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Congestive heart failure hospitalizations and survival in California: Patterns according to race ethnicity

AMERICAN HEART JOURNAL 1999年第5期137卷 919-927页

作者： Alexander, M Grumbach, K Remy, L Rowell, R Massie, BM Univ Calif San Francisco Med Effectiveness Res Ctr Diverse Populat Dept Family & Community Med Inst Hlth Policy Studies San Francisco CA 94143 USA Univ Calif San Francisco Dept Med Div Gen Internal Med San Francisco CA 94143 USA Univ Calif San Francisco Cardiovasc Res Inst San Francisco CA 94143 USA Kaiser Permanente Med Care Program Div Res Oakland CA 94611 USA

Background Congestive heart failure (CHF) disproportionately affects African Americans, but data are limited concerning CHF hospitalization patterns among Hispanic and Asian populations, the 2 fastest growing ethnic groups in the United States, and race/ethnic patterns of rehospitalization and survival among patients with CHF are unknown. We conducted a study to assess rates of CHF hospitalization, readmission, and survival among diverse populations in California. Methods and Results we used 2 study designs. First, we calculated the population-based incidence of CHF hospitalization in California in 1991. Next we conducted a retrospective cohort study that identified patients initially hospitalized for CHF in 1991 or 1992 and followed these patients For 12 months after their index hospitalization to determine their likelihood of rehospitalization or death. Data were analyzed with Cox proportional hazards models. African Americans had the highest rate of CHF hospitalization. Age-adjusted hospitalization rates were comparable among whites, Latinos, and Asian women and all lower than those in African American, whereas Asian men had the lowest rates. On adjusted analyses, African Americans were more likely than whites and Asians to be rehospitalized (relative risk 1.07;95% confidence interval 1.04 to 1.10). However, they were less likely to die within the 12-month follow-up period (relative risk 0.86;95% confidence interval 0.82 to 0.90). Whites, conversely, had the highest posthospitalization mortality rates. Conclusions These findings demonstrate important racial-ethnic differences in CHF morbidity and mortality rates. The disparate findings of higher hospitalization and rehospitalization rates and lower mortality rates among African Americans than whites may represent differences in the underlying pathophysiology of CHF in these groups or differences in access to quality care. Further studies are needed to explain these seemingly paradoxical outcomes.

关键词：非洲裔美国人/统计学和数值数据亚裔美国人/统计学和数值数据加利福尼亚/流行病学随访研究西班牙裔美国人/统计学和数值数据住院/统计学和数值数据发病率比例危险度模型回顾性研究存活率老年人女(雌)性人类男(雄)性

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Prospective analysis of complications 30 days after outpatient colonoscopy

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GASTROINTESTINAL ENDOSCOPY 1999年第3期50卷 322-328页

作者： Zubarik, R Fleischer, DE Mastropietro, C Lopez, J Carroll, J Benjamin, S Eisen, G Georgetown Univ Hosp Dept Gastroenterol Washington DC 20007 USA Vet Affairs Med Ctr Gastroenterol Sect Memphis TN USA

Background.. Our objective was to (1) determine whether more complications are reported by patients 30 days after outpatient colonoscopy than are discussed at our monthly morbidity and mortality conferences, (2) identify complications resulting in visits to the emergency department or physician's office or leading to hospitalization, and (3) assess which factors put patients at highest risk. A secondary goal was to determine the rate of work lost after outpatient colonoscopy. Methods: Trained interviewers performed standardized telephone interviews of consecutive outpatients undergoing colonoscopy at Georgetown University Hospital over a 1-year period. Results: One thousand one hundred ninety-six patients were contacted 30 days after outpatient colonoscopy and participated in our study. Twenty patients had complications that required a visit to an emergency department or physician. Ninety percent of these cases (18) were detected at 30 days, but 15% (3) were discussed at morbidity and mortality conferences. All seven complications that necessitated hospitalization were identified at 30 days, but only two were discussed at our morbidity and mortality conference. The most common complications reported by patients were abdominal discomfort (5.4%) and rectal bleeding (2.1%). Conclusion: More complications are detected by means of contacting patients 30 days after outpatient colonoscopy than are discussed at our morbidity and mortality conferences.

关键词：腹痛/流行病学腹痛/病因学缺勤门诊医疗/标准卡方分布队列研究结肠疾病/诊断结肠镜检查/方法结肠镜检查/标准随访研究胃肠出血/流行病学胃肠出血/病因学住院/统计学和数值数据肠穿孔/流行病学肠穿孔/病因学患病率前瞻性研究直肠/损伤成年人老年人女(雌)性人类男(雄)性中年人

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Trends in clinical and economic outcomes of coronary angioplasty from 1992 to 1995: A population-based analysis

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AMERICAN HEART JOURNAL 1999年第6期137卷 1012-1018页

作者： Cohen, EA Young, W Slaughter, PM Oh, P Naylor, CD Univ Toronto Sunnybrook Hlth Sci Ctr Dept Med Div Cardiol Toronto ON M4N 3M5 Canada Inst Clin Evaluat Sci Toronto ON Canada

Background The impact of recent developments in coronary angioplasty on the brood spectrum of patients treated in routine practice is largely undefined. Analysis of population-based data can provide insight into trends in clinical outcomes and associated costs of coronary angioplasty procedures. Methods and Results With the use of a comprehensive hospital discharge database covering more than 11 million Canadians, we analyzed 12,748 first-time angioplasty procedures performed from 1992 to 1995 inclusive. Patient demographics and major adverse events were recorded. With the use of forward linkage, readmissions within 12 months were classified according to procedure performed and/or most responsible diagnosis, The proportion of patients readmitted, the number of readmissions per index procedure, and diagnosis-specific readmission costs were compared by calendar year. Over the 4-year study period, there was a 21% increase in the annual volume of index procedures. There were no statistically significant differences between 1992 and 1995 in sex distribution, mean age, comorbid conditions, length of stay, or need for coronary bypass surgery related to the index procedure. The all-cause readmission rate declined from 51.6% to 47.2% between 1992 and 1995 (P <.001), primarily because of a decline in the admission rate for repeat revascularization from 24.8% to 19.6% (P <.001). The 12-month readmission cost declined by $435 (1994 Canadian dollars) per patient. Conclusions The clinical outcomes of coronary angioplasty in a broad cohort of patients have improved in recent years. Although readmissions within year of an angioplasty procedure remain common, the number related to repeat revascularization has declined, with an associated decline in downstream costs.

关键词：队列研究费用效益分析医院费用/统计学和数值数据医院费用/发展趋势住院/经济学住院/统计学和数值数据住院/发展趋势安大略病人再入院/经济学病人再入院/统计学和数值数据病人再入院/发展趋势再治疗/经济学再治疗/统计学和数值数据再治疗/发展趋势支架/经济学支架/统计学和数值数据支架/发展趋势治疗结果人类中年人

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JOURNAL OF TOXICOLOGY-CLINICAL TOXICOLOGY 1999年第7期37卷 817-826页

作者： McCaig, LF Burt, CW Ctr Dis Control & Prevent Ambulatory Care Stat Branch Div Hlth Care Stat Natl Ctr Hlth Stat Hyattsville MD 20782 USA

Background: Poisoning continues to be an important public health problem in the US. In 1995, 2 million human poison exposures were reported to all poison centers in the US. Hospital emergency department data may be used to examine the most critical nonfatal poisoning exposures. Methods: Data from the 1993-1996 National Hospital Ambulatory Medical Care Survey, which is a national probability sample survey of visits to emergency departments of nonFederal, short-stay, and general hospitals, were examined to describe poisoning-related emergency department visits in the US. Results: During 1993-1996, the average annual number of emergency department visits was 93 million, of which 37 million were injury related and 1 million were poisoning related. Children under 5 years of age had a significantly higher average annual rate of poisoning-related visits (84 visits per 10,000 persons) than persons 5-19 years of age and persons 35 years of age and over. "Poisoning by other and unspecified drugs and medicinal substances" was the leading diagnosis and was recorded at 21% of all poisoning-related visits. Poisoning-related visits were more often recorded as urgent (75%) and were more likely to result in hospital admission (22%) compared to illness visits (45% and 17%, respectively) and nonpoisoning-related injury visits (47% and 6%, respectively). Conclusions: Poisoning-related injury visits comprise a small (1%), but important component of the health care provided in emergency departments. An examination of different definitions of poisoning revealed that for emergency department data, it is most appropriate to use the poisoning E-codes from the injury data framework developed by the injury control community. Data from emergency departments are needed to monitor any changing patterns of nonfatal poisonings and to provide guidance for effective poison prevention programs.

关键词：急救医疗服务住院/统计学和数值数据中毒/流行病学中毒/死亡率概率社会经济因素美国/流行病学青少年成年人儿童儿童学龄前女(雌)性人类男(雄)性

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The risk of hospitalization for acute myocardial infarction among older adults

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JOURNALS OF GERONTOLOGY SERIES A-BIOLOGICAL SCIENCES AND MEDICAL SCIENCES 1999年第5期54卷 M254-M261页

作者： Wolinsky, FD Wyrwich, KW Jung, SC Gurney, JG St Louis Univ Sch Publ Hlth St Louis MO 63108 USA Natl Archive Computerized Data Aging Ann Arbor MI USA St Louis Univ Sch Med St Louis MO USA Northland Cardiol Kansas City MO USA

Background. The purpose of this study was to prospectively examine the risk of hospitalization for acute myocardial infarction (AMI) in a large,nationally representative sample of very old men and women. Methods. We utilized secondary analysis of the Longitudinal Study of Aging. Baseline (1984) in-person interview data were linked to Medicare hospitalization records for 1984-1991. Subjects were 6,071 noninstitutionalized adults 70 years old or older at baseline. Hospitalization for AMI was defined as having primary discharge diagnoses containing ICD9-CM 410 codes. Multivariable proportional hazards regression was used to evaluate the epidemiologic risks for all persons, and separately for women, men, self-respondents, those with no previous AMIs, and those with no history of coronary heart disease. Results. Of the sample, 357 persons (5.9%;172 women and 185 men) had at least one primary discharge diagnosis of AMI. Significant (p < .05) risk factors for being hospitalized with an AMI (adjusted hazards ratios in parentheses) from the pooled analysis were male gender(1.86), having no more than a grade school education (1.35), atherosclerosis (1.43), hypertension (1.29), coronary heart disease (1.63), angina (1.60), previous AMI (1.52), diabetes (1.89), and four or more lower body limitations (1.43). The gender-specific analyses, however, revealed that hypertension, angina, diabetes, and lower body limitations were risk factors only for women, and that having no more than a grade school education was a risk factor only for men. Conclusion. Men, especially those with low education, women with diabetes, angina, hypertension, or lower body limitations, and either men or women with previous AMIs, coronary heart disease, or atherosclerosis have elevated risks for AMI resulting in hospitalization, and they should be considered for evaluation and monitoring. Current protocols for therapeutic management should be adopted, and compliance should be encouraged.

关键词：日常生活活动心绞痛/流行病学动脉硬化/流行病学冠心病/流行病学糖尿病/流行病学教育程度医院记录住院/统计学和数值数据高血压/流行病学纵向研究 Medicare 多元分析心肌梗死/流行病学比值比病人出院比例危险度模型前瞻性研究危险因素性别因素美国/流行病学老年人老年人 80以上女(雌)性人类男(雄)性

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Disparate effects of the 1989 Loma Prieta and 1994 Northridge earthquakes on hospital admissions for acute myocardial infarction: Importance of superimposition of triggers

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AMERICAN HEART JOURNAL 1999年第5期137卷 830-836页

作者： Brown, DL Yeshiva Univ Albert Einstein Coll Med Div Cardiovasc Med Dept Med Bronx NY 10461 USA

Background Most occurrences of presumed triggers of acute myocardial infarction (AMI) do not actually trigger an AMI. The relation between vulnerability to development of AMI and timing of triggers of AMI is poorly understood. The 1989 Loma Prieta earthquake struck the San Francisco Bay Area at 5:04 PM during a period of relatively reduced circadian vulnerability to AMI. The 1994 Northridge earthquake awakened citizens of Los Angeles at 4:31 AM, also during a period of otherwise reduced vulnerability to AMI, bur superimposed the stress of the earthquake upon the known stress of awakening, Study of times of onset of natural disasters and their effect on precipitation of AMI may provide insight into the physiology of triggering. This study was designed to compare the triggering ability of 2 similarly intense earthquakes that occurred singly or superimposed upon another trigger. Methods and Results California discharge records were analyzed from the week before, the day of, and the 6 days after the Loma Prieta and Northridge earthquakes and the same dates of control years for total admissions, AMI admissions, and congestive heart failure admissions. There was no statistically Significant increase in AMI admissions in the San Francisco Bay Area on the day of the Loma Prieta earthquake compared with the days before or after the earthquake or compared with the same day in 1990. In contrast, there was a 110% increase in admission rate for AMI in Los Angeles County on the day of the Northridge earthquake compared with the average of the 7 days before the earthquake (z = 4,349, P < .001). Similarly, there was a >80% increased risk of admission for AMI:on the day of the Northridge earthquake in 1994 compared with the same date in 1995 (relative risk 1.828, 95% confidence intervals 1.289 to 2.592). Conclusions Extreme emotional stress superimposed on the stress of awakening results in enhanced triggering of AMI. When emotional stress occurs at less vulnerable periods, there is

关键词：加利福尼亚/流行病学随访研究住院/统计学和数值数据发病率心肌梗死/流行病学心肌梗死/病因学自然灾害病人入院/统计学和数值数据病人出院/统计学和数值数据回顾性研究应激心理学/并发症人类

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Effect of a home monitoring system on hospitalization and resource use for patients with heart failure

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AMERICAN HEART JOURNAL 1999年第4期138卷 633-640页

作者： Heidenreich, PA Ruggerio, CM Massie, BM Dept Vet Affairs Med Ctr Cardiol Sect Palo Alto CA 94304 USA Univ Calif San Francisco Sch Nursing San Francisco CA 94143 USA Univ Calif San Francisco Dept Med San Francisco CA USA Univ Calif San Francisco Cardiovasc Res Inst San Francisco CA 94143 USA Dept Vet Affairs Med Ctr Div Cardiol San Francisco CA USA

Background Heart failure has a large medical and economic impact on the elderly. Pair studies have shown that high-intensity multidisciplinary interventions at academic medical centers can reduce future hospitalizations. Our pilot study examined the effects of a low-intensity monitoring program on hospitalizations and cost of care for patients with heart failure treated by community physicians. Methods we enrolled 68 patients with heart failure (mean age 73 +/- 13 years, 53% merle) monitored by 31 physicians in a multidisciplinary program of patient education, daily self-monitoring, and physician notification of abnormal weight gain, vital signs, and symptoms. Comparisons of medical claims were made between the patients who received the intervention and a control group of 86 patients matched to the intervention group on medical claims during the preceding year. Results Compared with the prior year, medical claims per year decreased in the intervention group ($8500 +/- $13,000 to $7400 +/- $11,400), whereas they increased in the control group ($9200 +/- $15,000 to $18,800 +/- $34,000, P < .05). Similar differences were observed for hospitalizations and total hospital days.. The program's effectiveness was unrelated to age, sex, or type of left ventricular dysfunction. Conclusions These findings suggest that a multidisciplinary program of patient education, monitoring, and physician notification can reduce resource use in patients with heart failure managed in a community setting.

关键词：病例对照研究卫生资源/经济学卫生资源/利用住院/统计学和数值数据保险索赔审核/统计学和数值数据监测便携式/方法生活质量存活率电话老年人女(雌)性人类男(雄)性

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The changing status of inpatient dermatology at American academic dermatology programs

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JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY 1999年第5期40卷 755-757页

作者： Kirsner, RS Yang, DG Kerdel, FA Univ Miami Sch Med Dept Dermatol & Cutaneous Surg Miami FL USA Univ Miami Sch Med Dept Epidemiol & Publ Hlth Miami FL USA

Background: Changes in health care delivery financing such as the adoption of the diagnosis-related groups (DRG) in 1983 has affected inpatient services of dermatology programs across the United States. Objective: The purpose of this study was to define the present status of inpatient dermatology at academic medical centers compared with 1982. Methods: Questionnaires inquiring about the state of inpatient service were sent to the chairpersons of each dermatology residency program in the United States. Results: Of the 71 programs responding, 79% reported a reduction in inpatient activity. Nearly half of the dermatology programs with dedicated dermatology beds in 1982 reported not continuing to have these in 1997 (41 to 24). The average number of patients admitted for skin disease decreased from 119 in 1982 to 36.5 in 1997, and the average daily census decreased from 8.9 to 2.2. Conclusion: There has been a decline in the number of patients hospitalized by academic dermatology departments and a shift of some patients hospitalized to beds where the attending is other than a dermatologist.

关键词：医学科学研究中心/统计学和数值数据门诊医疗/统计学和数值数据皮肤病学/教育皮肤病学/统计学和数值数据诊断相关患者组/统计学和数值数据医院病床数/统计学和数值数据住院/统计学和数值数据保险健康/统计学和数值数据实习医师和住院医师职务病人入院/统计学和数值数据皮肤疾病/流行病学皮肤疾病/治疗美国/流行病学人类

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Co-abuse of opiates and benzodiazepines

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IRISH JOURNAL OF MEDICAL SCIENCE 1999年第1期168卷 36-41页

作者： Rooney, S Kelly, G Bamford, L Sloan, D O'Connor, JJ Our Ladys Hosp Navan Meath Ireland

The objective of the study was to assess what differences exist between individuals who are dependent on opiates and benzodiazepines and compare to those who are dependent on opiates. A questionnaire was compiled and administered to patients who ha;I been consecutively admitted to an inpatient drug treatment unit. The prevalence of benzodiazepine dependency was 54 per cent [n=34]. Patients dependent on benzodiazepines and opiates were significantly older, had been admitted for methadone stabilisation and were more likely to have been prescribed a methadone maintenance programme prior to admission. They had used heroin longer, benzodiazepines more frequently, at larger doses for a longer duration of time and tended to use more drugs in general. They were found to be more psychologically vulnerable than those not dependent on benzodiazepines as they were significantly more likely to have described a past experience of depression and a past episode of deliberate self harm.

关键词：年龄分布镇咳药/治疗应用苯二氮|艹卓|类/中毒病例对照研究卡方分布共病现象数据收集药品和麻醉品检定/统计学和数值数据海洛因依赖/流行病学海洛因依赖/康复住院/统计学和数值数据发病率爱尔兰/流行病学 Logistic模型美沙酮/治疗应用阿片相关性障碍/流行病学阿片相关性障碍/康复性别分布物质相关性障碍/诊断物质相关性障碍/流行病学物质相关性障碍/康复青少年成年人女(雌)性人类男(雄)性中年人

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Quality of care for patients hospitalized with heart failure at academic medical centers

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AMERICAN HEART JOURNAL 1999年第6期137卷 1028-1034页

作者： Nohria, A Chen, YT Morton, DJ Walsh, R Vlasses, PH Krumholz, HM Yale Univ Sch Med Yale New Haven Hosp Ctr Outcomes Res & EvaluatSect Cardiovasc Med New Haven CT USA Yale Univ Sch Med Yale New Haven Hosp Ctr Outcomes Res & EvaluatDept Med New Haven CT USA Qualidigm Middletown CT USA Univ Healthsyst Chicago IL USA

Background The purpose of this study was to determine the standard of care provided by academic medical centers For the management of congestive heart failure (CHF). Methods and Results The standard of care was estimated by assessing adherence to the treatment guidelines published by the US Agency for Health Care Policy and Research among 522 patients hospitalized at 7 university hospitals with a diagnosis of CHF. Data were abstracted by retrospective chart review. Of the 522 patients analyzed, 435 (83%) had a left ventricular ejection fraction (LVEF) measured or documented. Among these patients, 192 were considered "ideal" candidates for angiotensin-converting enzyme (ACE) inhibitor therapy tie, with systolic dysfunction [LVEF <40%] and no contraindications to ACE inhibitors). In this cohort of "ideal" candidates, 138 (72%) were receiving ACE inhibitors at hospital discharge, including 60 (44%) who were prescribed doses recommended in large clinical trials. Compliance with patient education guidelines was assessed in all 487 patients who were alive at the time of discharge. Of these patients, 365 (75%) received dietary counseling, 404 (83%) were educated about exercise, 54 (11%) were instructed to follow daily weights, and 468 (96%) were counseled regarding medication compliance. Among the 87 smokers who were alive at time of discharge, 8 (9%) had documented advice to quit smoking. Conclusions This study indicates that academic medical centers performed fairly well on the assessment of LVEF, the prescription of ACE inhibitors at discharge, and on education regarding diet, exercise, and compliance with medications. However, the results suggest opportunities for improvement in ACE inhibitor dosing and patient education regarding the importance of monitoring daily weights and smoking cessation.

关键词：医学科学研究中心/标准医学科学研究中心/统计学和数值数据血管紧张素转换酶抑制药/治疗应用心脏病学科医院/标准心脏病学科医院/统计学和数值数据数据收集/方法住院/统计学和数值数据 Logistic模型质量指标卫生保健卫生保健质量/标准卫生保健质量/统计学和数值数据美国老年人老年人 80以上女(雌)性人类男(雄)性中年人

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