Smoking cessation strategies and evaluation.

The success of smoking cessation interventions appears to be most closely related to the amount of positive reinforcement that the smoker receives for not smoking (unpublished data). The goal of the clinic is to reinforce not smoking over the longest period of time. The program outlined focuses on helping the smoker who wants to stop smoking, it demands a minimal amount of time from the physician and it is self-supporting. If these guidelines are followed, the physician should find that helping the smokers who want help to stop smoking is a productive and rewarding experience.

Relation of saphenous vein graft obstruction to serum cholesterol levels.

OBJECTIVES: To determine the potential of lipid-lowering therapy to reduce saphenous vein graft obstruction, we retrospectively studied the association between graft obstruction and serum cholesterol levels. BACKGROUND: Atherosclerosis is the major cause of vein graft obstruction. Approximately 50% of grafts are occluded by 10 years after operation. It remains to be established whether lipid control affects long-term graft survival. METHODS: We carried out a retrospective review of all 284 patients who had undergone coronary artery bypass graft surgery at Juntendo University Hospital between 1976 and 1991 and met the following additional criteria: at least one saphenous vein graft, repeat coronary arteriography at some point after coronary artery bypass graft surgery and a serum cholesterol level > or = 200 mg/dl before operation. Saphenous vein graft obstruction rates were compared among three groups classified by serum cholesterol levels at follow-up arteriography: group I < 200 mg/dl; group II 200 to 239 mg/dl; group III > or = 240 mg/dl. A vein graft was considered obstructed if it was narrowed by > or = 70%. RESULTS: In group I, 88% of grafts were not obstructed 7 years after operation. The respective rates were 61% in group II and 57% in group III (p < 0.005). This relation was true for vein grafts to the left anterior descending and other coronary arteries. CONCLUSIONS: Lower serum cholesterol levels are associated with lower rates of vein graft obstruction for up to 7 years. This suggests that cholesterol-lowering therapy may improve long-term saphenous vein graft survival after coronary artery bypass surgery.

A comparison of two methods to recruit physicians to deliver smoking cessation interventions.

To address the problem of recruiting physicians to deliver smoking cessation interventions, Doctors Helping Smokers included a trial of physician recruitment strategies. In round 1 of Doctors Helping Smokers, three types of informational materials were mailed directly to 1110 family physicians. The physicians were asked to return a postcard if they were interested in participating in a 1-month trial of a smoking cessation intervention. Response did not differ among the three conditions; overall, 9.8% of physicians (95% confidence limits [CL], 8.0, 11.6) responded and 6.0% (95% CL, 4.6, 7.4) eventually participated in the intervention trial. The same procedure was repeated for round 2 of Doctors Helping Smokers with direct mailing to all general internists and cardiologists (n = 1108) on the mailing list of the Minnesota Medical Association. Five percent (95% CL, 3.7, 6.3) of the internists responded and 2.7% (95% CL, 1.7, 3.7) participated in the trial. Recruitment for round 3 made use of repeated face-to-face recruitment efforts at the physician's office through a managed-care organization that held contracts with the physician's clinic to provide care for its enrollees. Six months after the initiation of round 3, 59% (95% CL, 49%, 67%) of the 126 primary care physicians reported that they were giving their patients smoking cessation advice and completing the smoking intervention records. Eighteen months after the initiation of round 3, 56% (95% CL, 47%, 65%) of the 116 primary care physicians who remained in the practice reported continued activity in the project.

Evaluating the effectiveness of dyslipidemia control strategies.

While cost-effectiveness analyses of anti-hyperlipidemia programs featuring drug treatment suggest that the best use of public dollars is to delay treatment until an individual develops coronary heart disease, a comprehensive hyperlipidemia treatment policy must take a broader perspective. The high case-fatality rates of patients exhibiting first manifestations of coronary heart disease, the limited population impact of interventions aimed solely at high risk groups, the cost of testing to identify the high risk segment of the population, the social origins of the behavioral risk factors for coronary heart disease, and the perspective of the individual must also be considered. Available data suggest that the best public policy to control the burden of heart disease is one with two components: On the one hand, all individuals without clinically manifest heart disease would be encouraged to adopt healthy behaviors without an attempt to sort the population into 'high' and 'not high' risk groups. On the other hand, the risk factors of individuals who already have coronary heart disease would be treated aggressively with a case-management system of follow-up. The data that support this conclusion are presented in this paper.

Time trends in the prevalence of atherosclerosis: a population-based autopsy study.

PURPOSE: Mortality from coronary heart disease is declining but little is known about trends in the prevalence of atherosclerosis. Autopsy rates in Olmsted County, Minnesota, are higher than the national average, offering an opportunity to address this matter. In this study, we determined the prevalence of anatomic coronary disease among autopsied Olmsted County residents and examined the generalizability of these findings. SUBJECTS AND METHODS: Reports of the 2,562 autopsies performed between 1979 and 1994 on Olmsted County residents > or =20 years of age were reviewed for the presence of coronary disease. RESULTS: Among autopsied decedents less than 60 years old at death and among coroner's cases, the prevalence of anatomic coronary disease declined with time (P for trend = 0.05); no trend was detected among older persons or noncoroner's cases. By logistic regression analysis, the crude odds ratio ([OR] per 5 years) for the association between time and anatomic coronary disease was 0.94 (95% confidence interval [CI]: 0.86 to 1.03; P = 0.18]. Age, sex, and antemortem diagnosis of heart disease were also strongly related to the presence of disease. After adjustment for sex and antemortem diagnosis of heart disease, the prevalence of anatomic coronary disease decreased more in younger people than in older people (age 40 years: OR 0.43 [95% CI: 0.24 to 0.80]; age 60 years: OR 0.62 [95% CI: 0.45 to 0.87]; age 80 years: OR 0.89 [95% CI: 0.64 to 1.23]). CONCLUSION: The prevalence of anatomic coronary disease at autopsy decreased between 1979 and 1994, particularly among younger people, supporting the notion that the burden of coronary disease has shifted toward the elderly. These results suggest that the decreased incidence of coronary artery disease has contributed to the recent decrease in coronary mortality, particularly among younger people.

A population-based estimate of candidacy rates for the implantable cardioverter-defibrillator.

The implantable cardioverter-defibrillator (ICD) increases survival of patients who receive the device. However, candidacy rates have not been calculated for a defined population, and the potential effect of the device on the survival of all patients with heart disease has not been estimated. To make these calculations, medical records were reviewed for 1976 to 1988 in a population demographically similar to the white population of the United States. Definite and possible candidates were identified on the basis of American Heart Association/American College of Cardiology guidelines. Candidacy rates ranged from 3.3/100,000 (counting only definite candidates for the entire period) to 8.7/100,000 (counting definite and possible candidates after 1980). Extrapolated to the 1990 U.S. population, estimates ranged from 8,207 to 21,637 new candidates each year. During an average follow-up of 5 years, half of all deaths among candidates had the potential to be delayed by an ICD. In a similar population that has a death rate from heart disease of approximately 280/100,000, 0.6 to 1.6% of subjects have the potential to have their deaths delayed to some extent by an ICD.

Implementing nurse-based systems to provide American Indian women with breast and cervical cancer screening.

OBJECTIVE: To describe the factors critical to implementation of a nurse-based system to increase access for American Indian women to breast and cervical cancer screening. MATERIAL AND METHODS: We report the experience of 103 nurses at 40 clinics who were trained to use the nurse-based screening system. In addition, the critical elements are discussed in the context of one particularly successful site. RESULTS: Fifteen factors were identified as critical to the implementation of a nurse-based cancer screening process once a nurse had been trained to perform clinical breast examinations and collect Papanicolaou (Pap) test specimens: knowledge of benefit, skills, organization, adequate return, perceived patient demand, perceived effectiveness, legitimacy, confidence, commitment, adequate resources, a data-driven iterative approach to program implementation, an objective measure of quality, leadership, the passage of time, and a focus on delivering the service to the patient. For example, in one site that was particularly successful, the nurses, administrators, and other key health-care professionals contributed their respective resources to implement the screening program. The program was also supported by the lay community, the state board of nursing, and the state health department breast and cervical cancer control program. During the 3-year study period, the 103 nurses performed screening tests on 2,483 women, and only 18 of the Pap test specimens were unsatisfactory. CONCLUSION: Nurse-based systems designed to collect high-quality Pap test specimens and perform detailed clinical breast examinations can be implemented if the factors that are critical to implementation are identified and addressed.

Making "time" for preventive services.

Although the implementation of clinical preventive services is a high priority on the national agenda and physicians acknowledge the importance of these services, implementation rates remain far below the target years after the recommendations have been released. Physicians repeatedly report that the reason for not providing preventive services is that they do not have "time." In this article, we identify attributes of the health-services system that create this phenomenon. We present evidence that formal delivery systems for preventive services must be developed if the "time" problem is to be solved, and we review why preventive-services systems need to be integrated into the current health-services system. Finally, we list the attributes that we believe a preventive-services system must have if it is to be successful. The success of clinical trials of such systems indicates that our goals of preventive services can be achieved if all persons who have an investment in clinical preventive services commit themselves to developing and supporting these systems.

Effectiveness research and assessment of clinical outcome: a review of Federal Government and medical community involvement.

Because of their concern about the increasing costs of health care, industry and government contractors for health care will attempt to control health-care costs for the foreseeable future. New proposals for cost containment include those that are focused on cost alone--for example, expenditure limits--and those that propose to control costs by limiting medical interventions to those of known efficacy. This latter attempt has come to be known as "effectiveness research." Herein, we briefly review the history of quality assurance and cost-containment efforts in the United States, giving special attention to the current initiative based on effectiveness research. Although the effectiveness research initiative has shortcomings (for example, it will not provide guidance when data are not available), it seems to be superior to the current peer review system because it encourages the development of a knowledge base and deemphasizes punitive measures as a way to ensure quality and control costs. The Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) establishes a federal agency, the Agency for Health Care Policy and Research, within the Public Health Service to focus on effectiveness research.

The Rochester Coronary Heart Disease Project: effect of cigarette smoking, hypertension, diabetes, and steroidal estrogen use on coronary heart disease among 40- to 59-year-old women, 1960 through 1982.

A population-based case-control study of coronary heart disease (CHD) risk in young women attributable to cigarette smoking, hypertension, diabetes, and steroidal estrogen use was conducted among residents of Rochester, Minnesota. All newly diagnosed cases of CHD (sudden unexpected death [SUD], N = 18; myocardial infarction [MI], N = 90; and angina, N = 133) among female Rochester residents 40 to 59 years of age during the years 1960 through 1982 were identified, and two community control subjects were matched for age and duration of community medical record. The overall adjusted odds ratio (OR) for the association between steroidal estrogen use and definite CHD (MI and SUD) was 0.6 (95% confidence interval [CI] = 0.2 to 1.3). Smoking (OR = 5.1; 95% CI = 2.3 to 11.6), hypertension (OR = 4.8; 95% CI = 2.3 to 10.2), and diabetes (OR = 8.4; 95% CI = 1.6 to 44.5) were strong risk factors for CHD events. If considered causal, cigarette smoking accounted for 64% of all MIs and SUDs in the community, hypertension accounted for 45%, and diabetes accounted for 13%. Although steroidal estrogen exposure reduced CHD among these women by 14%, giving steroidal estrogens to all women in this age group might reduce the population rates of MI by as much as 45%.

Delivery rates for preventive services in 44 midwestern clinics.

OBJECTIVE: To determine the rates at which private primary-care clinics are recommending blood pressure and cholesterol measurement, smoking cessation, clinical breast examination, screening mammography, Papanicolaou testing, and influenza and pneumococcus immunizations. MATERIAL AND METHODS: We conducted a mail survey of 7,997 randomly selected patients from 44 primary-care clinics in and around Minneapolis-St. Paul, Minnesota, of whom 6,830 (85.4%) completed the questionnaire on preventive services delivery rates. The responses were analyzed statistically, including stratification by reason for the clinic visit. RESULTS: On the average, about two-thirds of the patients in each clinic reported being up-to-date on preventive services before their clinic visit; an exception was pneumococcus immunization (mean rate, 33%). Except for blood pressure and smoking cessation advice, less than 30% of patients who were not up-to-date on a preventive service were offered it if the clinic visit was for a reason other than a checkup or physical examination. For patients who said that they saw their physician for a checkup or physical examination, the rate was more than 50% only for Papanicolaou smear. In contrast, nearly all responding practitioners agreed that each of the eight preventive services was very important or important. CONCLUSION: Preventive services consensus goals are not being met, even for patients who report that their clinic visit was for a checkup or physical examination. This finding suggests that it may be necessary to develop clinical systems that support and enable the delivery of preventive services.

The Pine Ridge-Mayo National Aeronautics and Space Administration telemedicine project: program activities and participant reactions.

OBJECTIVE: To determine the response of participants to the Pine Ridge-Mayo National Aeronautics and Space Administration telemedicine project. DESIGN: We describe a 3-month demonstration project of medical education and clinical consultations conducted by means of satellite transmission. Postparticipation questionnaires and a postproject survey were used to assess the success of the activity. MATERIAL AND METHODS: Patients and employees at the Pine Ridge Indian Health Service Hospital in southwestern South Dakota and employees at Mayo Clinic Rochester participated in a telemedicine project, after which they completed exit surveys and a postproject questionnaire to ascertain the acceptability of this mode of health care. RESULTS: Almost all Pine Ridge and Mayo Clinic participants viewed the project as beneficial. The educational sessions received favorable evaluations, and almost two-thirds of the patients who completed evaluations thought the consultation had contributed to their medical care. More than 90% of the respondents from Pine Ridge and more than 85% of the respondents from Mayo Clinic Rochester said that they would recommend participation in this project to others. More than 90% of respondents from Pine Ridge and 80% of Mayo respondents agreed with the statement that the project should continue. CONCLUSION: These data suggest that a program of clinical consultation services, professional education, and patient education available by telemedicine might be viewed as beneficial.

Nicotine-replacement therapy with use of a transdermal nicotine patch--a randomized double-blind placebo-controlled trial.

The rate of smoking was significantly reduced in volunteer subjects by providing effective nicotine replacement, self-help material, and weekly visits with a nurse for 6 weeks. Nicotine-replacement therapy with a transdermal nicotine patch (Nicolan) almost doubled the 6-week smoking-cessation rate in comparison with that in a placebo group (77% versus 39%; P = 0.002) among subjects who were smoking at least 20 cigarettes per day at baseline. Although most subjects who used the active nicotine patches had skin reactions, the reactions were primarily mild. For use of both active and placebo patches, the level of patient compliance was high. Among subjects who continued to smoke, the use of cigarettes was decreased to less than 50% of the baseline smoking level in 7 of 7 with active nicotine patches and in 15 of 19 with placebo patches. Outcomes beyond 6 weeks showed a substantial relapse rate in both groups. Thus, when nicotine-replacement therapy is provided, a need exists for concurrent behavioral intervention and training for prevention of a relapse, neither of which was part of this protocol.

Validation of death certificate diagnosis of out-of-hospital coronary heart disease deaths in Olmsted County, Minnesota.

OBJECTIVE: To evaluate the validity of death certificate diagnosis of out-of-hospital (OOH) coronary heart disease (CHD) and sudden cardiac death (SCD) in Olmsted County, Minnesota, between 1981 and 1994. METHODS: In this review of the medical records, autopsy reports, and coroner's files, OOH deaths with heart disease as the underlying cause of death on the death certificate were classified into CHD (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 410-414) and non-CHD (other ICD-9-CM heart disease codes) deaths. A 10% random sample (n = 174) of these death certificates was reviewed by physicians, and published validation criteria were applied to classify these deaths into validated CHD or non-CHD categories. Sudden cardiac death was defined as validated CHD that occurred at an OOH location with less than 24 hours between symptom onset and death. RESULTS: The death certificate definition of OOH CHD death (ICD-9-CM codes 410-414) had high sensitivity and positive predictive value of 91% and 96%, respectively. The specificity and the negative predictive value were slightly lower at 86% and 72%, respectively. The sensitivity of death certificate diagnosis of CHD for validated SCD was 89%, and the positive predictive value was 77%. Using a more restrictive definition of SCD, that is, less than 1 hour between the onset of symptoms and death, the positive predictive value of CHD codes for SCD was lower at 52%. CONCLUSIONS: In Olmsted County, the positive predictive values of death certificate diagnosis for OOH CHD and SCD are high. Relying on death certificate diagnoses results in about 5% underestimation of the true CHD rates, whereas their use as a surrogate for SCD yields a 16% overestimation of the true SCD rates.

A program to increase breast and cervical cancer screening for Cambodian women in a midwestern community.

OBJECTIVE: To determine local screening rates for breast and cervical cancer screening among Cambodian women older than 50 years of age who had used the health-care system, to compare these rates with those for non-Cambodian women, to identify barriers to screening among Cambodians, and to implement community screening. MATERIAL AND METHODS: From review of medical records, cancer screening rates for 1 year among Cambodians (N = 57) were compared with rates for a matched non-Cambodian sample (N = 57). Southeast Asian focus groups identified barriers to screening as a basis for intervention. The intervention included community informational programs in the Cambodian language, group screening appointments, provision of transportation, use of female physicians and interpreters, and an informal clinic setting. Cancer screening rates were compared before and after the intervention. RESULTS: Initial screening rates for Cambodians were significantly lower than for the non-Cambodians. Expressed barriers included lack of knowledge about cancer, shyness at physical examination, lack of transportation, fear of a large, technical medical center, and individual appointments. After the intervention, community screening rates were almost 5 times higher than at baseline. CONCLUSION: The intervention was successful in overcoming organizational, economic, and cultural barriers to cancer screening among older Cambodian women in this setting.

The incidence and prevalence of congestive heart failure in Rochester, Minnesota.

Although congestive heart failure is a fairly common clinical syndrome and the societal costs associated with its care are high, relatively little is known about the incidence or prevalence of the condition in the community. Using the resources of the Rochester Epidemiology Project, we identified all 46 persons 0 through 74 years of age who had a new diagnosis of congestive heart failure during 1981 and all 113 persons with a prevalent diagnosis on Jan. 1, 1982, in the city of Rochester, Minnesota. After confirming the diagnosis in the medical record by using criteria similar to those in the Framingham study, we found the annual incidence of congestive heart failure to be 110 per 100,000 after adjusting for age. Incidence rates were higher among male than among female study subjects (157 versus 71 per 100,000). In both male and female subjects, the incidence generally increased with advancing age, reaching 1,618 per 100,000 and 981 per 100,000, respectively. Prevalence rates on Jan. 1, 1982, demonstrated similar patterns. Overall, the prevalence of congestive heart failure was higher among male than among female subjects (327 versus 214 per 100,000) and increased exponentially with advancing age, reaching almost 3% in both sexes. Survival after a diagnosis of congestive heart failure was extremely poor, with only 80% alive at 3 months and 66% at 1 year. These data underscore the effect of congestive heart failure in the community and provide estimates of the number of persons who might benefit from early intervention.

Busy physicians and preventive services for adults.

OBJECTIVE: To study the relationship between overall productivity and the rates at which primary care physicians, in a fee-for-service setting, deliver or prescribe preventive services to adult patients. PATIENTS AND METHODS: The charts of 452 adult patients treated by 8 family practitioners and 5 internists in a fee-for-service practice setting were randomly selected and abstracted for provision of 10 preventive services over a 27-month period. The percentage of eligible patients screened for each service was correlated with the production of each physician measured in relative value units (RVUs). RESULTS: The correlation coefficient between RVUs and the aggregate of the 10 services was 0.23 (95% confidence interval [CI], -0.36 to 0.70). The individual correlation coefficients between RVUs and 9 of the 10 preventive services ranged from -0.05 to 0.43. For cervical cancer screening, however, the correlation coefficient was -0.72 (95% CI, -0.91 to -0.24). CONCLUSION: With the exception of screening for cervical cancer, the data presented in this study do little to support physicians' common belief that lack of time is the reason they are unable to incorporate prevention strategies into their clinical practice.

Are coronary-care unit changes in therapy associated with improved survival of elderly patients with acute myocardial infarction?

OBJECTIVE: To determine whether changes in coronary-care unit therapy for elderly patients with acute myocardial infarction have been associated with improved survival. MATERIAL AND METHODS: We conducted a retrospective cohort analysis of all patients 70 years of age or older from Olmsted County, Minnesota, who were hospitalized in a coronary-care unit in this county for the treatment of acute myocardial infarction during one of three periods: 1976 through 1978, 1987 through 1989, and 1991. The effect of aspirin, heparin, beta-blockers, thrombolysis, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting on these elderly patients with acute myocardial infarction was assessed. RESULTS: Improvement in 30-day survival was significant for patients 80 years of age or older (45%, 69%, and 78% in 1976 through 1978, 1987 through 1989, and 1991, respectively; P = 0.01 for the trend) but not for patients 70 to 79 years of age (77%, 76%, and 81% for the three time periods, respectively; P = 0.65 for the trend). The opposite pattern was observed for survival in the period more than 30 days after the event. More intensive treatment in the hospital was associated with better 30-day survival (P < 0.0001). CONCLUSION: The improved survival of the elderly patients with acute myocardial infarction in these cohorts can be accounted for by changes in the therapy they received in the coronary-care units.

Trends in heart disease deaths in Olmsted County, Minnesota, 1979-1994.

BACKGROUND: Although age-adjusted heart disease mortality has declined since the 1960s, this decline may not have applied equally to all subgroups. OBJECTIVE: To examine recent trends in heart disease mortality, specifically in women and in the elderly. METHODS: Age- and sex-specific heart disease mortality (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 390-398, 402, 404-429) in Olmsted County, Minnesota, between 1979 and 1994 were studied. RESULTS: The total number of heart disease deaths was 3095; 1578 (51%) occurred in women and 1984 (64%) in persons aged 75 years or older. Most heart disease deaths (77%) were coronary disease deaths (ICD-9-CM codes 410-414). Age-adjusted heart disease mortality rates declined from 123 per 100,000 (95% confidence interval [CI], 102-144/100,000) in 1979 to 81 per 100,000 (95% CI, 67-95/100,000) in 1994. Poisson regression analyses indicated that the trends differed according to sex and age. For women, the relative risk (RR) of heart disease death in 1994 compared with 1979 was 0.69 vs 0.53 for men (P = .06). This equates to a decline in heart disease mortality of 2.5% per year in women or 32% over the period and 4.2% per year in men or 47% over the period. The decline was less pronounced as age increased (P < .001). For 60-year-old women, the RR for 1994 compared with 1979 was 0.59, whereas for 80-year-old women, the RR for 1994 compared with 1979 was 0.76. For men, the RR for 1994 compared with 1979 was 0.60 for 80-year-old men vs 0.46 for 60-year-old men. CONCLUSIONS: Between 1979 and 1994, in Olmsted County, the decline in heart disease mortality was of lesser magnitude in women and in the elderly, emphasizing the importance of age- and sex-specific trends to characterize time patterns in heart disease deaths to target preventive measures.

The CardioVision 2020 baseline community report card.

OBJECTIVE: To establish baseline data for the CardioVision 2020 program, a collaborative project in Olmsted County, Minnesota, organized to reduce cardiovascular disease rates by altering 5 health-related items: (1) eliminating tobacco use and exposure, (2) improving nutrition, (3) increasing physical activity, (4) lowering serum cholesterol level, and (5) controlling blood pressure. SUBJECTS AND METHODS: Data about tobacco use, diet, and physical activity were collected by random digit dial interview and follow-up questionnaire from a sample of the population. Blood pressure data were collected from medical records at Mayo Clinic, and serum cholesterol data were derived from the Mayo Clinic laboratory database. Data were stratified into 6 age groups. RESULTS: A total of 624 women and 608 men responded to the questionnaire. Population blood pressure data were available for 1,956 women and 1,084 men. Population serum cholesterol data were available for 17,042 women and 12,511 men. Except for women in the 30- to 39-year-old age group, less than 10% of the population sampled met 4 or 5 goals. Conversely, about 90% of the population met at least 1 goal, and about 80% met 1, 2, or 3 of the goals. CONCLUSION: The data from the Olmsted County population indicate considerable opportunity to reduce this population's burden of cardiovascular disease.