not for black men (-9.5%, p-for-trend = 0.43). CONCLUSIONS: Younger patients have not experienced comparable declines in HF hospital stay, LOS, and in-hospital mortality as older patients. Black men remain a vulnerable population for HF hospital stay.


Assuntos
Insuficiência Cardíaca/epidemiologia , Mortalidade Hospitalar/tendências , Tempo de Internação/tendências , Adolescente , Adulto , Grupo com Ancestrais do Continente Africano/estatística & dados numéricos , Distribuição por Idade , Idoso , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Inquéritos Epidemiológicos , Humanos , Seguro Saúde , Tempo de Internação/estatística & dados numéricos , Masculino , Medicaid , Medicare , Pessoa de Meia-Idade , Insuficiência Renal/epidemiologia , Insuficiência Respiratória/epidemiologia , Distribuição por Sexo , Choque/epidemiologia , Estados Unidos/epidemiologia , Adulto Jovem
19.
JAMA ; 309(6): 587-93, 2013 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-23403683

RESUMO

IMPORTANCE: The Centers for Medicare & Medicaid Services publicly reports hospital 30-day, all-cause, risk-standardized mortality rates (RSMRs) and 30-day, all-cause, risk-standardized readmission rates (RSRRs) for acute myocardial infarction, heart failure, and pneumonia. The evaluation of hospital performance as measured by RSMRs and RSRRs has not been well characterized. OBJECTIVE: To determine the relationship between hospital RSMRs and RSRRs overall and within subgroups defined by hospital characteristics. DESIGN, SETTING, AND PARTICIPANTS: We studied Medicare fee-for-service beneficiaries discharged with acute myocardial infarction, heart failure, or pneumonia between July 1, 2005, and June 30, 2008 (4506 hospitals for acute myocardial infarction, 4767 hospitals for heart failure, and 4811 hospitals for pneumonia). We quantified the correlation between hospital RSMRs and RSRRs using weighted linear correlation; evaluated correlations in groups defined by hospital characteristics; and determined the proportion of hospitals with better and worse performance on both measures. MAIN OUTCOME MEASURES: Hospital 30-day RSMRs and RSRRs. RESULTS: Mean RSMRs and RSRRs, respectively, were 16.60% and 19.94% for acute myocardial infarction, 11.17% and 24.56% for heart failure, and 11.64% and 18.22% for pneumonia. The correlations between RSMRs and RSRRs were 0.03 (95% CI, -0.002 to 0.06) for acute myocardial infarction, -0.17 (95% CI, -0.20 to -0.14) for heart failure, and 0.002 (95% CI, -0.03 to 0.03) for pneumonia. The results were similar for subgroups defined by hospital characteristics. Although there was a significant negative linear relationship between RSMRs and RSRRs for heart failure, the shared variance between them was only 2.9% (r2 = 0.029), with the correlation most prominent for hospitals with RSMR <11%. CONCLUSION AND RELEVANCE: Risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.


Assuntos
Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar/tendências , Hospitais/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Idoso , Estudos de Coortes , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/terapia , Hospitais/classificação , Humanos , Masculino , Medicare/estatística & dados numéricos , Mortalidade/tendências , Infarto do Miocárdio/terapia , Alta do Paciente/estatística & dados numéricos , Pneumonia/terapia , Indicadores de Qualidade em Assistência à Saúde , Risco Ajustado , Estados Unidos
20.
J Am Coll Cardiol ; 60(24): 2504-12, 2012 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-23158536

RESUMO

OBJECTIVES: The purpose of this study was to estimate heart failure (HF) and cardiomyopathy (CM) rates after adjuvant trastuzumab therapy and chemotherapy in a population of older women with early-stage breast cancer. BACKGROUND: Newer biologic therapies for breast cancer such as trastuzumab have been reported to increase HF and CM in clinical trials, especially in combination with anthracycline chemotherapy. Elderly patients, however, typically have a higher prevalence of cardiovascular risk factors and have been underrepresented in trastuzumab clinical trials. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data from 2000 through 2007, we identified women 67 to 94 years of age with early-stage breast cancer. We calculated 3-year incidence rates of HF or CM for the following mutually exclusive treatment groups: trastuzumab (with or without nonanthracycline chemotherapy), anthracycline plus trastuzumab, anthracycline (without trastuzumab and with or without nonanthracycline chemotherapy), other nonanthracycline chemotherapy, or no adjuvant chemotherapy or trastuzumab therapy. HF or CM events were ascertained from administrative Medicare claims. Poisson regression was used to quantify risk of HF or CM, adjusting for sociodemographic factors, cancer characteristics, and cardiovascular conditions. RESULTS: We identified 45,537 older women (mean age: 76.2 years, standard deviation: 6.2 years) with early-stage breast cancer. Adjusted 3-year HF or CM incidence rates were higher for patients receiving trastuzumab (32.1 per 100 patients) and anthracycline plus trastuzumab (41.9 per 100 patients) compared with no adjuvant therapy (18.1 per 100 patients, p < 0.001). Adding trastuzumab to anthracycline therapy added 12.1, 17.9, and 21.7 HF or CM events per 100 patients over 1, 2, and 3 years of follow-up, respectively. CONCLUSIONS: HF or CM are common complications after trastuzumab therapy for older women, with higher rates than those reported from clinical trials.


Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Antineoplásicos/efeitos adversos , Neoplasias da Mama/tratamento farmacológico , Cardiomiopatias/induzido quimicamente , Insuficiência Cardíaca/induzido quimicamente , Idoso , Idoso de 80 Anos ou mais , Cardiomiopatias/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Humanos , Incidência , Programa de SEER , Trastuzumab
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