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Community Resources Help Obese Elderly With CVD Preserve Function
Existing community resources such as the cooperative extension programs available in most U.S. counties can help obese, physically impaired elderly people with cardiovascular disease improve and preserve their physical functioning, according to a report published online Jan. 24 in the Archives of Internal Medicine.
Such linkage between the health care system and cooperative extension programs in North Carolina boosted obese elderly patients’ levels of physical activity and weight loss, which in turn improved their mobility "substantially," said W. Jack Rejeski, Ph.D., of the department of health and exercise science and geriatric medicine, Wake Forest University, Winston-Salem, N.C., and his associates.
"The intervention was successfully translated into a community setting with results ... comparable with those observed in the best randomized controlled trials conducted in academic health centers," the investigators noted.
They enrolled 288 overweight or obese adults (body mass index greater than 28 kg/m2) aged 60-79 years who had limited mobility in a randomized, controlled trial to evaluate the intervention. The study subjects either had known cardiovascular disease or were at high risk from cardiometabolic dysfunction.
The subjects were randomly assigned to a physical activity intervention alone, a physical activity plus weight-loss intervention, or a control group, and were followed for 18 months. The interventions were delivered at existing Cooperative Extension Centers by Cooperative Extension agents (also known as family and consumer sciences educators) who were field faculty from North Carolina State University, Raleigh, with degrees in home economics and/or nutrition education.
"Cooperative Extension Centers are located ... in most counties nationwide. Cooperative extension specialists provide unbiased, research-based information to the public in such areas as agriculture, human nutrition, diet and health, food safety, gerontology, and human development," Dr. Rejeski and his colleagues noted.
The physical activity intervention involved three 90-minute group activity and counseling sessions and one 30-minute individual counseling session per month aimed at getting patients to gradually increase and maintain more than 30 minutes of moderately intense activity most days of the week, for a total of 150 minutes per week.
The combined activity plus weight-loss intervention added to this a program to reduce caloric intake, with a goal of losing 7%-10% of baseline weight and maintaining that loss. This intervention included cooking demonstrations and food tastings illustrating the preparation of palatable but low-fat, low-calorie foods, as well as counseling to guide subjects to self-regulate their eating behaviors.
Within 6 months, physical activity alone resulted in a 1% weight loss and improved the subjects’ performance on the 400-meter walking test, which reflects overall mobility and physical functioning. However, that benefit had largely disappeared by 18 months.
In contrast, the combined intervention produced a substantial 8.5% weight loss within 6 months, which was maintained throughout follow-up, along with a significant improvement on the 400-meter walking test that also persisted until the conclusion of the trial.
"We surmise that the benefit of [the combined intervention] was due either to increased motivation to be physically active when one has lost weight, and/or that being physically active is perceptually or objectively less demanding once one has lost weight," the investigators said (Arch. Intern. Med. 2011 [doi:10.1001/archinternmed.2010.522]).
In comparison, the control group lost only 1% of their baseline weight and showed progressive impairment of mobility on the 400-meter walking test over time.
With the combined intervention, the study subjects who had the worst performance on the walking test at baseline were the ones who showed the greatest improvement.
These results show that community-based combined intervention "can have a favorable effect on preserving the mobility of older, obese adults who are at risk for or have CVD. The magnitude of change that we observed ... was comparable with data from highly successful, medical center-based intervention research," Dr. Rejeski and his associates said.
Adverse events were more frequent with the combined intervention than in the other two groups, but these mostly involved transient musculoskeletal complaints that quickly resolved. "Only 2 of the [39] serious adverse events were definitely related to treatment," the researchers added.
This study was supported by the National Heart, Lung, and Blood Institute, the National Institute for Aging, and the General Clinical Research Centers. No financial disclosures were reported.
Existing community resources such as the cooperative extension programs available in most U.S. counties can help obese, physically impaired elderly people with cardiovascular disease improve and preserve their physical functioning, according to a report published online Jan. 24 in the Archives of Internal Medicine.
Such linkage between the health care system and cooperative extension programs in North Carolina boosted obese elderly patients’ levels of physical activity and weight loss, which in turn improved their mobility "substantially," said W. Jack Rejeski, Ph.D., of the department of health and exercise science and geriatric medicine, Wake Forest University, Winston-Salem, N.C., and his associates.
"The intervention was successfully translated into a community setting with results ... comparable with those observed in the best randomized controlled trials conducted in academic health centers," the investigators noted.
They enrolled 288 overweight or obese adults (body mass index greater than 28 kg/m2) aged 60-79 years who had limited mobility in a randomized, controlled trial to evaluate the intervention. The study subjects either had known cardiovascular disease or were at high risk from cardiometabolic dysfunction.
The subjects were randomly assigned to a physical activity intervention alone, a physical activity plus weight-loss intervention, or a control group, and were followed for 18 months. The interventions were delivered at existing Cooperative Extension Centers by Cooperative Extension agents (also known as family and consumer sciences educators) who were field faculty from North Carolina State University, Raleigh, with degrees in home economics and/or nutrition education.
"Cooperative Extension Centers are located ... in most counties nationwide. Cooperative extension specialists provide unbiased, research-based information to the public in such areas as agriculture, human nutrition, diet and health, food safety, gerontology, and human development," Dr. Rejeski and his colleagues noted.
The physical activity intervention involved three 90-minute group activity and counseling sessions and one 30-minute individual counseling session per month aimed at getting patients to gradually increase and maintain more than 30 minutes of moderately intense activity most days of the week, for a total of 150 minutes per week.
The combined activity plus weight-loss intervention added to this a program to reduce caloric intake, with a goal of losing 7%-10% of baseline weight and maintaining that loss. This intervention included cooking demonstrations and food tastings illustrating the preparation of palatable but low-fat, low-calorie foods, as well as counseling to guide subjects to self-regulate their eating behaviors.
Within 6 months, physical activity alone resulted in a 1% weight loss and improved the subjects’ performance on the 400-meter walking test, which reflects overall mobility and physical functioning. However, that benefit had largely disappeared by 18 months.
In contrast, the combined intervention produced a substantial 8.5% weight loss within 6 months, which was maintained throughout follow-up, along with a significant improvement on the 400-meter walking test that also persisted until the conclusion of the trial.
"We surmise that the benefit of [the combined intervention] was due either to increased motivation to be physically active when one has lost weight, and/or that being physically active is perceptually or objectively less demanding once one has lost weight," the investigators said (Arch. Intern. Med. 2011 [doi:10.1001/archinternmed.2010.522]).
In comparison, the control group lost only 1% of their baseline weight and showed progressive impairment of mobility on the 400-meter walking test over time.
With the combined intervention, the study subjects who had the worst performance on the walking test at baseline were the ones who showed the greatest improvement.
These results show that community-based combined intervention "can have a favorable effect on preserving the mobility of older, obese adults who are at risk for or have CVD. The magnitude of change that we observed ... was comparable with data from highly successful, medical center-based intervention research," Dr. Rejeski and his associates said.
Adverse events were more frequent with the combined intervention than in the other two groups, but these mostly involved transient musculoskeletal complaints that quickly resolved. "Only 2 of the [39] serious adverse events were definitely related to treatment," the researchers added.
This study was supported by the National Heart, Lung, and Blood Institute, the National Institute for Aging, and the General Clinical Research Centers. No financial disclosures were reported.
Existing community resources such as the cooperative extension programs available in most U.S. counties can help obese, physically impaired elderly people with cardiovascular disease improve and preserve their physical functioning, according to a report published online Jan. 24 in the Archives of Internal Medicine.
Such linkage between the health care system and cooperative extension programs in North Carolina boosted obese elderly patients’ levels of physical activity and weight loss, which in turn improved their mobility "substantially," said W. Jack Rejeski, Ph.D., of the department of health and exercise science and geriatric medicine, Wake Forest University, Winston-Salem, N.C., and his associates.
"The intervention was successfully translated into a community setting with results ... comparable with those observed in the best randomized controlled trials conducted in academic health centers," the investigators noted.
They enrolled 288 overweight or obese adults (body mass index greater than 28 kg/m2) aged 60-79 years who had limited mobility in a randomized, controlled trial to evaluate the intervention. The study subjects either had known cardiovascular disease or were at high risk from cardiometabolic dysfunction.
The subjects were randomly assigned to a physical activity intervention alone, a physical activity plus weight-loss intervention, or a control group, and were followed for 18 months. The interventions were delivered at existing Cooperative Extension Centers by Cooperative Extension agents (also known as family and consumer sciences educators) who were field faculty from North Carolina State University, Raleigh, with degrees in home economics and/or nutrition education.
"Cooperative Extension Centers are located ... in most counties nationwide. Cooperative extension specialists provide unbiased, research-based information to the public in such areas as agriculture, human nutrition, diet and health, food safety, gerontology, and human development," Dr. Rejeski and his colleagues noted.
The physical activity intervention involved three 90-minute group activity and counseling sessions and one 30-minute individual counseling session per month aimed at getting patients to gradually increase and maintain more than 30 minutes of moderately intense activity most days of the week, for a total of 150 minutes per week.
The combined activity plus weight-loss intervention added to this a program to reduce caloric intake, with a goal of losing 7%-10% of baseline weight and maintaining that loss. This intervention included cooking demonstrations and food tastings illustrating the preparation of palatable but low-fat, low-calorie foods, as well as counseling to guide subjects to self-regulate their eating behaviors.
Within 6 months, physical activity alone resulted in a 1% weight loss and improved the subjects’ performance on the 400-meter walking test, which reflects overall mobility and physical functioning. However, that benefit had largely disappeared by 18 months.
In contrast, the combined intervention produced a substantial 8.5% weight loss within 6 months, which was maintained throughout follow-up, along with a significant improvement on the 400-meter walking test that also persisted until the conclusion of the trial.
"We surmise that the benefit of [the combined intervention] was due either to increased motivation to be physically active when one has lost weight, and/or that being physically active is perceptually or objectively less demanding once one has lost weight," the investigators said (Arch. Intern. Med. 2011 [doi:10.1001/archinternmed.2010.522]).
In comparison, the control group lost only 1% of their baseline weight and showed progressive impairment of mobility on the 400-meter walking test over time.
With the combined intervention, the study subjects who had the worst performance on the walking test at baseline were the ones who showed the greatest improvement.
These results show that community-based combined intervention "can have a favorable effect on preserving the mobility of older, obese adults who are at risk for or have CVD. The magnitude of change that we observed ... was comparable with data from highly successful, medical center-based intervention research," Dr. Rejeski and his associates said.
Adverse events were more frequent with the combined intervention than in the other two groups, but these mostly involved transient musculoskeletal complaints that quickly resolved. "Only 2 of the [39] serious adverse events were definitely related to treatment," the researchers added.
This study was supported by the National Heart, Lung, and Blood Institute, the National Institute for Aging, and the General Clinical Research Centers. No financial disclosures were reported.
FROM ARCHIVES OF INTERNAL MEDICINE
Community Resources Help Obese Elderly With CVD Preserve Function
Existing community resources such as the cooperative extension programs available in most U.S. counties can help obese, physically impaired elderly people with cardiovascular disease improve and preserve their physical functioning, according to a report published online Jan. 24 in the Archives of Internal Medicine.
Such linkage between the health care system and cooperative extension programs in North Carolina boosted obese elderly patients’ levels of physical activity and weight loss, which in turn improved their mobility "substantially," said W. Jack Rejeski, Ph.D., of the department of health and exercise science and geriatric medicine, Wake Forest University, Winston-Salem, N.C., and his associates.
"The intervention was successfully translated into a community setting with results ... comparable with those observed in the best randomized controlled trials conducted in academic health centers," the investigators noted.
They enrolled 288 overweight or obese adults (body mass index greater than 28 kg/m2) aged 60-79 years who had limited mobility in a randomized, controlled trial to evaluate the intervention. The study subjects either had known cardiovascular disease or were at high risk from cardiometabolic dysfunction.
The subjects were randomly assigned to a physical activity intervention alone, a physical activity plus weight-loss intervention, or a control group, and were followed for 18 months. The interventions were delivered at existing Cooperative Extension Centers by Cooperative Extension agents (also known as family and consumer sciences educators) who were field faculty from North Carolina State University, Raleigh, with degrees in home economics and/or nutrition education.
"Cooperative Extension Centers are located ... in most counties nationwide. Cooperative extension specialists provide unbiased, research-based information to the public in such areas as agriculture, human nutrition, diet and health, food safety, gerontology, and human development," Dr. Rejeski and his colleagues noted.
The physical activity intervention involved three 90-minute group activity and counseling sessions and one 30-minute individual counseling session per month aimed at getting patients to gradually increase and maintain more than 30 minutes of moderately intense activity most days of the week, for a total of 150 minutes per week.
The combined activity plus weight-loss intervention added to this a program to reduce caloric intake, with a goal of losing 7%-10% of baseline weight and maintaining that loss. This intervention included cooking demonstrations and food tastings illustrating the preparation of palatable but low-fat, low-calorie foods, as well as counseling to guide subjects to self-regulate their eating behaviors.
Within 6 months, physical activity alone resulted in a 1% weight loss and improved the subjects’ performance on the 400-meter walking test, which reflects overall mobility and physical functioning. However, that benefit had largely disappeared by 18 months.
In contrast, the combined intervention produced a substantial 8.5% weight loss within 6 months, which was maintained throughout follow-up, along with a significant improvement on the 400-meter walking test that also persisted until the conclusion of the trial.
"We surmise that the benefit of [the combined intervention] was due either to increased motivation to be physically active when one has lost weight, and/or that being physically active is perceptually or objectively less demanding once one has lost weight," the investigators said (Arch. Intern. Med. 2011 [doi:10.1001/archinternmed.2010.522]).
In comparison, the control group lost only 1% of their baseline weight and showed progressive impairment of mobility on the 400-meter walking test over time.
With the combined intervention, the study subjects who had the worst performance on the walking test at baseline were the ones who showed the greatest improvement.
These results show that community-based combined intervention "can have a favorable effect on preserving the mobility of older, obese adults who are at risk for or have CVD. The magnitude of change that we observed ... was comparable with data from highly successful, medical center-based intervention research," Dr. Rejeski and his associates said.
Adverse events were more frequent with the combined intervention than in the other two groups, but these mostly involved transient musculoskeletal complaints that quickly resolved. "Only 2 of the [39] serious adverse events were definitely related to treatment," the researchers added.
This study was supported by the National Heart, Lung, and Blood Institute, the National Institute for Aging, and the General Clinical Research Centers. No financial disclosures were reported.
Existing community resources such as the cooperative extension programs available in most U.S. counties can help obese, physically impaired elderly people with cardiovascular disease improve and preserve their physical functioning, according to a report published online Jan. 24 in the Archives of Internal Medicine.
Such linkage between the health care system and cooperative extension programs in North Carolina boosted obese elderly patients’ levels of physical activity and weight loss, which in turn improved their mobility "substantially," said W. Jack Rejeski, Ph.D., of the department of health and exercise science and geriatric medicine, Wake Forest University, Winston-Salem, N.C., and his associates.
"The intervention was successfully translated into a community setting with results ... comparable with those observed in the best randomized controlled trials conducted in academic health centers," the investigators noted.
They enrolled 288 overweight or obese adults (body mass index greater than 28 kg/m2) aged 60-79 years who had limited mobility in a randomized, controlled trial to evaluate the intervention. The study subjects either had known cardiovascular disease or were at high risk from cardiometabolic dysfunction.
The subjects were randomly assigned to a physical activity intervention alone, a physical activity plus weight-loss intervention, or a control group, and were followed for 18 months. The interventions were delivered at existing Cooperative Extension Centers by Cooperative Extension agents (also known as family and consumer sciences educators) who were field faculty from North Carolina State University, Raleigh, with degrees in home economics and/or nutrition education.
"Cooperative Extension Centers are located ... in most counties nationwide. Cooperative extension specialists provide unbiased, research-based information to the public in such areas as agriculture, human nutrition, diet and health, food safety, gerontology, and human development," Dr. Rejeski and his colleagues noted.
The physical activity intervention involved three 90-minute group activity and counseling sessions and one 30-minute individual counseling session per month aimed at getting patients to gradually increase and maintain more than 30 minutes of moderately intense activity most days of the week, for a total of 150 minutes per week.
The combined activity plus weight-loss intervention added to this a program to reduce caloric intake, with a goal of losing 7%-10% of baseline weight and maintaining that loss. This intervention included cooking demonstrations and food tastings illustrating the preparation of palatable but low-fat, low-calorie foods, as well as counseling to guide subjects to self-regulate their eating behaviors.
Within 6 months, physical activity alone resulted in a 1% weight loss and improved the subjects’ performance on the 400-meter walking test, which reflects overall mobility and physical functioning. However, that benefit had largely disappeared by 18 months.
In contrast, the combined intervention produced a substantial 8.5% weight loss within 6 months, which was maintained throughout follow-up, along with a significant improvement on the 400-meter walking test that also persisted until the conclusion of the trial.
"We surmise that the benefit of [the combined intervention] was due either to increased motivation to be physically active when one has lost weight, and/or that being physically active is perceptually or objectively less demanding once one has lost weight," the investigators said (Arch. Intern. Med. 2011 [doi:10.1001/archinternmed.2010.522]).
In comparison, the control group lost only 1% of their baseline weight and showed progressive impairment of mobility on the 400-meter walking test over time.
With the combined intervention, the study subjects who had the worst performance on the walking test at baseline were the ones who showed the greatest improvement.
These results show that community-based combined intervention "can have a favorable effect on preserving the mobility of older, obese adults who are at risk for or have CVD. The magnitude of change that we observed ... was comparable with data from highly successful, medical center-based intervention research," Dr. Rejeski and his associates said.
Adverse events were more frequent with the combined intervention than in the other two groups, but these mostly involved transient musculoskeletal complaints that quickly resolved. "Only 2 of the [39] serious adverse events were definitely related to treatment," the researchers added.
This study was supported by the National Heart, Lung, and Blood Institute, the National Institute for Aging, and the General Clinical Research Centers. No financial disclosures were reported.
Existing community resources such as the cooperative extension programs available in most U.S. counties can help obese, physically impaired elderly people with cardiovascular disease improve and preserve their physical functioning, according to a report published online Jan. 24 in the Archives of Internal Medicine.
Such linkage between the health care system and cooperative extension programs in North Carolina boosted obese elderly patients’ levels of physical activity and weight loss, which in turn improved their mobility "substantially," said W. Jack Rejeski, Ph.D., of the department of health and exercise science and geriatric medicine, Wake Forest University, Winston-Salem, N.C., and his associates.
"The intervention was successfully translated into a community setting with results ... comparable with those observed in the best randomized controlled trials conducted in academic health centers," the investigators noted.
They enrolled 288 overweight or obese adults (body mass index greater than 28 kg/m2) aged 60-79 years who had limited mobility in a randomized, controlled trial to evaluate the intervention. The study subjects either had known cardiovascular disease or were at high risk from cardiometabolic dysfunction.
The subjects were randomly assigned to a physical activity intervention alone, a physical activity plus weight-loss intervention, or a control group, and were followed for 18 months. The interventions were delivered at existing Cooperative Extension Centers by Cooperative Extension agents (also known as family and consumer sciences educators) who were field faculty from North Carolina State University, Raleigh, with degrees in home economics and/or nutrition education.
"Cooperative Extension Centers are located ... in most counties nationwide. Cooperative extension specialists provide unbiased, research-based information to the public in such areas as agriculture, human nutrition, diet and health, food safety, gerontology, and human development," Dr. Rejeski and his colleagues noted.
The physical activity intervention involved three 90-minute group activity and counseling sessions and one 30-minute individual counseling session per month aimed at getting patients to gradually increase and maintain more than 30 minutes of moderately intense activity most days of the week, for a total of 150 minutes per week.
The combined activity plus weight-loss intervention added to this a program to reduce caloric intake, with a goal of losing 7%-10% of baseline weight and maintaining that loss. This intervention included cooking demonstrations and food tastings illustrating the preparation of palatable but low-fat, low-calorie foods, as well as counseling to guide subjects to self-regulate their eating behaviors.
Within 6 months, physical activity alone resulted in a 1% weight loss and improved the subjects’ performance on the 400-meter walking test, which reflects overall mobility and physical functioning. However, that benefit had largely disappeared by 18 months.
In contrast, the combined intervention produced a substantial 8.5% weight loss within 6 months, which was maintained throughout follow-up, along with a significant improvement on the 400-meter walking test that also persisted until the conclusion of the trial.
"We surmise that the benefit of [the combined intervention] was due either to increased motivation to be physically active when one has lost weight, and/or that being physically active is perceptually or objectively less demanding once one has lost weight," the investigators said (Arch. Intern. Med. 2011 [doi:10.1001/archinternmed.2010.522]).
In comparison, the control group lost only 1% of their baseline weight and showed progressive impairment of mobility on the 400-meter walking test over time.
With the combined intervention, the study subjects who had the worst performance on the walking test at baseline were the ones who showed the greatest improvement.
These results show that community-based combined intervention "can have a favorable effect on preserving the mobility of older, obese adults who are at risk for or have CVD. The magnitude of change that we observed ... was comparable with data from highly successful, medical center-based intervention research," Dr. Rejeski and his associates said.
Adverse events were more frequent with the combined intervention than in the other two groups, but these mostly involved transient musculoskeletal complaints that quickly resolved. "Only 2 of the [39] serious adverse events were definitely related to treatment," the researchers added.
This study was supported by the National Heart, Lung, and Blood Institute, the National Institute for Aging, and the General Clinical Research Centers. No financial disclosures were reported.
FROM ARCHIVES OF INTERNAL MEDICINE
Major Finding: A community-based intervention conducted by Cooperative Extension agents, which combined increased physical activity with caloric control, produced a substantial (8.5%) weight loss and improved mobility as measured by the 400-meter walking test.
Data Source: An 18-month randomized, controlled study involving 288 obese and physically impaired adults aged 60-79 years who had cardiovascular disease or cardiometabolic dysfunction.
Disclosures: This study was supported by the National Heart, Lung, and Blood Institute, the National Institute for Aging, and the General Clinical Research Centers. No financial conflicts of interest were reported.
Electronic Records Fail to Deliver Better-Quality Outpatient Care
Electronic health records, either with or without features to aid clinical decision making, failed to improve the quality of outpatient care in a study of more than 240,000 physician visits across the country, according to a report published online Jan. 24 in Archives of Internal Medicine.
The study findings "cast doubt on the argument that the use of electronic health records is a ‘magic bullet’ for health care quality improvement, as some advocates imply," according to Max J. Romano and Dr. Randall S. Stafford of the prevention research center at Stanford (Calif.) University.
"Since 1991, the Institute of Medicine has repeatedly called for increasing electronic health record (EHR) use to improve health care quality," the authors wrote, adding that "the American Reinvestment and Recovery Act stimulus bill set aside $19.2 billion to promote health information technology use in the United States, with the underlying assumption that more health IT is better.
"Nonetheless, evidence linking increased national use of outpatient EHRs to improved quality is lacking," as are data supporting included clinical decision support tools, Mr. Romano and Dr. Stafford said.
They analyzed data from two nationally representative samples collected by the National Center for Health Statistics in 2005-2007, the most recent years available. This included 243,478 patient visits to office-based, emergency department, and outpatient department physicians in family medicine, internal medicine, geriatrics, pediatrics, and general practice.
To evaluate the quality of care provided during these visits, 20 quality indicators were assessed in five areas: pharmacologic management of chronic diseases (such as atrial fibrillation, coronary artery disease, heart failure, hyperlipidemia, asthma, and hypertension); appropriate antibiotic use in urinary tract and viral upper respiratory tract infections; preventive counseling regarding diet, exercise, and smoking cessation; appropriate use of screening tests such as blood pressure measurement, urinalysis, and echocardiography; and inappropriate prescribing in the elderly.
Electronic health records were used in approximately 30% of all patient visits, and clinical decision support features were used in 17%. Neither EHR nor clinical decision support features were associated with higher-quality care.
When an EHR was used, care quality was better than when no EHR was used for only 1 of the 20 quality indicators (dietary counseling). Similarly, when a clinical decision support feature was used, care quality was better for only 1 of 20 quality indicators (avoidance of unnecessary electrocardiography during routine examinations).
An analysis of the office-based visits separately from the hospital-based visits showed similar results. The use of a clinical decision support feature was helpful only in avoiding inappropriate ECGs in office-based visits. And such features were helpful in promoting smoking cessation counseling in hospital-based visits, but actually were linked to poorer performance in the use of inhaled corticosteroids for asthma and the use of appropriate blood pressure monitoring.
The investigators found that EHRs were used much more frequently during visits in the Western United States than in other regions. A post-hoc analysis showed that this did not correlate with improved care in the Western United States. "Western visits had higher quality than other regions for 2 indicators (appropriate antibiotic use in respiratory infection and avoiding inappropriate ECG ordering), worse quality for 3 indicators (UTI antibiotic selection, diet counseling, and exercise counseling), and similar quality for the remaining 15 indicators," they wrote (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.527]).
Since the use of EHRs and clinical decision support features is expected to increase because of federal incentives associated with their use, the real world performance of such systems "should be monitored carefully and [their] impact and cost evaluated rigorously," Mr. Romano and Dr. Stafford added.
In invited commentary accompanying the report, Dr. Clement McDonald and Dr. Swapna Abhyankar said that the "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," said Dr. McDonald and Dr. Abhyankar of the National Library of Medicine in Bethesda, Md.
They reported no relevant financial disclosures. This study was supported by the National Heart, Lung, and Blood Institute and Stanford University.
The "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial, said Dr. Clement McDonald and Dr. Swapna Abhyankar.
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," they wrote.
Clement McDonald, M.D., and Swapna Abhyankar, M.D., are with the National Library of Medicine in Bethesda, Md. They reported no relevant financial disclosures. These comments were taken from their invited commentary that accompanied the report by Mr. Romano and Dr. Stafford (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
The "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial, said Dr. Clement McDonald and Dr. Swapna Abhyankar.
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," they wrote.
Clement McDonald, M.D., and Swapna Abhyankar, M.D., are with the National Library of Medicine in Bethesda, Md. They reported no relevant financial disclosures. These comments were taken from their invited commentary that accompanied the report by Mr. Romano and Dr. Stafford (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
The "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial, said Dr. Clement McDonald and Dr. Swapna Abhyankar.
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," they wrote.
Clement McDonald, M.D., and Swapna Abhyankar, M.D., are with the National Library of Medicine in Bethesda, Md. They reported no relevant financial disclosures. These comments were taken from their invited commentary that accompanied the report by Mr. Romano and Dr. Stafford (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
Electronic health records, either with or without features to aid clinical decision making, failed to improve the quality of outpatient care in a study of more than 240,000 physician visits across the country, according to a report published online Jan. 24 in Archives of Internal Medicine.
The study findings "cast doubt on the argument that the use of electronic health records is a ‘magic bullet’ for health care quality improvement, as some advocates imply," according to Max J. Romano and Dr. Randall S. Stafford of the prevention research center at Stanford (Calif.) University.
"Since 1991, the Institute of Medicine has repeatedly called for increasing electronic health record (EHR) use to improve health care quality," the authors wrote, adding that "the American Reinvestment and Recovery Act stimulus bill set aside $19.2 billion to promote health information technology use in the United States, with the underlying assumption that more health IT is better.
"Nonetheless, evidence linking increased national use of outpatient EHRs to improved quality is lacking," as are data supporting included clinical decision support tools, Mr. Romano and Dr. Stafford said.
They analyzed data from two nationally representative samples collected by the National Center for Health Statistics in 2005-2007, the most recent years available. This included 243,478 patient visits to office-based, emergency department, and outpatient department physicians in family medicine, internal medicine, geriatrics, pediatrics, and general practice.
To evaluate the quality of care provided during these visits, 20 quality indicators were assessed in five areas: pharmacologic management of chronic diseases (such as atrial fibrillation, coronary artery disease, heart failure, hyperlipidemia, asthma, and hypertension); appropriate antibiotic use in urinary tract and viral upper respiratory tract infections; preventive counseling regarding diet, exercise, and smoking cessation; appropriate use of screening tests such as blood pressure measurement, urinalysis, and echocardiography; and inappropriate prescribing in the elderly.
Electronic health records were used in approximately 30% of all patient visits, and clinical decision support features were used in 17%. Neither EHR nor clinical decision support features were associated with higher-quality care.
When an EHR was used, care quality was better than when no EHR was used for only 1 of the 20 quality indicators (dietary counseling). Similarly, when a clinical decision support feature was used, care quality was better for only 1 of 20 quality indicators (avoidance of unnecessary electrocardiography during routine examinations).
An analysis of the office-based visits separately from the hospital-based visits showed similar results. The use of a clinical decision support feature was helpful only in avoiding inappropriate ECGs in office-based visits. And such features were helpful in promoting smoking cessation counseling in hospital-based visits, but actually were linked to poorer performance in the use of inhaled corticosteroids for asthma and the use of appropriate blood pressure monitoring.
The investigators found that EHRs were used much more frequently during visits in the Western United States than in other regions. A post-hoc analysis showed that this did not correlate with improved care in the Western United States. "Western visits had higher quality than other regions for 2 indicators (appropriate antibiotic use in respiratory infection and avoiding inappropriate ECG ordering), worse quality for 3 indicators (UTI antibiotic selection, diet counseling, and exercise counseling), and similar quality for the remaining 15 indicators," they wrote (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.527]).
Since the use of EHRs and clinical decision support features is expected to increase because of federal incentives associated with their use, the real world performance of such systems "should be monitored carefully and [their] impact and cost evaluated rigorously," Mr. Romano and Dr. Stafford added.
In invited commentary accompanying the report, Dr. Clement McDonald and Dr. Swapna Abhyankar said that the "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," said Dr. McDonald and Dr. Abhyankar of the National Library of Medicine in Bethesda, Md.
They reported no relevant financial disclosures. This study was supported by the National Heart, Lung, and Blood Institute and Stanford University.
Electronic health records, either with or without features to aid clinical decision making, failed to improve the quality of outpatient care in a study of more than 240,000 physician visits across the country, according to a report published online Jan. 24 in Archives of Internal Medicine.
The study findings "cast doubt on the argument that the use of electronic health records is a ‘magic bullet’ for health care quality improvement, as some advocates imply," according to Max J. Romano and Dr. Randall S. Stafford of the prevention research center at Stanford (Calif.) University.
"Since 1991, the Institute of Medicine has repeatedly called for increasing electronic health record (EHR) use to improve health care quality," the authors wrote, adding that "the American Reinvestment and Recovery Act stimulus bill set aside $19.2 billion to promote health information technology use in the United States, with the underlying assumption that more health IT is better.
"Nonetheless, evidence linking increased national use of outpatient EHRs to improved quality is lacking," as are data supporting included clinical decision support tools, Mr. Romano and Dr. Stafford said.
They analyzed data from two nationally representative samples collected by the National Center for Health Statistics in 2005-2007, the most recent years available. This included 243,478 patient visits to office-based, emergency department, and outpatient department physicians in family medicine, internal medicine, geriatrics, pediatrics, and general practice.
To evaluate the quality of care provided during these visits, 20 quality indicators were assessed in five areas: pharmacologic management of chronic diseases (such as atrial fibrillation, coronary artery disease, heart failure, hyperlipidemia, asthma, and hypertension); appropriate antibiotic use in urinary tract and viral upper respiratory tract infections; preventive counseling regarding diet, exercise, and smoking cessation; appropriate use of screening tests such as blood pressure measurement, urinalysis, and echocardiography; and inappropriate prescribing in the elderly.
Electronic health records were used in approximately 30% of all patient visits, and clinical decision support features were used in 17%. Neither EHR nor clinical decision support features were associated with higher-quality care.
When an EHR was used, care quality was better than when no EHR was used for only 1 of the 20 quality indicators (dietary counseling). Similarly, when a clinical decision support feature was used, care quality was better for only 1 of 20 quality indicators (avoidance of unnecessary electrocardiography during routine examinations).
An analysis of the office-based visits separately from the hospital-based visits showed similar results. The use of a clinical decision support feature was helpful only in avoiding inappropriate ECGs in office-based visits. And such features were helpful in promoting smoking cessation counseling in hospital-based visits, but actually were linked to poorer performance in the use of inhaled corticosteroids for asthma and the use of appropriate blood pressure monitoring.
The investigators found that EHRs were used much more frequently during visits in the Western United States than in other regions. A post-hoc analysis showed that this did not correlate with improved care in the Western United States. "Western visits had higher quality than other regions for 2 indicators (appropriate antibiotic use in respiratory infection and avoiding inappropriate ECG ordering), worse quality for 3 indicators (UTI antibiotic selection, diet counseling, and exercise counseling), and similar quality for the remaining 15 indicators," they wrote (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.527]).
Since the use of EHRs and clinical decision support features is expected to increase because of federal incentives associated with their use, the real world performance of such systems "should be monitored carefully and [their] impact and cost evaluated rigorously," Mr. Romano and Dr. Stafford added.
In invited commentary accompanying the report, Dr. Clement McDonald and Dr. Swapna Abhyankar said that the "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," said Dr. McDonald and Dr. Abhyankar of the National Library of Medicine in Bethesda, Md.
They reported no relevant financial disclosures. This study was supported by the National Heart, Lung, and Blood Institute and Stanford University.
From Archives of Internal Medicine
Electronic Records Fail to Deliver Better-Quality Outpatient Care
Electronic health records, either with or without features to aid clinical decision making, failed to improve the quality of outpatient care in a study of more than 240,000 physician visits across the country, according to a report published online Jan. 24 in Archives of Internal Medicine.
The study findings "cast doubt on the argument that the use of electronic health records is a ‘magic bullet’ for health care quality improvement, as some advocates imply," according to Max J. Romano and Dr. Randall S. Stafford of the prevention research center at Stanford (Calif.) University.
"Since 1991, the Institute of Medicine has repeatedly called for increasing electronic health record (EHR) use to improve health care quality," the authors wrote, adding that "the American Reinvestment and Recovery Act stimulus bill set aside $19.2 billion to promote health information technology use in the United States, with the underlying assumption that more health IT is better.
"Nonetheless, evidence linking increased national use of outpatient EHRs to improved quality is lacking," as are data supporting included clinical decision support tools, Mr. Romano and Dr. Stafford said.
They analyzed data from two nationally representative samples collected by the National Center for Health Statistics in 2005-2007, the most recent years available. This included 243,478 patient visits to office-based, emergency department, and outpatient department physicians in family medicine, internal medicine, geriatrics, pediatrics, and general practice.
To evaluate the quality of care provided during these visits, 20 quality indicators were assessed in five areas: pharmacologic management of chronic diseases (such as atrial fibrillation, coronary artery disease, heart failure, hyperlipidemia, asthma, and hypertension); appropriate antibiotic use in urinary tract and viral upper respiratory tract infections; preventive counseling regarding diet, exercise, and smoking cessation; appropriate use of screening tests such as blood pressure measurement, urinalysis, and echocardiography; and inappropriate prescribing in the elderly.
Electronic health records were used in approximately 30% of all patient visits, and clinical decision support features were used in 17%. Neither EHR nor clinical decision support features were associated with higher-quality care.
When an EHR was used, care quality was better than when no EHR was used for only 1 of the 20 quality indicators (dietary counseling). Similarly, when a clinical decision support feature was used, care quality was better for only 1 of 20 quality indicators (avoidance of unnecessary electrocardiography during routine examinations).
An analysis of the office-based visits separately from the hospital-based visits showed similar results. The use of a clinical decision support feature was helpful only in avoiding inappropriate ECGs in office-based visits. And such features were helpful in promoting smoking cessation counseling in hospital-based visits, but actually were linked to poorer performance in the use of inhaled corticosteroids for asthma and the use of appropriate blood pressure monitoring.
The investigators found that EHRs were used much more frequently during visits in the Western United States than in other regions. A post-hoc analysis showed that this did not correlate with improved care in the Western United States. "Western visits had higher quality than other regions for 2 indicators (appropriate antibiotic use in respiratory infection and avoiding inappropriate ECG ordering), worse quality for 3 indicators (UTI antibiotic selection, diet counseling, and exercise counseling), and similar quality for the remaining 15 indicators," they wrote (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.527]).
Since the use of EHRs and clinical decision support features is expected to increase because of federal incentives associated with their use, the real world performance of such systems "should be monitored carefully and [their] impact and cost evaluated rigorously," Mr. Romano and Dr. Stafford added.
In invited commentary accompanying the report, Dr. Clement McDonald and Dr. Swapna Abhyankar said that the "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," said Dr. McDonald and Dr. Abhyankar of the National Library of Medicine in Bethesda, Md.
They reported no relevant financial disclosures. This study was supported by the National Heart, Lung, and Blood Institute and Stanford University.
The "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial, said Dr. Clement McDonald and Dr. Swapna Abhyankar.
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," they wrote.
Clement McDonald, M.D., and Swapna Abhyankar, M.D., are with the National Library of Medicine in Bethesda, Md. They reported no relevant financial disclosures. These comments were taken from their invited commentary that accompanied the report by Mr. Romano and Dr. Stafford (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
The "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial, said Dr. Clement McDonald and Dr. Swapna Abhyankar.
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," they wrote.
Clement McDonald, M.D., and Swapna Abhyankar, M.D., are with the National Library of Medicine in Bethesda, Md. They reported no relevant financial disclosures. These comments were taken from their invited commentary that accompanied the report by Mr. Romano and Dr. Stafford (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
The "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial, said Dr. Clement McDonald and Dr. Swapna Abhyankar.
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," they wrote.
Clement McDonald, M.D., and Swapna Abhyankar, M.D., are with the National Library of Medicine in Bethesda, Md. They reported no relevant financial disclosures. These comments were taken from their invited commentary that accompanied the report by Mr. Romano and Dr. Stafford (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
Electronic health records, either with or without features to aid clinical decision making, failed to improve the quality of outpatient care in a study of more than 240,000 physician visits across the country, according to a report published online Jan. 24 in Archives of Internal Medicine.
The study findings "cast doubt on the argument that the use of electronic health records is a ‘magic bullet’ for health care quality improvement, as some advocates imply," according to Max J. Romano and Dr. Randall S. Stafford of the prevention research center at Stanford (Calif.) University.
"Since 1991, the Institute of Medicine has repeatedly called for increasing electronic health record (EHR) use to improve health care quality," the authors wrote, adding that "the American Reinvestment and Recovery Act stimulus bill set aside $19.2 billion to promote health information technology use in the United States, with the underlying assumption that more health IT is better.
"Nonetheless, evidence linking increased national use of outpatient EHRs to improved quality is lacking," as are data supporting included clinical decision support tools, Mr. Romano and Dr. Stafford said.
They analyzed data from two nationally representative samples collected by the National Center for Health Statistics in 2005-2007, the most recent years available. This included 243,478 patient visits to office-based, emergency department, and outpatient department physicians in family medicine, internal medicine, geriatrics, pediatrics, and general practice.
To evaluate the quality of care provided during these visits, 20 quality indicators were assessed in five areas: pharmacologic management of chronic diseases (such as atrial fibrillation, coronary artery disease, heart failure, hyperlipidemia, asthma, and hypertension); appropriate antibiotic use in urinary tract and viral upper respiratory tract infections; preventive counseling regarding diet, exercise, and smoking cessation; appropriate use of screening tests such as blood pressure measurement, urinalysis, and echocardiography; and inappropriate prescribing in the elderly.
Electronic health records were used in approximately 30% of all patient visits, and clinical decision support features were used in 17%. Neither EHR nor clinical decision support features were associated with higher-quality care.
When an EHR was used, care quality was better than when no EHR was used for only 1 of the 20 quality indicators (dietary counseling). Similarly, when a clinical decision support feature was used, care quality was better for only 1 of 20 quality indicators (avoidance of unnecessary electrocardiography during routine examinations).
An analysis of the office-based visits separately from the hospital-based visits showed similar results. The use of a clinical decision support feature was helpful only in avoiding inappropriate ECGs in office-based visits. And such features were helpful in promoting smoking cessation counseling in hospital-based visits, but actually were linked to poorer performance in the use of inhaled corticosteroids for asthma and the use of appropriate blood pressure monitoring.
The investigators found that EHRs were used much more frequently during visits in the Western United States than in other regions. A post-hoc analysis showed that this did not correlate with improved care in the Western United States. "Western visits had higher quality than other regions for 2 indicators (appropriate antibiotic use in respiratory infection and avoiding inappropriate ECG ordering), worse quality for 3 indicators (UTI antibiotic selection, diet counseling, and exercise counseling), and similar quality for the remaining 15 indicators," they wrote (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.527]).
Since the use of EHRs and clinical decision support features is expected to increase because of federal incentives associated with their use, the real world performance of such systems "should be monitored carefully and [their] impact and cost evaluated rigorously," Mr. Romano and Dr. Stafford added.
In invited commentary accompanying the report, Dr. Clement McDonald and Dr. Swapna Abhyankar said that the "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," said Dr. McDonald and Dr. Abhyankar of the National Library of Medicine in Bethesda, Md.
They reported no relevant financial disclosures. This study was supported by the National Heart, Lung, and Blood Institute and Stanford University.
Electronic health records, either with or without features to aid clinical decision making, failed to improve the quality of outpatient care in a study of more than 240,000 physician visits across the country, according to a report published online Jan. 24 in Archives of Internal Medicine.
The study findings "cast doubt on the argument that the use of electronic health records is a ‘magic bullet’ for health care quality improvement, as some advocates imply," according to Max J. Romano and Dr. Randall S. Stafford of the prevention research center at Stanford (Calif.) University.
"Since 1991, the Institute of Medicine has repeatedly called for increasing electronic health record (EHR) use to improve health care quality," the authors wrote, adding that "the American Reinvestment and Recovery Act stimulus bill set aside $19.2 billion to promote health information technology use in the United States, with the underlying assumption that more health IT is better.
"Nonetheless, evidence linking increased national use of outpatient EHRs to improved quality is lacking," as are data supporting included clinical decision support tools, Mr. Romano and Dr. Stafford said.
They analyzed data from two nationally representative samples collected by the National Center for Health Statistics in 2005-2007, the most recent years available. This included 243,478 patient visits to office-based, emergency department, and outpatient department physicians in family medicine, internal medicine, geriatrics, pediatrics, and general practice.
To evaluate the quality of care provided during these visits, 20 quality indicators were assessed in five areas: pharmacologic management of chronic diseases (such as atrial fibrillation, coronary artery disease, heart failure, hyperlipidemia, asthma, and hypertension); appropriate antibiotic use in urinary tract and viral upper respiratory tract infections; preventive counseling regarding diet, exercise, and smoking cessation; appropriate use of screening tests such as blood pressure measurement, urinalysis, and echocardiography; and inappropriate prescribing in the elderly.
Electronic health records were used in approximately 30% of all patient visits, and clinical decision support features were used in 17%. Neither EHR nor clinical decision support features were associated with higher-quality care.
When an EHR was used, care quality was better than when no EHR was used for only 1 of the 20 quality indicators (dietary counseling). Similarly, when a clinical decision support feature was used, care quality was better for only 1 of 20 quality indicators (avoidance of unnecessary electrocardiography during routine examinations).
An analysis of the office-based visits separately from the hospital-based visits showed similar results. The use of a clinical decision support feature was helpful only in avoiding inappropriate ECGs in office-based visits. And such features were helpful in promoting smoking cessation counseling in hospital-based visits, but actually were linked to poorer performance in the use of inhaled corticosteroids for asthma and the use of appropriate blood pressure monitoring.
The investigators found that EHRs were used much more frequently during visits in the Western United States than in other regions. A post-hoc analysis showed that this did not correlate with improved care in the Western United States. "Western visits had higher quality than other regions for 2 indicators (appropriate antibiotic use in respiratory infection and avoiding inappropriate ECG ordering), worse quality for 3 indicators (UTI antibiotic selection, diet counseling, and exercise counseling), and similar quality for the remaining 15 indicators," they wrote (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.527]).
Since the use of EHRs and clinical decision support features is expected to increase because of federal incentives associated with their use, the real world performance of such systems "should be monitored carefully and [their] impact and cost evaluated rigorously," Mr. Romano and Dr. Stafford added.
In invited commentary accompanying the report, Dr. Clement McDonald and Dr. Swapna Abhyankar said that the "dismal" results reported by Mr. Romano and Dr. Stafford were surprising, given that previously reported randomized controlled trials had found that the use of EHRs and clinical decision support features were strongly beneficial (Arch. Intern. Med. 2011 Jan. 24 [doi:10.1001/archinternmed.2010.518]).
"We know from multiple randomized controlled trials that well-implemented clinical decision support systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level.
"The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and clinical decision support systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data," said Dr. McDonald and Dr. Abhyankar of the National Library of Medicine in Bethesda, Md.
They reported no relevant financial disclosures. This study was supported by the National Heart, Lung, and Blood Institute and Stanford University.
FROM THE ARCHIVES OF INTERNAL MEDICINE
Major Finding: Neither electronic health records nor clinical decision support tools were associated with improved care in outpatient visits with family medicine, internal medicine, geriatrics, pediatrics, or general practice physicians.
Data Source: Analysis of national survey data on 243,478 visits with outpatient physicians in 2005-2007.
Disclosures: This study was supported by the National Heart, Lung, and Blood Institute and Stanford University.
Smoking Raises Risk of Breast Cancer Modestly
Smoking raises the risk of breast cancer modestly, according to a report in the Jan. 24 issue of Archives of Internal Medicine.
Several measures of smoking – including the current quantity of cigarettes smoked, the past quantity of cigarettes smoked, the age at smoking onset, the duration of smoking, and total pack-years of smoking – correlated with risk of breast cancer in an updated analysis of data from the Nurses’ Health Study (NHS).
The strongest association was found in women who began smoking before giving birth for the first time, said Dr. Fei Xue of Brigham and Women’s Hospital and Harvard Medical School, Boston, and associates.
There have been numerous previous studies of this issue, but they have yielded a mix of positive, inverse, and null associations. In what the investigators described as "the largest [study] so far on the association between smoking and breast cancer risk," Dr. Xue and colleagues assessed data on 111,140 women participating in the prospective NHS from 1976 through 2006.
During that time there were 8,772 incident cases of breast cancer.
Women who had ever smoked had a "marginally increased" incidence of the disease compared with those who had never smoked, and the rate appeared to be comparable between current smokers and past smokers. "Every increase of 20 pack-years of smoking after menarche was associated with a marginal increase of incidence of breast cancer after adjusting for other risk factors," the researchers said.
Breast cancer risk was elevated in women who smoked 25 or more cigarettes per day either currently or in the past, women who began smoking at or before the age of 17, and women who smoked for 20 years or longer. "In most of the previous studies, these smoking measures were not mutually adjusted. In [our] study, we created an index of active smoking that integrates quantity, age at which one started smoking, and duration of smoking.
"The results suggested that, although an elevated risk for light smokers and moderate smokers was not apparent, heavy smokers who started smoking early in life, smoked for a long duration, and smoked a high quantity were at the highest risk of breast cancer, supporting an independent and additive effect from various smoking measures on breast carcinogenesis," they said (Arch. Intern. Med. 2011:171:125-33).
Starting to smoke before the first birth also was strongly associated with breast cancer. "All previous studies that have separately evaluated smoking before and after the first birth have found a similar pattern, suggesting that smoking before the first birth may be more important to breast carcinogenesis than smoking after the first birth," Dr. Xue and associates wrote.
"Smoking before menopause was positively associated with breast cancer risk, and there were hints from our results that smoking after menopause might be associated with a slightly decreased breast cancer risk. This difference suggests an antiestrogenic effect of smoking among postmenopausal women that may further reduce their already low endogenous estrogen levels.
"Conversely, among premenopausal women, any antiestrogenic effect of smoking may not be strong enough to significantly reduce endogenous estrogen levels, leaving the dominant carcinogenic effect of smoking," the researchers said.
In contrast to active smoking, passive smoking in childhood or adulthood was not associated with breast cancer risk. "Our results combined with the evidence from previous prospective cohort studies collectively suggest that passive smoking may not play an important role in the etiology of breast cancer. Nonetheless, we found that regular exposure to passive smoking may magnify the effect of active smoking," Dr. Xue and colleagues wrote.
The Nurses’ Health Study was funded by the National Cancer Institute. Dr. Xue and associates reported no relevant financial disclosures.
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Doctor’s Bio
Smoking raises the risk of breast cancer modestly, according to a report in the Jan. 24 issue of Archives of Internal Medicine.
Several measures of smoking – including the current quantity of cigarettes smoked, the past quantity of cigarettes smoked, the age at smoking onset, the duration of smoking, and total pack-years of smoking – correlated with risk of breast cancer in an updated analysis of data from the Nurses’ Health Study (NHS).
The strongest association was found in women who began smoking before giving birth for the first time, said Dr. Fei Xue of Brigham and Women’s Hospital and Harvard Medical School, Boston, and associates.
There have been numerous previous studies of this issue, but they have yielded a mix of positive, inverse, and null associations. In what the investigators described as "the largest [study] so far on the association between smoking and breast cancer risk," Dr. Xue and colleagues assessed data on 111,140 women participating in the prospective NHS from 1976 through 2006.
During that time there were 8,772 incident cases of breast cancer.
Women who had ever smoked had a "marginally increased" incidence of the disease compared with those who had never smoked, and the rate appeared to be comparable between current smokers and past smokers. "Every increase of 20 pack-years of smoking after menarche was associated with a marginal increase of incidence of breast cancer after adjusting for other risk factors," the researchers said.
Breast cancer risk was elevated in women who smoked 25 or more cigarettes per day either currently or in the past, women who began smoking at or before the age of 17, and women who smoked for 20 years or longer. "In most of the previous studies, these smoking measures were not mutually adjusted. In [our] study, we created an index of active smoking that integrates quantity, age at which one started smoking, and duration of smoking.
"The results suggested that, although an elevated risk for light smokers and moderate smokers was not apparent, heavy smokers who started smoking early in life, smoked for a long duration, and smoked a high quantity were at the highest risk of breast cancer, supporting an independent and additive effect from various smoking measures on breast carcinogenesis," they said (Arch. Intern. Med. 2011:171:125-33).
Starting to smoke before the first birth also was strongly associated with breast cancer. "All previous studies that have separately evaluated smoking before and after the first birth have found a similar pattern, suggesting that smoking before the first birth may be more important to breast carcinogenesis than smoking after the first birth," Dr. Xue and associates wrote.
"Smoking before menopause was positively associated with breast cancer risk, and there were hints from our results that smoking after menopause might be associated with a slightly decreased breast cancer risk. This difference suggests an antiestrogenic effect of smoking among postmenopausal women that may further reduce their already low endogenous estrogen levels.
"Conversely, among premenopausal women, any antiestrogenic effect of smoking may not be strong enough to significantly reduce endogenous estrogen levels, leaving the dominant carcinogenic effect of smoking," the researchers said.
In contrast to active smoking, passive smoking in childhood or adulthood was not associated with breast cancer risk. "Our results combined with the evidence from previous prospective cohort studies collectively suggest that passive smoking may not play an important role in the etiology of breast cancer. Nonetheless, we found that regular exposure to passive smoking may magnify the effect of active smoking," Dr. Xue and colleagues wrote.
The Nurses’ Health Study was funded by the National Cancer Institute. Dr. Xue and associates reported no relevant financial disclosures.
Smoking raises the risk of breast cancer modestly, according to a report in the Jan. 24 issue of Archives of Internal Medicine.
Several measures of smoking – including the current quantity of cigarettes smoked, the past quantity of cigarettes smoked, the age at smoking onset, the duration of smoking, and total pack-years of smoking – correlated with risk of breast cancer in an updated analysis of data from the Nurses’ Health Study (NHS).
The strongest association was found in women who began smoking before giving birth for the first time, said Dr. Fei Xue of Brigham and Women’s Hospital and Harvard Medical School, Boston, and associates.
There have been numerous previous studies of this issue, but they have yielded a mix of positive, inverse, and null associations. In what the investigators described as "the largest [study] so far on the association between smoking and breast cancer risk," Dr. Xue and colleagues assessed data on 111,140 women participating in the prospective NHS from 1976 through 2006.
During that time there were 8,772 incident cases of breast cancer.
Women who had ever smoked had a "marginally increased" incidence of the disease compared with those who had never smoked, and the rate appeared to be comparable between current smokers and past smokers. "Every increase of 20 pack-years of smoking after menarche was associated with a marginal increase of incidence of breast cancer after adjusting for other risk factors," the researchers said.
Breast cancer risk was elevated in women who smoked 25 or more cigarettes per day either currently or in the past, women who began smoking at or before the age of 17, and women who smoked for 20 years or longer. "In most of the previous studies, these smoking measures were not mutually adjusted. In [our] study, we created an index of active smoking that integrates quantity, age at which one started smoking, and duration of smoking.
"The results suggested that, although an elevated risk for light smokers and moderate smokers was not apparent, heavy smokers who started smoking early in life, smoked for a long duration, and smoked a high quantity were at the highest risk of breast cancer, supporting an independent and additive effect from various smoking measures on breast carcinogenesis," they said (Arch. Intern. Med. 2011:171:125-33).
Starting to smoke before the first birth also was strongly associated with breast cancer. "All previous studies that have separately evaluated smoking before and after the first birth have found a similar pattern, suggesting that smoking before the first birth may be more important to breast carcinogenesis than smoking after the first birth," Dr. Xue and associates wrote.
"Smoking before menopause was positively associated with breast cancer risk, and there were hints from our results that smoking after menopause might be associated with a slightly decreased breast cancer risk. This difference suggests an antiestrogenic effect of smoking among postmenopausal women that may further reduce their already low endogenous estrogen levels.
"Conversely, among premenopausal women, any antiestrogenic effect of smoking may not be strong enough to significantly reduce endogenous estrogen levels, leaving the dominant carcinogenic effect of smoking," the researchers said.
In contrast to active smoking, passive smoking in childhood or adulthood was not associated with breast cancer risk. "Our results combined with the evidence from previous prospective cohort studies collectively suggest that passive smoking may not play an important role in the etiology of breast cancer. Nonetheless, we found that regular exposure to passive smoking may magnify the effect of active smoking," Dr. Xue and colleagues wrote.
The Nurses’ Health Study was funded by the National Cancer Institute. Dr. Xue and associates reported no relevant financial disclosures.
FROM ARCHIVES OF INTERNAL MEDICINE
Major Finding: Women who were current or past smokers have a modestly higher risk of developing breast cancer than women who never smoked.
Data Source: An updated analysis of data collected on 111,140 subjects followed for 30 years in the Nurses’ Health Study.
Disclosures: The Nurses’ Health Study was funded by the National Cancer Institute. Dr. Xue and associates reported no relevant financial disclosures.
Half of Recurrent ACS Due to Existing 'Mild' Lesions
Approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, according to a report in the Jan. 20 issue of the New England Journal of Medicine.
The rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, said Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.
They conducted the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study using new imaging tools that help characterize the content of coronary lesions, to identify factors that raise the risk for recurrent ACS.
The study, conducted at 37 medical centers in the United States and Europe, was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available radiofrequency intravascular ultrasonography of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.
Unlike the other imaging techniques, radiofrequency intravascular ultrasonography provides data about tissue composition. It allowed the investigators to classify coronary lesions as thin-cap fibroatheroma, thick-cap fibroatheroma, pathologic intimal thickening, fibrotic plaque, or fibrocalcific plaque.
The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.
"We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions," Dr. Stone and his colleagues said.
"Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common," they noted.
Radiofrequency intravascular ultrasonography at baseline revealed that most of the "nonculprit" coronary lesions – those that had been considered mild on the index angiography and were not treated at that time – were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.
In contrast, no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.
These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.
However, "there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention," the investigators noted (N. Engl. J. Med. 2011:364:226-35).
First, this method lacks specificity at present. Radiofrequency intravascular ultrasonography identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.
"Even when all three predictive variables were present, the event rate rose to only 18%," they said.
Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 "nonculprit" lesions seen on angiography could be evaluated by radiofrequency intravascular ultrasonography.
Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.
And fourth, it is still unclear what therapies should be used when the technique identifies these high-risk lesions.
CLARIFICATION, 1/26/2011: The original version of this article did not list disclosures, which are included below.
PROSPECT and was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, Boston Scientific, Merck, Edwards Lifesciences, Bioabsorbable Therapeutics, Asten BioPharma, AstraZeneca, Prescient, Eli Lilly, Bristol-Myers Squibb,and Sanofi-Aventis; and owning stock or stock options in numerous companies including CoreValve, Savacor, Xtent, FlowCardia, Ovalum Vascular, and MediGuide. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.
Approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, according to a report in the Jan. 20 issue of the New England Journal of Medicine.
The rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, said Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.
They conducted the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study using new imaging tools that help characterize the content of coronary lesions, to identify factors that raise the risk for recurrent ACS.
The study, conducted at 37 medical centers in the United States and Europe, was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available radiofrequency intravascular ultrasonography of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.
Unlike the other imaging techniques, radiofrequency intravascular ultrasonography provides data about tissue composition. It allowed the investigators to classify coronary lesions as thin-cap fibroatheroma, thick-cap fibroatheroma, pathologic intimal thickening, fibrotic plaque, or fibrocalcific plaque.
The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.
"We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions," Dr. Stone and his colleagues said.
"Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common," they noted.
Radiofrequency intravascular ultrasonography at baseline revealed that most of the "nonculprit" coronary lesions – those that had been considered mild on the index angiography and were not treated at that time – were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.
In contrast, no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.
These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.
However, "there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention," the investigators noted (N. Engl. J. Med. 2011:364:226-35).
First, this method lacks specificity at present. Radiofrequency intravascular ultrasonography identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.
"Even when all three predictive variables were present, the event rate rose to only 18%," they said.
Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 "nonculprit" lesions seen on angiography could be evaluated by radiofrequency intravascular ultrasonography.
Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.
And fourth, it is still unclear what therapies should be used when the technique identifies these high-risk lesions.
CLARIFICATION, 1/26/2011: The original version of this article did not list disclosures, which are included below.
PROSPECT and was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, Boston Scientific, Merck, Edwards Lifesciences, Bioabsorbable Therapeutics, Asten BioPharma, AstraZeneca, Prescient, Eli Lilly, Bristol-Myers Squibb,and Sanofi-Aventis; and owning stock or stock options in numerous companies including CoreValve, Savacor, Xtent, FlowCardia, Ovalum Vascular, and MediGuide. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.
Approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, according to a report in the Jan. 20 issue of the New England Journal of Medicine.
The rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, said Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.
They conducted the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study using new imaging tools that help characterize the content of coronary lesions, to identify factors that raise the risk for recurrent ACS.
The study, conducted at 37 medical centers in the United States and Europe, was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available radiofrequency intravascular ultrasonography of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.
Unlike the other imaging techniques, radiofrequency intravascular ultrasonography provides data about tissue composition. It allowed the investigators to classify coronary lesions as thin-cap fibroatheroma, thick-cap fibroatheroma, pathologic intimal thickening, fibrotic plaque, or fibrocalcific plaque.
The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.
"We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions," Dr. Stone and his colleagues said.
"Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common," they noted.
Radiofrequency intravascular ultrasonography at baseline revealed that most of the "nonculprit" coronary lesions – those that had been considered mild on the index angiography and were not treated at that time – were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.
In contrast, no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.
These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.
However, "there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention," the investigators noted (N. Engl. J. Med. 2011:364:226-35).
First, this method lacks specificity at present. Radiofrequency intravascular ultrasonography identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.
"Even when all three predictive variables were present, the event rate rose to only 18%," they said.
Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 "nonculprit" lesions seen on angiography could be evaluated by radiofrequency intravascular ultrasonography.
Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.
And fourth, it is still unclear what therapies should be used when the technique identifies these high-risk lesions.
CLARIFICATION, 1/26/2011: The original version of this article did not list disclosures, which are included below.
PROSPECT and was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, Boston Scientific, Merck, Edwards Lifesciences, Bioabsorbable Therapeutics, Asten BioPharma, AstraZeneca, Prescient, Eli Lilly, Bristol-Myers Squibb,and Sanofi-Aventis; and owning stock or stock options in numerous companies including CoreValve, Savacor, Xtent, FlowCardia, Ovalum Vascular, and MediGuide. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Half of Recurrent ACS Due to Existing 'Mild' Lesions
Approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, according to a report in the Jan. 20 issue of the New England Journal of Medicine.
The rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, said Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.
They conducted the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study using new imaging tools that help characterize the content of coronary lesions, to identify factors that raise the risk for recurrent ACS.
The study, conducted at 37 medical centers in the United States and Europe, was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available radiofrequency intravascular ultrasonography of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.
Unlike the other imaging techniques, radiofrequency intravascular ultrasonography provides data about tissue composition. It allowed the investigators to classify coronary lesions as thin-cap fibroatheroma, thick-cap fibroatheroma, pathologic intimal thickening, fibrotic plaque, or fibrocalcific plaque.
The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.
"We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions," Dr. Stone and his colleagues said.
"Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common," they noted.
Radiofrequency intravascular ultrasonography at baseline revealed that most of the "nonculprit" coronary lesions – those that had been considered mild on the index angiography and were not treated at that time – were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.
In contrast, no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.
These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.
However, "there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention," the investigators noted (N. Engl. J. Med. 2011:364:226-35).
First, this method lacks specificity at present. Radiofrequency intravascular ultrasonography identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.
"Even when all three predictive variables were present, the event rate rose to only 18%," they said.
Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 "nonculprit" lesions seen on angiography could be evaluated by radiofrequency intravascular ultrasonography.
Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.
And fourth, it is still unclear what therapies should be used when the technique identifies these high-risk lesions.
CLARIFICATION, 1/26/2011: The original version of this article did not list disclosures, which are included below.
PROSPECT and was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, Boston Scientific, Merck, Edwards Lifesciences, Bioabsorbable Therapeutics, Asten BioPharma, AstraZeneca, Prescient, Eli Lilly, Bristol-Myers Squibb,and Sanofi-Aventis; and owning stock or stock options in numerous companies including CoreValve, Savacor, Xtent, FlowCardia, Ovalum Vascular, and MediGuide. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.
Approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, according to a report in the Jan. 20 issue of the New England Journal of Medicine.
The rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, said Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.
They conducted the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study using new imaging tools that help characterize the content of coronary lesions, to identify factors that raise the risk for recurrent ACS.
The study, conducted at 37 medical centers in the United States and Europe, was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available radiofrequency intravascular ultrasonography of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.
Unlike the other imaging techniques, radiofrequency intravascular ultrasonography provides data about tissue composition. It allowed the investigators to classify coronary lesions as thin-cap fibroatheroma, thick-cap fibroatheroma, pathologic intimal thickening, fibrotic plaque, or fibrocalcific plaque.
The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.
"We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions," Dr. Stone and his colleagues said.
"Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common," they noted.
Radiofrequency intravascular ultrasonography at baseline revealed that most of the "nonculprit" coronary lesions – those that had been considered mild on the index angiography and were not treated at that time – were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.
In contrast, no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.
These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.
However, "there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention," the investigators noted (N. Engl. J. Med. 2011:364:226-35).
First, this method lacks specificity at present. Radiofrequency intravascular ultrasonography identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.
"Even when all three predictive variables were present, the event rate rose to only 18%," they said.
Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 "nonculprit" lesions seen on angiography could be evaluated by radiofrequency intravascular ultrasonography.
Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.
And fourth, it is still unclear what therapies should be used when the technique identifies these high-risk lesions.
CLARIFICATION, 1/26/2011: The original version of this article did not list disclosures, which are included below.
PROSPECT and was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, Boston Scientific, Merck, Edwards Lifesciences, Bioabsorbable Therapeutics, Asten BioPharma, AstraZeneca, Prescient, Eli Lilly, Bristol-Myers Squibb,and Sanofi-Aventis; and owning stock or stock options in numerous companies including CoreValve, Savacor, Xtent, FlowCardia, Ovalum Vascular, and MediGuide. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.
Approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, according to a report in the Jan. 20 issue of the New England Journal of Medicine.
The rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, said Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.
They conducted the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study using new imaging tools that help characterize the content of coronary lesions, to identify factors that raise the risk for recurrent ACS.
The study, conducted at 37 medical centers in the United States and Europe, was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available radiofrequency intravascular ultrasonography of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.
Unlike the other imaging techniques, radiofrequency intravascular ultrasonography provides data about tissue composition. It allowed the investigators to classify coronary lesions as thin-cap fibroatheroma, thick-cap fibroatheroma, pathologic intimal thickening, fibrotic plaque, or fibrocalcific plaque.
The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.
"We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions," Dr. Stone and his colleagues said.
"Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common," they noted.
Radiofrequency intravascular ultrasonography at baseline revealed that most of the "nonculprit" coronary lesions – those that had been considered mild on the index angiography and were not treated at that time – were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.
In contrast, no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.
These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.
However, "there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention," the investigators noted (N. Engl. J. Med. 2011:364:226-35).
First, this method lacks specificity at present. Radiofrequency intravascular ultrasonography identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.
"Even when all three predictive variables were present, the event rate rose to only 18%," they said.
Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 "nonculprit" lesions seen on angiography could be evaluated by radiofrequency intravascular ultrasonography.
Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.
And fourth, it is still unclear what therapies should be used when the technique identifies these high-risk lesions.
CLARIFICATION, 1/26/2011: The original version of this article did not list disclosures, which are included below.
PROSPECT and was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.
Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, Boston Scientific, Merck, Edwards Lifesciences, Bioabsorbable Therapeutics, Asten BioPharma, AstraZeneca, Prescient, Eli Lilly, Bristol-Myers Squibb,and Sanofi-Aventis; and owning stock or stock options in numerous companies including CoreValve, Savacor, Xtent, FlowCardia, Ovalum Vascular, and MediGuide. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Low Plasma Beta-Amyloid Ratio Linked to Faster Cognitive Decline
Older adults without dementia who had a low ratio of beta-amyloid 42:40 in plasma showed faster cognitive decline in a 9-year study than did those with a higher ratio of the two beta-amyloid peptides, according to a report in the Jan. 19 issue of JAMA.
This cognitive decline was more marked in subjects who had less cognitive reserve, as estimated by their lower educational attainment and lower literacy.
"These results are important, as the prevalence of cognitive impairment is increasing exponentially and prevention will be crucial. To identify those at risk of dementia, biomarkers like plasma beta-amyloid level that are relatively easy to obtain and minimally invasive could be useful," wrote Dr. Kristine Yaffe of the University of California, San Francisco, and her associates.
The investigators assessed the relationship between beta-amyloid levels and cognitive decline using a cohort of 3,075 community-dwelling residents of Memphis and Pittsburgh who had been enrolled in an aging study in 1997-1998 when they were 70-79 years old. They studied 997 of the individuals who had undergone repeated cognitive assessments during follow-up through 2007.
The mean age at baseline was 74 years. Approximately 555 of the study subjects were women, and 54% were African American.
A low beta-amyloid 42:40 ratio at baseline was significantly associated with greater cognitive decline on the Modified Mini-Mental State Examination, which has a maximum score of 100. Mean scores on the Modified Mini-Mental State Examination after 9 years of follow-up declined 6.59 points among people in the lowest tertile of plasma beta-amyloid 42:40 ratio, 6.16 points among those in the middle tertile, and 3.60 points among those in the highest tertile.
The investigators also detected a significant, but less robust, association between tertiles of plasma beta-amyloid 42 levels and cognitive decline.
Both associations remained significant when the data were adjusted to account for subject age, race, education level, smoking status, diabetes status, and apolipoprotein E e4 status, according to Dr. Yaffe and her colleagues (JAMA 2011;305:261-6).
Moreover, the association between plasma beta-amyloid 42:40 ratio and cognitive decline was strongest among people with a low cognitive reserve (as measured by less than a high school diploma or 6th grade literacy) and weakest among people with higher cognitive reserve. People who carried the apolipoprotein E e4 allele also showed a stronger association between plasma beta-amyloid 42:40 ratio and cognitive decline.
"Our results suggest that the plasma beta-amyloid 42:40 ratio appears to be a biomarker of cognitive decline," the researchers noted.
The modifying effect of cognitive reserve on the association between cognitive decline and plasma beta-amyloid 42:40 ratio "suggests possible pathways, such as cognitive activity or ongoing education, for mitigating or preventing beta-amyloid effects on cognition," they added.
The investigators did not measure cerebrospinal fluid levels of beta-amyloid 42 and 40 and so could not correlate them with plasma levels of the peptides, Dr. Yaffe and her associates said.
This study was supported by the National Institute on Aging. No relevant financial disclosures were reported.
"The most important message from this and similar studies is that differences in proteins and peptides can be found in peripheral fluids years before clinical onset of dementia," said Dr. Monique M.B. Breteler.
This is good news, suggesting that biomarkers can be developed or discovered that will enable more accurate and earlier diagnosis of neurodegenerative diseases, and that these biomarkers can be obtained relatively easily and with minimal invasiveness.
However, further investigations using rigorous designs and methods are needed before the role of plasma beta-amyloid 42:40 in either diagnosis or prognosis is established, she noted.
Monique M.B. Breteler, M.D., is in the department of epidemiology at Erasmus University, Rotterdam, the Netherlands. She reported no relevant financial disclosures. These comments were taken from her editorial accompanying Dr. Yaffe’s report (JAMA 2011;305:304-5).
"The most important message from this and similar studies is that differences in proteins and peptides can be found in peripheral fluids years before clinical onset of dementia," said Dr. Monique M.B. Breteler.
This is good news, suggesting that biomarkers can be developed or discovered that will enable more accurate and earlier diagnosis of neurodegenerative diseases, and that these biomarkers can be obtained relatively easily and with minimal invasiveness.
However, further investigations using rigorous designs and methods are needed before the role of plasma beta-amyloid 42:40 in either diagnosis or prognosis is established, she noted.
Monique M.B. Breteler, M.D., is in the department of epidemiology at Erasmus University, Rotterdam, the Netherlands. She reported no relevant financial disclosures. These comments were taken from her editorial accompanying Dr. Yaffe’s report (JAMA 2011;305:304-5).
"The most important message from this and similar studies is that differences in proteins and peptides can be found in peripheral fluids years before clinical onset of dementia," said Dr. Monique M.B. Breteler.
This is good news, suggesting that biomarkers can be developed or discovered that will enable more accurate and earlier diagnosis of neurodegenerative diseases, and that these biomarkers can be obtained relatively easily and with minimal invasiveness.
However, further investigations using rigorous designs and methods are needed before the role of plasma beta-amyloid 42:40 in either diagnosis or prognosis is established, she noted.
Monique M.B. Breteler, M.D., is in the department of epidemiology at Erasmus University, Rotterdam, the Netherlands. She reported no relevant financial disclosures. These comments were taken from her editorial accompanying Dr. Yaffe’s report (JAMA 2011;305:304-5).
Older adults without dementia who had a low ratio of beta-amyloid 42:40 in plasma showed faster cognitive decline in a 9-year study than did those with a higher ratio of the two beta-amyloid peptides, according to a report in the Jan. 19 issue of JAMA.
This cognitive decline was more marked in subjects who had less cognitive reserve, as estimated by their lower educational attainment and lower literacy.
"These results are important, as the prevalence of cognitive impairment is increasing exponentially and prevention will be crucial. To identify those at risk of dementia, biomarkers like plasma beta-amyloid level that are relatively easy to obtain and minimally invasive could be useful," wrote Dr. Kristine Yaffe of the University of California, San Francisco, and her associates.
The investigators assessed the relationship between beta-amyloid levels and cognitive decline using a cohort of 3,075 community-dwelling residents of Memphis and Pittsburgh who had been enrolled in an aging study in 1997-1998 when they were 70-79 years old. They studied 997 of the individuals who had undergone repeated cognitive assessments during follow-up through 2007.
The mean age at baseline was 74 years. Approximately 555 of the study subjects were women, and 54% were African American.
A low beta-amyloid 42:40 ratio at baseline was significantly associated with greater cognitive decline on the Modified Mini-Mental State Examination, which has a maximum score of 100. Mean scores on the Modified Mini-Mental State Examination after 9 years of follow-up declined 6.59 points among people in the lowest tertile of plasma beta-amyloid 42:40 ratio, 6.16 points among those in the middle tertile, and 3.60 points among those in the highest tertile.
The investigators also detected a significant, but less robust, association between tertiles of plasma beta-amyloid 42 levels and cognitive decline.
Both associations remained significant when the data were adjusted to account for subject age, race, education level, smoking status, diabetes status, and apolipoprotein E e4 status, according to Dr. Yaffe and her colleagues (JAMA 2011;305:261-6).
Moreover, the association between plasma beta-amyloid 42:40 ratio and cognitive decline was strongest among people with a low cognitive reserve (as measured by less than a high school diploma or 6th grade literacy) and weakest among people with higher cognitive reserve. People who carried the apolipoprotein E e4 allele also showed a stronger association between plasma beta-amyloid 42:40 ratio and cognitive decline.
"Our results suggest that the plasma beta-amyloid 42:40 ratio appears to be a biomarker of cognitive decline," the researchers noted.
The modifying effect of cognitive reserve on the association between cognitive decline and plasma beta-amyloid 42:40 ratio "suggests possible pathways, such as cognitive activity or ongoing education, for mitigating or preventing beta-amyloid effects on cognition," they added.
The investigators did not measure cerebrospinal fluid levels of beta-amyloid 42 and 40 and so could not correlate them with plasma levels of the peptides, Dr. Yaffe and her associates said.
This study was supported by the National Institute on Aging. No relevant financial disclosures were reported.
Older adults without dementia who had a low ratio of beta-amyloid 42:40 in plasma showed faster cognitive decline in a 9-year study than did those with a higher ratio of the two beta-amyloid peptides, according to a report in the Jan. 19 issue of JAMA.
This cognitive decline was more marked in subjects who had less cognitive reserve, as estimated by their lower educational attainment and lower literacy.
"These results are important, as the prevalence of cognitive impairment is increasing exponentially and prevention will be crucial. To identify those at risk of dementia, biomarkers like plasma beta-amyloid level that are relatively easy to obtain and minimally invasive could be useful," wrote Dr. Kristine Yaffe of the University of California, San Francisco, and her associates.
The investigators assessed the relationship between beta-amyloid levels and cognitive decline using a cohort of 3,075 community-dwelling residents of Memphis and Pittsburgh who had been enrolled in an aging study in 1997-1998 when they were 70-79 years old. They studied 997 of the individuals who had undergone repeated cognitive assessments during follow-up through 2007.
The mean age at baseline was 74 years. Approximately 555 of the study subjects were women, and 54% were African American.
A low beta-amyloid 42:40 ratio at baseline was significantly associated with greater cognitive decline on the Modified Mini-Mental State Examination, which has a maximum score of 100. Mean scores on the Modified Mini-Mental State Examination after 9 years of follow-up declined 6.59 points among people in the lowest tertile of plasma beta-amyloid 42:40 ratio, 6.16 points among those in the middle tertile, and 3.60 points among those in the highest tertile.
The investigators also detected a significant, but less robust, association between tertiles of plasma beta-amyloid 42 levels and cognitive decline.
Both associations remained significant when the data were adjusted to account for subject age, race, education level, smoking status, diabetes status, and apolipoprotein E e4 status, according to Dr. Yaffe and her colleagues (JAMA 2011;305:261-6).
Moreover, the association between plasma beta-amyloid 42:40 ratio and cognitive decline was strongest among people with a low cognitive reserve (as measured by less than a high school diploma or 6th grade literacy) and weakest among people with higher cognitive reserve. People who carried the apolipoprotein E e4 allele also showed a stronger association between plasma beta-amyloid 42:40 ratio and cognitive decline.
"Our results suggest that the plasma beta-amyloid 42:40 ratio appears to be a biomarker of cognitive decline," the researchers noted.
The modifying effect of cognitive reserve on the association between cognitive decline and plasma beta-amyloid 42:40 ratio "suggests possible pathways, such as cognitive activity or ongoing education, for mitigating or preventing beta-amyloid effects on cognition," they added.
The investigators did not measure cerebrospinal fluid levels of beta-amyloid 42 and 40 and so could not correlate them with plasma levels of the peptides, Dr. Yaffe and her associates said.
This study was supported by the National Institute on Aging. No relevant financial disclosures were reported.
FROM JAMA
Major Finding: A low plasma beta-amyloid 42:40 ratio was associated with faster cognitive decline during 9 years of follow-up.
Data Source: A secondary analysis of data collected in a prospective observational study of aging that involved 997 older adults who were free of dementia at baseline.
Disclosures: This study was supported by the National Institute on Aging. No relevant financial disclosures were reported.
Escitalopram May Ease Menopausal Hot Flashes
The selective serotonin reuptake inhibitor escitalopram rapidly reduces the frequency and severity of hot flashes in menopausal women, according to a report in the Jan. 19 issue of JAMA.
In a multicenter, randomized clinical trial comparing 10 or 20 mg per day of escitalopram with placebo, the drug’s benefit "was only modestly less than that reported in a meta-analysis of estrogen therapy," said Ellen W. Freeman, Ph.D., of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and her associates.
"Our findings suggest that among healthy women, 10 to 20 mg/day of escitalopram provides a nonhormonal, off-label option that is effective and well tolerated in the management of menopausal hot flashes," they said.
The double-blind trial involved 205 women who were in the menopausal transition, were postmenopausal, or had undergone hysterectomy with one or both ovaries intact. A total of 95 of the women self-reported as African American, 102 as white, and 8 as other. These subjects recorded at least 28 hot flashes or night sweats per week in a daily diary for 3 weeks before enrollment, or hot flashes or night sweats rated as bothersome or severe 4 or more days per week.
The women were randomly assigned to receive oral escitalopram (10 mg) or a matching placebo for 8 weeks. If they did not show a reduction in hot flash frequency or at least a 50% reduction in hot flash severity at 4 weeks, the dose was escalated to 20 mg of active drug or placebo.
At baseline, the mean frequency of hot flashes was 9.78 per day. After 8 weeks, that decreased by nearly half, to 5.26 per day in women taking escitalopram. This reduction was significantly greater than the 33% decrease to 6.43 hot flashes per day in the placebo group.
A total of 55% of women receiving active drug showed a decline of at least 50% in hot flash frequency, compared with 36% of women receiving placebo. Similarly, 19% of the escitalopram group showed a decline of at least 75% in hot flash frequency, compared with only 9% of the placebo group.
Data from the study subjects’ daily diaries showed that every week for the duration of the study, the frequency of hot flashes was significantly decreased in the escitalopram group, compared with the placebo group, Dr. Freeman and her colleagues said (JAMA 2010;305:267-74).
Escitalopram also diminished the severity of hot flashes by 24%, compared with a decrease of 14% with placebo. A total of 70% of women taking the active drug reported satisfaction with treatment, compared with 43% of those taking placebo.
These benefits were consistent across all subgroups of subjects, regardless of the women’s race, menopausal status, depression scores, or anxiety scores.
Treatment response was rapid, with women in the escitalopram group showing significant improvement in hot flash frequency and severity within 1 week of starting treatment, the investigators noted.
The study subjects were followed up about 3 weeks after discontinuing their study medication. Hot flash frequency had rebounded by a significantly greater amount in the escitalopram group (7.18 hot flashes per day) than in the placebo group (6.65 hot flashes per day), as had the severity of hot flashes.
A total of 64% of the women taking escitalopram said they wanted to continue taking their assigned medication, compared with only 42% of those in the placebo group.
"It is noteworthy that women who were not clinically anxious or depressed responded to escitalopram," which suggests that the mechanism underlying the drug’s effect on hot flashes may differ from that underlying its effect in psychiatric conditions. This finding also supports the hypothesis that serotonin receptors play a role in the pathogenesis of hot flashes, Dr. Freeman and her associates said.
Overall, 53% of women taking escitalopram and 63% taking placebo reported newly emergent adverse effects, none of which were serious. Nine women in the escitalopram group and two in the placebo group discontinued treatment because of adverse events, including dizziness, vivid dreams, nausea, and excessive sweating.
Dr. Freeman and her colleagues reported that to their knowledge, their clinical trial is the first to examine whether racial differences exist in response to SSRI treatment for hot flashes. Previous studies have shown that African American women are more likely to report hot flashes than their white counterparts. However, Dr. Freeman found that "race did not significantly affect the response to escitalopram in the present study."
Additional studies are needed to compare the efficacy of SSRIs and selective serotonin norepinephrine inhibitors in treating hot flashes related to menopause, they reported.
This study was supported by the National Institute on Aging, the Eunice Kennedy Shriver National Institute of Child Health and Development, the National Center for Complementary and Alternative Medicine, the Office of Research on Women’s Health, the Indiana Clinical and Translational Sciences Institute, and the National Center for Research Resources. Forest Laboratories provided the escitalopram and placebo pills. Dr. Freeman reported ties to Forest Laboratories, Wyeth, Pfizer, Xanodyne Pharmaceuticals, Pherin Pharmaceuticals, and Bayer Health Care, and her associates also reported ties to numerous drug companies.
The selective serotonin reuptake inhibitor escitalopram rapidly reduces the frequency and severity of hot flashes in menopausal women, according to a report in the Jan. 19 issue of JAMA.
In a multicenter, randomized clinical trial comparing 10 or 20 mg per day of escitalopram with placebo, the drug’s benefit "was only modestly less than that reported in a meta-analysis of estrogen therapy," said Ellen W. Freeman, Ph.D., of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and her associates.
"Our findings suggest that among healthy women, 10 to 20 mg/day of escitalopram provides a nonhormonal, off-label option that is effective and well tolerated in the management of menopausal hot flashes," they said.
The double-blind trial involved 205 women who were in the menopausal transition, were postmenopausal, or had undergone hysterectomy with one or both ovaries intact. A total of 95 of the women self-reported as African American, 102 as white, and 8 as other. These subjects recorded at least 28 hot flashes or night sweats per week in a daily diary for 3 weeks before enrollment, or hot flashes or night sweats rated as bothersome or severe 4 or more days per week.
The women were randomly assigned to receive oral escitalopram (10 mg) or a matching placebo for 8 weeks. If they did not show a reduction in hot flash frequency or at least a 50% reduction in hot flash severity at 4 weeks, the dose was escalated to 20 mg of active drug or placebo.
At baseline, the mean frequency of hot flashes was 9.78 per day. After 8 weeks, that decreased by nearly half, to 5.26 per day in women taking escitalopram. This reduction was significantly greater than the 33% decrease to 6.43 hot flashes per day in the placebo group.
A total of 55% of women receiving active drug showed a decline of at least 50% in hot flash frequency, compared with 36% of women receiving placebo. Similarly, 19% of the escitalopram group showed a decline of at least 75% in hot flash frequency, compared with only 9% of the placebo group.
Data from the study subjects’ daily diaries showed that every week for the duration of the study, the frequency of hot flashes was significantly decreased in the escitalopram group, compared with the placebo group, Dr. Freeman and her colleagues said (JAMA 2010;305:267-74).
Escitalopram also diminished the severity of hot flashes by 24%, compared with a decrease of 14% with placebo. A total of 70% of women taking the active drug reported satisfaction with treatment, compared with 43% of those taking placebo.
These benefits were consistent across all subgroups of subjects, regardless of the women’s race, menopausal status, depression scores, or anxiety scores.
Treatment response was rapid, with women in the escitalopram group showing significant improvement in hot flash frequency and severity within 1 week of starting treatment, the investigators noted.
The study subjects were followed up about 3 weeks after discontinuing their study medication. Hot flash frequency had rebounded by a significantly greater amount in the escitalopram group (7.18 hot flashes per day) than in the placebo group (6.65 hot flashes per day), as had the severity of hot flashes.
A total of 64% of the women taking escitalopram said they wanted to continue taking their assigned medication, compared with only 42% of those in the placebo group.
"It is noteworthy that women who were not clinically anxious or depressed responded to escitalopram," which suggests that the mechanism underlying the drug’s effect on hot flashes may differ from that underlying its effect in psychiatric conditions. This finding also supports the hypothesis that serotonin receptors play a role in the pathogenesis of hot flashes, Dr. Freeman and her associates said.
Overall, 53% of women taking escitalopram and 63% taking placebo reported newly emergent adverse effects, none of which were serious. Nine women in the escitalopram group and two in the placebo group discontinued treatment because of adverse events, including dizziness, vivid dreams, nausea, and excessive sweating.
Dr. Freeman and her colleagues reported that to their knowledge, their clinical trial is the first to examine whether racial differences exist in response to SSRI treatment for hot flashes. Previous studies have shown that African American women are more likely to report hot flashes than their white counterparts. However, Dr. Freeman found that "race did not significantly affect the response to escitalopram in the present study."
Additional studies are needed to compare the efficacy of SSRIs and selective serotonin norepinephrine inhibitors in treating hot flashes related to menopause, they reported.
This study was supported by the National Institute on Aging, the Eunice Kennedy Shriver National Institute of Child Health and Development, the National Center for Complementary and Alternative Medicine, the Office of Research on Women’s Health, the Indiana Clinical and Translational Sciences Institute, and the National Center for Research Resources. Forest Laboratories provided the escitalopram and placebo pills. Dr. Freeman reported ties to Forest Laboratories, Wyeth, Pfizer, Xanodyne Pharmaceuticals, Pherin Pharmaceuticals, and Bayer Health Care, and her associates also reported ties to numerous drug companies.
The selective serotonin reuptake inhibitor escitalopram rapidly reduces the frequency and severity of hot flashes in menopausal women, according to a report in the Jan. 19 issue of JAMA.
In a multicenter, randomized clinical trial comparing 10 or 20 mg per day of escitalopram with placebo, the drug’s benefit "was only modestly less than that reported in a meta-analysis of estrogen therapy," said Ellen W. Freeman, Ph.D., of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and her associates.
"Our findings suggest that among healthy women, 10 to 20 mg/day of escitalopram provides a nonhormonal, off-label option that is effective and well tolerated in the management of menopausal hot flashes," they said.
The double-blind trial involved 205 women who were in the menopausal transition, were postmenopausal, or had undergone hysterectomy with one or both ovaries intact. A total of 95 of the women self-reported as African American, 102 as white, and 8 as other. These subjects recorded at least 28 hot flashes or night sweats per week in a daily diary for 3 weeks before enrollment, or hot flashes or night sweats rated as bothersome or severe 4 or more days per week.
The women were randomly assigned to receive oral escitalopram (10 mg) or a matching placebo for 8 weeks. If they did not show a reduction in hot flash frequency or at least a 50% reduction in hot flash severity at 4 weeks, the dose was escalated to 20 mg of active drug or placebo.
At baseline, the mean frequency of hot flashes was 9.78 per day. After 8 weeks, that decreased by nearly half, to 5.26 per day in women taking escitalopram. This reduction was significantly greater than the 33% decrease to 6.43 hot flashes per day in the placebo group.
A total of 55% of women receiving active drug showed a decline of at least 50% in hot flash frequency, compared with 36% of women receiving placebo. Similarly, 19% of the escitalopram group showed a decline of at least 75% in hot flash frequency, compared with only 9% of the placebo group.
Data from the study subjects’ daily diaries showed that every week for the duration of the study, the frequency of hot flashes was significantly decreased in the escitalopram group, compared with the placebo group, Dr. Freeman and her colleagues said (JAMA 2010;305:267-74).
Escitalopram also diminished the severity of hot flashes by 24%, compared with a decrease of 14% with placebo. A total of 70% of women taking the active drug reported satisfaction with treatment, compared with 43% of those taking placebo.
These benefits were consistent across all subgroups of subjects, regardless of the women’s race, menopausal status, depression scores, or anxiety scores.
Treatment response was rapid, with women in the escitalopram group showing significant improvement in hot flash frequency and severity within 1 week of starting treatment, the investigators noted.
The study subjects were followed up about 3 weeks after discontinuing their study medication. Hot flash frequency had rebounded by a significantly greater amount in the escitalopram group (7.18 hot flashes per day) than in the placebo group (6.65 hot flashes per day), as had the severity of hot flashes.
A total of 64% of the women taking escitalopram said they wanted to continue taking their assigned medication, compared with only 42% of those in the placebo group.
"It is noteworthy that women who were not clinically anxious or depressed responded to escitalopram," which suggests that the mechanism underlying the drug’s effect on hot flashes may differ from that underlying its effect in psychiatric conditions. This finding also supports the hypothesis that serotonin receptors play a role in the pathogenesis of hot flashes, Dr. Freeman and her associates said.
Overall, 53% of women taking escitalopram and 63% taking placebo reported newly emergent adverse effects, none of which were serious. Nine women in the escitalopram group and two in the placebo group discontinued treatment because of adverse events, including dizziness, vivid dreams, nausea, and excessive sweating.
Dr. Freeman and her colleagues reported that to their knowledge, their clinical trial is the first to examine whether racial differences exist in response to SSRI treatment for hot flashes. Previous studies have shown that African American women are more likely to report hot flashes than their white counterparts. However, Dr. Freeman found that "race did not significantly affect the response to escitalopram in the present study."
Additional studies are needed to compare the efficacy of SSRIs and selective serotonin norepinephrine inhibitors in treating hot flashes related to menopause, they reported.
This study was supported by the National Institute on Aging, the Eunice Kennedy Shriver National Institute of Child Health and Development, the National Center for Complementary and Alternative Medicine, the Office of Research on Women’s Health, the Indiana Clinical and Translational Sciences Institute, and the National Center for Research Resources. Forest Laboratories provided the escitalopram and placebo pills. Dr. Freeman reported ties to Forest Laboratories, Wyeth, Pfizer, Xanodyne Pharmaceuticals, Pherin Pharmaceuticals, and Bayer Health Care, and her associates also reported ties to numerous drug companies.
FROM JAMA
Major Finding: Escitalopram decreased the frequency of hot flashes by nearly half, from 9.78 per day to 5.26 per day.
Data Source: An 8-week multicenter, randomized, double-blind clinical trial involving 205 women.
Disclosures: This study was supported by the National Institute of Aging, the Eunice Kennedy Shriver National Institute of Child Health and Development, the National Center for Complementary and Alternative Medicine, the Office of Research on Women’s Health, the Indiana Clinical and Translational Sciences Institute, and the National Center for Research Resources. Forest Laboratories provided the escitalopram and placebo pills. Dr. Freeman reported ties to Forest Laboratories, Wyeth, Pfizer, Xanodyne Pharmaceuticals, Pherin Pharmaceuticals, and Bayer Health Care, and her associates also reported ties to numerous drug companies.
Time Constraints Limit Full-Body Skin Exams
A majority of dermatologists, internists, and family physicians routinely perform full-body examinations for skin cancer – but time constraints and patient reluctance are common barriers to better exam rates, according to a report in the January issue of the Archives of Dermatology.
A total of 81% of dermatologists, 56% of internists, and 60% of family physicians in a nationally representative sample reported that they routinely perform the skin cancer examinations.
All three groups of physicians also identified barriers to performing skin examinations more often, but the barriers varied by specialty, said Susan A. Oliveria, Sc.D., of Memorial Sloan-Kettering Cancer Center’s dermatology service, New York, and her associates (Arch. Dermatol. 2011;147:39-44).
The investigators assessed skin cancer screening practices because little is known about the subject, and a better understanding both of the obstacles and of the facilitating factors could help improve primary and secondary screening.
To examine the issue, the researchers used data from a survey to which 1,669 physicians in group or solo private practice responded. The respondents included 679 dermatologists, 431 internists, and 559 family physicians. Most reported that they saw 200-600 patients per month, and most were aged 41-60 years.
Approximately 54% of internists and family physicians reported that time constraints prevented them from doing full-body skin exams more frequently, compared with only 31% of dermatologists. Half of the internists and family physicians also said that "competing comorbidities" often took priority over skin exams, compared with only 16% of dermatologists.
In contrast, significantly more dermatologists (44%) identified patient embarrassment or reluctance as a barrier to performing full-body skin exams, compared with internists (33%) or family physicians (31%). That is likely because most patients see a dermatologist for an isolated skin condition such as a wart or rash, the investigators noted, and do not expect to undress for a full-body exam.
In contrast, patients expect to undress for an internist or family physician, because disrobing for pelvic or rectal exams often is part of their annual physical examinations. Moreover, primary care physicians "have years to build up relationships with their patients," the study authors explained, while dermatologists typically do not.
To overcome that barrier, "dermatologists could educate their patients about the role of a full-body skin examination in a routine visit by providing them with written material to read and establishing a comforting physician-patient relationship," Dr. Oliveria and her colleagues said.
All the physicians reported that they were more likely to screen for skin cancer in patients who had one or more risk factors for the disease. Even so, only 87% of dermatologists, 65% of internists, and 70% of family physicians reported that they performed full-body exams in most of their high-risk patients.
Another common reason for performing a full-body skin cancer screen was the same for all three specialties: having a patient ask to have such an exam or to have a suspicious mole checked. That shows that it is important to maintain public education programs encouraging patients to request skin exams or mole checks, the researchers said.
Fewer internists (56%) and family physicians (54%) than dermatologists (78%) reported that their skill and expertise at performing skin exams and diagnosing skin cancer facilitated their screening practices. That finding suggests that enhanced dermatologic training during medical school and continuing medical education programs would be beneficial, the investigators added.
The National Cancer Institute supported the study. No financial conflicts of interest were reported.
A majority of dermatologists, internists, and family physicians routinely perform full-body examinations for skin cancer – but time constraints and patient reluctance are common barriers to better exam rates, according to a report in the January issue of the Archives of Dermatology.
A total of 81% of dermatologists, 56% of internists, and 60% of family physicians in a nationally representative sample reported that they routinely perform the skin cancer examinations.
All three groups of physicians also identified barriers to performing skin examinations more often, but the barriers varied by specialty, said Susan A. Oliveria, Sc.D., of Memorial Sloan-Kettering Cancer Center’s dermatology service, New York, and her associates (Arch. Dermatol. 2011;147:39-44).
The investigators assessed skin cancer screening practices because little is known about the subject, and a better understanding both of the obstacles and of the facilitating factors could help improve primary and secondary screening.
To examine the issue, the researchers used data from a survey to which 1,669 physicians in group or solo private practice responded. The respondents included 679 dermatologists, 431 internists, and 559 family physicians. Most reported that they saw 200-600 patients per month, and most were aged 41-60 years.
Approximately 54% of internists and family physicians reported that time constraints prevented them from doing full-body skin exams more frequently, compared with only 31% of dermatologists. Half of the internists and family physicians also said that "competing comorbidities" often took priority over skin exams, compared with only 16% of dermatologists.
In contrast, significantly more dermatologists (44%) identified patient embarrassment or reluctance as a barrier to performing full-body skin exams, compared with internists (33%) or family physicians (31%). That is likely because most patients see a dermatologist for an isolated skin condition such as a wart or rash, the investigators noted, and do not expect to undress for a full-body exam.
In contrast, patients expect to undress for an internist or family physician, because disrobing for pelvic or rectal exams often is part of their annual physical examinations. Moreover, primary care physicians "have years to build up relationships with their patients," the study authors explained, while dermatologists typically do not.
To overcome that barrier, "dermatologists could educate their patients about the role of a full-body skin examination in a routine visit by providing them with written material to read and establishing a comforting physician-patient relationship," Dr. Oliveria and her colleagues said.
All the physicians reported that they were more likely to screen for skin cancer in patients who had one or more risk factors for the disease. Even so, only 87% of dermatologists, 65% of internists, and 70% of family physicians reported that they performed full-body exams in most of their high-risk patients.
Another common reason for performing a full-body skin cancer screen was the same for all three specialties: having a patient ask to have such an exam or to have a suspicious mole checked. That shows that it is important to maintain public education programs encouraging patients to request skin exams or mole checks, the researchers said.
Fewer internists (56%) and family physicians (54%) than dermatologists (78%) reported that their skill and expertise at performing skin exams and diagnosing skin cancer facilitated their screening practices. That finding suggests that enhanced dermatologic training during medical school and continuing medical education programs would be beneficial, the investigators added.
The National Cancer Institute supported the study. No financial conflicts of interest were reported.
A majority of dermatologists, internists, and family physicians routinely perform full-body examinations for skin cancer – but time constraints and patient reluctance are common barriers to better exam rates, according to a report in the January issue of the Archives of Dermatology.
A total of 81% of dermatologists, 56% of internists, and 60% of family physicians in a nationally representative sample reported that they routinely perform the skin cancer examinations.
All three groups of physicians also identified barriers to performing skin examinations more often, but the barriers varied by specialty, said Susan A. Oliveria, Sc.D., of Memorial Sloan-Kettering Cancer Center’s dermatology service, New York, and her associates (Arch. Dermatol. 2011;147:39-44).
The investigators assessed skin cancer screening practices because little is known about the subject, and a better understanding both of the obstacles and of the facilitating factors could help improve primary and secondary screening.
To examine the issue, the researchers used data from a survey to which 1,669 physicians in group or solo private practice responded. The respondents included 679 dermatologists, 431 internists, and 559 family physicians. Most reported that they saw 200-600 patients per month, and most were aged 41-60 years.
Approximately 54% of internists and family physicians reported that time constraints prevented them from doing full-body skin exams more frequently, compared with only 31% of dermatologists. Half of the internists and family physicians also said that "competing comorbidities" often took priority over skin exams, compared with only 16% of dermatologists.
In contrast, significantly more dermatologists (44%) identified patient embarrassment or reluctance as a barrier to performing full-body skin exams, compared with internists (33%) or family physicians (31%). That is likely because most patients see a dermatologist for an isolated skin condition such as a wart or rash, the investigators noted, and do not expect to undress for a full-body exam.
In contrast, patients expect to undress for an internist or family physician, because disrobing for pelvic or rectal exams often is part of their annual physical examinations. Moreover, primary care physicians "have years to build up relationships with their patients," the study authors explained, while dermatologists typically do not.
To overcome that barrier, "dermatologists could educate their patients about the role of a full-body skin examination in a routine visit by providing them with written material to read and establishing a comforting physician-patient relationship," Dr. Oliveria and her colleagues said.
All the physicians reported that they were more likely to screen for skin cancer in patients who had one or more risk factors for the disease. Even so, only 87% of dermatologists, 65% of internists, and 70% of family physicians reported that they performed full-body exams in most of their high-risk patients.
Another common reason for performing a full-body skin cancer screen was the same for all three specialties: having a patient ask to have such an exam or to have a suspicious mole checked. That shows that it is important to maintain public education programs encouraging patients to request skin exams or mole checks, the researchers said.
Fewer internists (56%) and family physicians (54%) than dermatologists (78%) reported that their skill and expertise at performing skin exams and diagnosing skin cancer facilitated their screening practices. That finding suggests that enhanced dermatologic training during medical school and continuing medical education programs would be beneficial, the investigators added.
The National Cancer Institute supported the study. No financial conflicts of interest were reported.
FROM THE ARCHIVES OF DERMATOLOGY
Major Finding: 81% of dermatologists, 56% of internists, and 60% of family physicians report that they routinely perform full-body examinations for skin cancer.
Data Source: Survey of a representative sample of 679 dermatologists, 431 internists, and 559 family physicians.
Disclosures: The National Cancer Institute–supported the study. No financial conflicts of interest were reported.