Correlates of major complications or death in patients admitted to the hospital with congestive heart failure.

BACKGROUND: When triaging a patient who has heart failure, the physician must estimate the patient's shortterm risk of a major complication or death. METHODS: Prospective cohort study of 435 patients admitted nonelectively to an urban university hospital between February 2, 1993, and February 2, 1994, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph. RESULTS: Major adverse events occurred in 18% of patients who had ejection fractions less than 0.50, 16% of those with ejection fractions of 0.50 or more, and 19% of those with previous heart failure, ejection fractions of 0.50 or more, and no significant valvular disease. In multivariate analyses of all patients, independent correlates (P < or = .01) of major complications or death during hospitalization were initial systolic blood pressure of 90 mm Hg or less (adjusted odds ratio [OR], 5.5; 95% confidence interval [CI], 1.7-17.1), respiratory rate more than 30 breaths per minute on admission to the hospital (OR, 4.6; 95% CI, 2.4-8.8), serum sodium level of 135 mmol/L or less (OR, 2.2; 95% CI, 1.3-4.0), and ST-T wave changes on initial electrocardiogram neither known to be old nor attributable to digoxin (OR, 5.1; 95% CI, 2.9-8.9). However, even patients with none of these 4 risk factors had a 6% rate of a major complication or death. CONCLUSIONS: No truly low-risk group existed. Patients without hypotension, tachypnea, hyponatremia, or electrocardiographic changes of ischemia represent the best candidates for triage to less intensely monitored settings, but clinical judgment is essential.

Diabetes in the African-American Medicare population. Morbidity, quality of care, and resource utilization.

OBJECTIVE: To determine whether African-American Medicare recipients with diabetes are at increased risk for morbidity, poor quality of care, and high resource utilization. RESEARCH DESIGN AND METHODS: We analyzed 1,376 patients with diabetes who were > or = 65 years of age and in the 1993 Medicare Current Beneficiary Survey. Morbidity measures were the Katz Index of Activities of Daily Living, Instrumental Activities of Daily Living, overall health perception, Charlson Comorbidity Index score, and diabetic complications. Quality of care standards were glycosylated hemoglobin measurements, ophthalmological visits, lipid testing, mammography, influenza vaccination, readmission within 30 days of hospital discharge, and outpatient visits within 4 weeks of hospital discharge. We stratified Medicare reimbursement by type of service and adjusted for sex, education, and age in multivariable analyses. RESULTS: Compared with white patients, African-American patients had worse health perception and lower quality of care. They were more likely to visit the emergency department and had fewer physician visits per year. African-Americans had higher reimbursement for home health services, but total reimbursement was similar after case-mix adjustment. CONCLUSIONS: Improved access to preventive care for older African-Americans with diabetes may improve health perception and use of the emergency department. The potential effect on total reimbursement is unclear. Future policy interventions to improve quality of care among Medicare patients with diabetes should especially target African-Americans.

Barriers to providing diabetes care in community health centers.

OBJECTIVE: We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS: In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS: Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS: Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.

Carboxy-substituted cinnamides: a novel series of potent, orally active LTB4 receptor antagonists.

A series of carboxy-substituted cinnamides were investigated as antagonists of the human cell surface leukotriene B4 (LTB4) receptor. Binding was determined through measurement of [3H]LTB4 displacement from human neutrophils. Receptor antagonism was confirmed through a functional assay, which measures inhibition of Ca2+ release in human neutrophils. Potent antagonists were discovered through optimization of a random screening hit, a p-(alpha-methylbenzyloxy)cinnamide, having low-micromolar activity. Substantial improvement of in vitro potency was realized by the attachment of a carboxylic acid moiety to the cinnamide phenyl ring through a flexible tether, leading to identification of compounds with low-nanomolar potency. Modification of the benzyloxy substituent, either through ortho-substitution on the benzyloxy phenyl group or through replacement of the ether oxygen with a methylene or sulfur atom, produced achiral antagonists of equal or greater potency. The most potent compounds in vitro were assayed for oral activity using the arachidonic acid-induced mouse ear edema model of inflammation. Several compounds in this series were found to significantly inhibit edema formation and myeloperoxidase activity in this model up to 17 h after oral administration. Representatives of this series have been shown to be potent and long-acting orally active inhibitors of the LTB4 receptor.

Correlates of early hospital readmission or death in patients with congestive heart failure.

Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of < or = 100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients.

Differences among geriatricians, general internists, and cardiologists in the care of patients with heart failure: a cautionary tale of quality assessment.

OBJECTIVES: To describe differences in the characteristics, processes of care, and resource utilization of patients with heart failure cared for by geriatricians, general internists, cardiologists, and combinations of physicians. DESIGN: A retrospective cohort study. SETTING: An urban academic medical center. PARTICIPANTS: A total of 439 outpatients with a billing diagnosis of heart failure or cardiomyopathy who were treated by geriatricians, general internists, cardiologists, and combinations of physicians. MEASUREMENTS: Demographic and clinical characteristics, medication use, diagnostic testing, hospitalizations, and inpatient and outpatient costs were measured. RESULTS: Compared with patients of cardiologists, patients cared for by geriatricians were older, more likely to have hypertension, diastolic dysfunction, and high comorbidity, and less likely to undergo echocardiography, cardiac catheterization, and electrocardiography. Use of angiotensin-converting enzyme inhibitors was similar among patients with reduced systolic function. Patients cared for by geriatricians had the same costs, rates of hospitalization, and likelihood of being symptomatic as patients of cardiologists. CONCLUSIONS: The processes of care for patients with heart failure seen solely by geriatricians differ from those for patients seen by other physicians, but the case-mix also varies. Assessment of left ventricular function by geriatricians probably needs to be increased. However, although they were older and had more comorbidity, patients of geriatricians had total costs and symptomatology similar to those of patients of cardiologists. Future work is needed to identify those patients most likely to benefit from treatment by geriatricians and to determine how care can be optimally coordinated among different types of physicians and health providers.

Variations in the care of elderly persons with diabetes among endocrinologists, general internists, and geriatricians.

BACKGROUND: The American Diabetes Association (ADA) clinical practice recommendations have been widely promoted, but they lack a geriatric-specific approach to care. We aimed to determine the style of care that endocrinologists, general internists, and geriatricians provided to their elderly patients with diabetes and to what extent these medical professionals adhered to the ADA standards. METHODS: We performed a retrospective cohort study of a stratified sample of 531 diabetic patients aged 65 years and older from the endocrinology, general internal medicine, and geriatrics clinics of an urban academic medical center. RESULTS: Patients of geriatricians were older, had higher comorbidity, and were more likely to be demented. The average number of diabetic complications was similar across the specialties, although patients of endocrinologists had higher prevalence of neuropathy and retinopathy compared with patients of geriatricians. Endocrinologists were more likely to use insulin, multiple types of insulin, and combined oral hypoglycemic and insulin therapies. Most patients had hemoglobin A1c measured, and average values were similarly high across specialties at 8.6%. Blood pressures were above 130/85 mm Hg in 85% of the patients. All specialties rarely measured urine microalbumin; geriatricians seldom performed fractionated cholesterol tests, and ophthalmology visits occurred in only half of the patients. CONCLUSION: Endocrinologists had the most aggressive, complex diabetes treatment regimens, although geriatricians had older patients with more dementia and lower prevalence of microvascular complications. Average hemoglobin A1c levels and blood pressures were higher than recommended among patients of all three specialties. Screening for diabetic complications and hyperlipidemia was lower than advised.

Emergency department utilization by noninstitutionalized elders.

OBJECTIVES: To the best of the authors' knowledge, no nationally representative, population-based study has characterized the proportion of elders using the emergency department (ED) and factors associated with ED use by elders. This article describes the proportion of elder Medicare beneficiaries using the ED and identifies attributes associated with elder ED users as compared with nonusers. METHODS: The 1993 Medicare Current Beneficiary Survey was used, a national, population-based, cross-sectional survey of Medicare beneficiaries linked with Medicare claims data. The study population was limited to 9,784 noninstitutionalized individuals aged 66 years or older. The Andersen model of health service utilization was used, which explains variation in ED use through a combination of predisposing (demographic and social), enabling (access to care), and need (comorbidity and health status) characteristics. RESULTS: Eighteen percent of the sample used the ED at least once during 1993. Univariate analysis showed ED users were older; were less educated and lived alone; had lower income and higher Charlson Comorbidity Index scores; and were less satisfied with their ability to access care than nonusers (p < 0.01, chi-square). Logistic regression identified older age, less education, living alone, higher comorbidity scores, worse reported health, and increased difficulties with activities of daily living as factors associated with ED use (p < 0.05). Need characteristics predicted ED use with the greatest accuracy. CONCLUSIONS: The proportion of elder ED users is slightly higher than previously reported among Medicare beneficiaries. Need (comorbidity and health status) characteristics predict ED utilization with the greatest accuracy.

Appropriateness of medication selection for older persons in an urban academic emergency department.

OBJECTIVES: To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes. METHODS: The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy-nine percent of the patients were African-American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug-disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health-related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study. RESULTS: Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug-disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug-disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death. CONCLUSIONS: Suboptimal medication selection was fairly common and was associated with worse patient-reported health-related quality of life.

Health outcomes and managed care: discussing the hidden issues.

Too often the debate over health outcomes and managed care has glossed over a series of complex social, political, and ethical issues. Exciting advances in outcomes research have raised hopes for logical medical reform. However, science alone will not optimize our patients' health, since value judgements are necessary and integral parts of attempts to improve health outcomes within managed care organizations. Therefore, to form healthcare policy that is both fair and efficient, we must examine the fundamental values and ethical concerns that are imbedded in our efforts to shape care. We must openly discuss the hidden issues including: (1) trade-offs between standardization of care and provider-patient autonomy; (2) effects of financial incentives on physicians' professionalism; (3) opportunity costs inherent in the design of insurance plans; (4) responsibilities of managed care plans for the health of the public; (5) judicious and valid uses of data systems; and (6) the politics of uncertainty.

Developing a conceptual framework for understanding illness and attitudes in older, urban African Americans with diabetes.

PURPOSE: This study was conducted to better understand how older African Americans with diabetes view their illness, and to develop a conceptual framework for approaching their care. METHODS: Researchers conducted interviews of 19 African American patients 65 years or older who attended clinics at an urban academic medical center. The mean age of the patients was 73 years, 58% were female, 63% had a complication from diabetes, and 58% were taking insulin. Patients were asked open-ended questions about how diabetes affected their lives and their attitudes toward treatment. Data were analyzed through a grounded-theory perspective. RESULTS: Patients showed variation in the degree to which they believed that diabetes affected their lives and how aggressive they wished treatment to be. Themes included issues of quality of life, health beliefs, and the social context. Paradoxical, contradictory statements were common, expressing ambivalence and uncertainty regarding the effect of the illness and the treatment. CONCLUSIONS: Wide variation exists in the attitudes of older African Americans toward their diabetes and treatment. Patients frequently expressed ambivalence toward the care of their illness. Providers should explore these issues and help patients resolve their ambivalence if patient preferences are to be respected in the overall treatment plan.

Gender differences in 1-year survival and quality of life among patients admitted with congestive heart failure.

OBJECTIVES: Gender differences in 1-year survival and health-related quality of life (HRQOL) among patients admitted with heart failure were determined. METHODS: Subjects of this prospective cohort study were 435 patients admitted nonelectively between February 2, 1993 and February 2, 1994 to an urban university hospital with shortness of breath or fatigue and evidence of heart failure on admission chest radiograph. Survival was calculated among all patients, and health-related quality of life was calculated among 259 (68%) consenting participants as measured by the Medical Outcomes Study Short Form-36 and Short Form-36 Physical and Mental Component Summary scales. RESULTS: By 1 year, 106 (24%) patients had died, regardless of gender. Independent correlates of death were increasing Charlson Comorbidity Index score, initial serum sodium of 135 mmol/L or less, and white race. Among the 179 (90%) of 200 survivors who responded at all time points, health-related quality of life scores improved from admission but were still generally low, particularly among women. Even after adjusting for clinical and socioeconomic variables as well as baseline health-related quality-of-life scores, women still had less improvement at 1 year than men for the Physical Component Summary scale. Women rated the quality of inpatient care lower than men and also tended to rate the quality of follow-up outpatient care lower. CONCLUSIONS: One-year mortality was high and health-related quality of life was low in patients admitted with heart failure. Women had less improvement in physical health status and perceived their quality of care to be lower and thus may require interventions.

Factors contributing to the hospitalization of patients with congestive heart failure.

OBJECTIVES: This study identifies acute precipitants of hospitalization and evaluates utilization of angiotension-converting enzyme inhibitors in patients admitted with congestive heart failure. METHODS: Cross-sectional chart-review study was done of 435 patients admitted nonelectively from February 1993 to February 1994 to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure. RESULTS: The most common identifiable abnormalities associated with clinical deterioration prior to admission were acute anginal chest pain (33%), respiratory infection (16%), uncontrolled hypertension with initial systolic blood pressure > or = 180 mm Hg (15%), atrial arrhythmia with heart rate > or = 120 (8%), and noncompliance with medications (15%) or diet (6%); in 34% of patients, no clear cause could be identified. After exclusion of those who were already on a different vasodilator or who had relative contraindications, 18 (32%) of the patients with ejection fractions < or = 0.35 measured prior to admission were not taking an angiotensin-converting enzyme inhibitor on presentation to the hospital. CONCLUSIONS: Interventions to improve compliance, the control of hypertension, and the appropriate use of angiotensin-converting enzyme inhibitors may prevent many hospitalizations of heart-failure patients.

Specialty differences in the care of older patients with diabetes.

OBJECTIVES: To determine differences in health status, quality of care, and resource utilization among older diabetic Medicare patients cared for by endocrinologists, internists, family practitioners, and general practitioners. METHODS: The authors analyzed 1,637 patients with diabetes age 65 years or older in the 1994 Medicare Current Beneficiary Survey, a database that links patient surveys to 12 months of Medicare claims data. MEASURES: Measures of morbidity were Basic and Instrumental Activities of Daily Living, health perception, Charlson Comorbidity Index score, and diabetic complications. Quality of care markers were measurement of ophthalmologic visit, lipid testing, glycosylated hemoglobin measurement, mammography, influenza vaccination, early hospital readmission, outpatient follow-up, and patient satisfaction. Resource utilization included reimbursement, relative value units, physician and emergency department visits, and hospitalizations. Age, gender, race, and education were adjusted for in multivariable analyses. RESULTS: Compared with patients of family practitioners, patients of endocrinologists and internists had more comorbidity and diabetic complications but similar health perception and deficiencies in activities of daily living. The patients of endocrinologists also had higher utilization of ophthalmologic screening, lipid testing, and glycosylated hemoglobin measurement than the patients of generalist physicians, but similar rates of influenza vaccination. Patients of endocrinologists and internists had higher total reimbursement than those of family practitioners and general practitioners. Patient satisfaction was generally similar. CONCLUSIONS: Older diabetic patients of endocrinologists had higher utilization of diabetes-specific process of care measures and had similar functional status despite more diabetic complications. However, they received a more costly style of care than patients of family practitioners and general practitioners. Future work needs to explore the optimal coordination of care of diabetic patients among different health providers.