Mitchel L. Zoler, PhD

NEW YORK – A patient-centered, medical-home approach to care for patients with multiple chronic diseases when they are discharged from the hospital and back in their own residences substantially cut their rate of hospital readmissions, suggesting that this new model of home-based medical care pays for itself by avoiding hospitalization costs.

"We think it’s very important for the U.S. health care system to move its focus from hospital to home, with care management that prevents unnecessary emergency department visits and hospital admissions," Dr. Eric C. Rackow said at the course.

"You can alter the outcomes at home [of patients with diabetes and other chronic diseases] if you keep patients healthier and more functional at home and out of the hospital," said Dr. Rackow, professor of medicine at New York University, and president and CEO of SeniorBridge, a company that provides medical services to patients when they are in their homes.

"We have health plan contracts where we have shown a 50% reduction in hospitalization and readmissions rates, producing a 50% drop in the cost per member per month," Dr. Rackow said in an interview. Although SeniorBridge is relatively unique in offering the services from a variety of health care professionals for in-home services to patients, the model is amenable to scale up, he said. "Doctors are the captains, but it’s the nurses, social workers, nutritionists, and pharmacists who actually are in the patients’ homes. Physicians can manage a large number of patients. It’s a cost-effective way to extend the physician’s reach."

To document the impact that home-based intervention can have, he presented data collected by SeniorBridge from 503 patients aged 65 years or older that the company managed during 2008-2010. Eighty-eight of these patients who had diabetes and multiple other chronic conditions had a hospital readmission rate of 21% during their first 30 days at home following discharge from their index hospitalization. The other 415 patients managed by SeniorBridge had multiple chronic conditions but no diabetes, and they had an 11% rehospitalization rate during their first 30 days at home. In contrast, a historic control of similar elderly Americans with multiple chronic conditions who did not receive comprehensive care at home following their hospital discharge had a 33% readmission rate, Dr. Rackow said.

Another data analysis showed that 230 elderly SeniorBridge–treated patients with diabetes and multiple chronic diseases averaged 0.37 hospitalizations/year, and 1,486 elderly SeniorBridge-treated patients with multiple chronic diseases but no diabetes averaged 0.28 hospitalizations/year. By comparison, Medicare data showed a rate of 1.3 hospitalizations/year among similar patients receiving conventional care following a hospital discharge.

Multiple chronic illnesses are a hallmark of elderly patients with diabetes, affecting three-quarters of Americans 65 years or older with diabetes, Dr. Rackow said. The combination of diabetes, chronic obstructive pulmonary disease, and heart failure forms a common comorbidity constellation among elderly patients with diabetes, he noted.

Patients with several simultaneous chronic illnesses face special physical and cognitive challenges that pose problems for their self-directed care, he said. "The functional limitations [triggered by multiple chronic diseases] and the inability to self-manage tips patients and causes frequent hospitalizations." That’s why home medical services that aid a patient’s self management can have such a significant impact on rehospitalization rates.

Payment for SeniorBridge’s services has come from Medicaid, private insurers, and from long-term insurance policies. Medicare does not currently pay for these services, Dr. Rackow said.

Dr. Rackow is an employee, stockholder, and board member of SeniorBridge.

Here is a related video on "How Patients View Chronic Disease."

NEW YORK – A patient-centered, medical-home approach to care for patients with multiple chronic diseases when they are discharged from the hospital and back in their own residences substantially cut their rate of hospital readmissions, suggesting that this new model of home-based medical care pays for itself by avoiding hospitalization costs.

"We think it’s very important for the U.S. health care system to move its focus from hospital to home, with care management that prevents unnecessary emergency department visits and hospital admissions," Dr. Eric C. Rackow said at the course.

"You can alter the outcomes at home [of patients with diabetes and other chronic diseases] if you keep patients healthier and more functional at home and out of the hospital," said Dr. Rackow, professor of medicine at New York University, and president and CEO of SeniorBridge, a company that provides medical services to patients when they are in their homes.

"We have health plan contracts where we have shown a 50% reduction in hospitalization and readmissions rates, producing a 50% drop in the cost per member per month," Dr. Rackow said in an interview. Although SeniorBridge is relatively unique in offering the services from a variety of health care professionals for in-home services to patients, the model is amenable to scale up, he said. "Doctors are the captains, but it’s the nurses, social workers, nutritionists, and pharmacists who actually are in the patients’ homes. Physicians can manage a large number of patients. It’s a cost-effective way to extend the physician’s reach."

To document the impact that home-based intervention can have, he presented data collected by SeniorBridge from 503 patients aged 65 years or older that the company managed during 2008-2010. Eighty-eight of these patients who had diabetes and multiple other chronic conditions had a hospital readmission rate of 21% during their first 30 days at home following discharge from their index hospitalization. The other 415 patients managed by SeniorBridge had multiple chronic conditions but no diabetes, and they had an 11% rehospitalization rate during their first 30 days at home. In contrast, a historic control of similar elderly Americans with multiple chronic conditions who did not receive comprehensive care at home following their hospital discharge had a 33% readmission rate, Dr. Rackow said.

Another data analysis showed that 230 elderly SeniorBridge–treated patients with diabetes and multiple chronic diseases averaged 0.37 hospitalizations/year, and 1,486 elderly SeniorBridge-treated patients with multiple chronic diseases but no diabetes averaged 0.28 hospitalizations/year. By comparison, Medicare data showed a rate of 1.3 hospitalizations/year among similar patients receiving conventional care following a hospital discharge.

Multiple chronic illnesses are a hallmark of elderly patients with diabetes, affecting three-quarters of Americans 65 years or older with diabetes, Dr. Rackow said. The combination of diabetes, chronic obstructive pulmonary disease, and heart failure forms a common comorbidity constellation among elderly patients with diabetes, he noted.

Patients with several simultaneous chronic illnesses face special physical and cognitive challenges that pose problems for their self-directed care, he said. "The functional limitations [triggered by multiple chronic diseases] and the inability to self-manage tips patients and causes frequent hospitalizations." That’s why home medical services that aid a patient’s self management can have such a significant impact on rehospitalization rates.

Payment for SeniorBridge’s services has come from Medicaid, private insurers, and from long-term insurance policies. Medicare does not currently pay for these services, Dr. Rackow said.

Dr. Rackow is an employee, stockholder, and board member of SeniorBridge.

Here is a related video on "How Patients View Chronic Disease."

NEW YORK – A patient-centered, medical-home approach to care for patients with multiple chronic diseases when they are discharged from the hospital and back in their own residences substantially cut their rate of hospital readmissions, suggesting that this new model of home-based medical care pays for itself by avoiding hospitalization costs.

"We think it’s very important for the U.S. health care system to move its focus from hospital to home, with care management that prevents unnecessary emergency department visits and hospital admissions," Dr. Eric C. Rackow said at the course.

"You can alter the outcomes at home [of patients with diabetes and other chronic diseases] if you keep patients healthier and more functional at home and out of the hospital," said Dr. Rackow, professor of medicine at New York University, and president and CEO of SeniorBridge, a company that provides medical services to patients when they are in their homes.

"We have health plan contracts where we have shown a 50% reduction in hospitalization and readmissions rates, producing a 50% drop in the cost per member per month," Dr. Rackow said in an interview. Although SeniorBridge is relatively unique in offering the services from a variety of health care professionals for in-home services to patients, the model is amenable to scale up, he said. "Doctors are the captains, but it’s the nurses, social workers, nutritionists, and pharmacists who actually are in the patients’ homes. Physicians can manage a large number of patients. It’s a cost-effective way to extend the physician’s reach."

To document the impact that home-based intervention can have, he presented data collected by SeniorBridge from 503 patients aged 65 years or older that the company managed during 2008-2010. Eighty-eight of these patients who had diabetes and multiple other chronic conditions had a hospital readmission rate of 21% during their first 30 days at home following discharge from their index hospitalization. The other 415 patients managed by SeniorBridge had multiple chronic conditions but no diabetes, and they had an 11% rehospitalization rate during their first 30 days at home. In contrast, a historic control of similar elderly Americans with multiple chronic conditions who did not receive comprehensive care at home following their hospital discharge had a 33% readmission rate, Dr. Rackow said.

Another data analysis showed that 230 elderly SeniorBridge–treated patients with diabetes and multiple chronic diseases averaged 0.37 hospitalizations/year, and 1,486 elderly SeniorBridge-treated patients with multiple chronic diseases but no diabetes averaged 0.28 hospitalizations/year. By comparison, Medicare data showed a rate of 1.3 hospitalizations/year among similar patients receiving conventional care following a hospital discharge.

Multiple chronic illnesses are a hallmark of elderly patients with diabetes, affecting three-quarters of Americans 65 years or older with diabetes, Dr. Rackow said. The combination of diabetes, chronic obstructive pulmonary disease, and heart failure forms a common comorbidity constellation among elderly patients with diabetes, he noted.

Patients with several simultaneous chronic illnesses face special physical and cognitive challenges that pose problems for their self-directed care, he said. "The functional limitations [triggered by multiple chronic diseases] and the inability to self-manage tips patients and causes frequent hospitalizations." That’s why home medical services that aid a patient’s self management can have such a significant impact on rehospitalization rates.

Payment for SeniorBridge’s services has come from Medicaid, private insurers, and from long-term insurance policies. Medicare does not currently pay for these services, Dr. Rackow said.

Dr. Rackow is an employee, stockholder, and board member of SeniorBridge.

Here is a related video on "How Patients View Chronic Disease."

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

NEW YORK – When prescribing second-generation antipsychotic medications, physicians should start with the agents in this class least likely to cause metabolic adverse effects and only move to prescribing psychotropics with more frequent metabolic effects when necessary, Dr. David C. Henderson said at the meeting sponsored by the American Diabetes Association.

"If we can get patients off the offending drugs and onto more neutral drugs, their risk [for cardiometabolic adverse events] would be much better," said Dr. Henderson, a psychiatrist at Harvard University and director of the schizophrenia, weight reduction, and glucose metabolism research program at Massachusetts General Hospital in Boston.

The two worst offenders of the second-generation antipsychotics are clozapine (Clozaril) and olanzapine (Zyprexa). Both drugs cause most patients to gain weight over a prolonged period of time – up to 3.5 years – and they also impair insulin sensitivity. They also pose an "extremely high risk for triggering types 2 diabetes," a risk Dr. Henderson likened to the diabetes risk faced by Pima Indians. He estimated that about a third of patients on clozapine develop type 2 diabetes. A significantly more neutral option is risperidone (Risperdal and also available in generic formulations). The drugs with the most benign profiles are ziprasidone (Geodon) followed by aripiprazole (Abilify), Dr. Henderson said in an interview. The danger that these drugs pose of causing type 2 diabetes "is not a class effect" and, in fact, their risk for this adverse effect is quite variable.

Prescribing these agents with awareness of their relative dangers for triggering weight gain and dampening insulin sensitivity has become more critical in recent years as "use of these drugs has risen dramatically," he said. As a class, second-generation antipsychotics are now prescribed for a range of psychiatric illnesses, including mood disorders and posttraumatic stress disorder. "Antipsychotics are everywhere," he noted.

In addition, patients with psychiatric illness are inherently vulnerable to the consequences of cardiometabolic derangements because cardiovascular disease is the most frequent cause of death among these patients.

"I start by prescribing the least offensive drug, the safest drug, and then work my way up the risk ladder" if patients fail to respond to less risky agents. "Psychiatrists get stuck on whether one drug works better than another, when in fact none work any better, except possibly clozapine." The more immediate and practical issue is to find the drug that will produce a favorable outcome in each psychiatric patient. "Some patients need a riskier drug, but you should work your way up the ladder" of safety, he said. Once an effective drug is found, the next step is determining what adjunctive treatments the patient needs to counter the adverse metabolic effects and stay healthy while on psychiatric medication.

"I prescribe lipid-lowering medication, and I use metformin to treat insulin resistance. I also follow the patient’s hemoglobin A1c level," and he also repeatedly promotes to patients their need to maintain a healthy diet and exercise, Dr. Henderson said.

Dr. Henderson said that he has been a consultant to Merck and Pfizer and that he has received research support from Janssen and Johnson & Johnson.

LOS ANGELES – During the first 5 years following a stroke, elderly patients have a unique pattern of comorbidity and hospitalization. This pattern sets them apart from similarly aged people who didn’t experience a stroke as well as from elderly patients who have had acute myocardial infarction, based on a review of more than 5,700 age- and gender-matched Medicare beneficiaries.

Following a stroke, Medicare patients showed a substantially higher rate of hospitalizations for hip fracture or pneumonia, compared with matched people without a history of stroke. These findings indicate that these excess events in stroke survivors "are not just due to age or the effects of acute hospitalization," Dr. Kamakshi Lakshminarayan said at the International Stroke Conference.

The analysis also showed that during the first year following a stroke or MI, the rate of any acute care hospitalization reached 49% in the poststroke patients and 55% in the post-MI patients, strikingly higher than the 20% rate among the matched elderly people with no history of either event.

The first year following a stroke or MI is when the rate of acute care hospitalization "peels away from the general Medicare population. This is where we need to intervene" to reduce the incidence of the complications that lead to hospitalizations, said Dr. Lakshminarayan, a stroke epidemiologist at the University of Minnesota in Minneapolis.

She and her associates studied 823 Medicare patients aged 65-84 years who had a validated, acute ischemic stroke during 2000 that led to hospitalization at any of 19 Minnesota hospitals. The researchers assembled two comparison groups of Medicare beneficiaries who matched the stroke group by age, sex, and race, including 823 patients with an acute MI treated at the same 19 hospitals, and 4,115 matched people from Minnesota with no history of stroke or recent MI.

The stroke and MI patients matched up fairly closely for their cumulative 30-day, 1-year, and 5-year mortality, although the stroke patients had significantly higher rates of death following hospital discharge at both 1 year and 5 years after the initial hospitalization. Cumulative mortality in both postevent groups dwarfed the rate among the people who had neither a stroke nor MI. At 1 year, cumulative mortality ran 24% in the stroke patients, 22% in the MI patients, and 4% in the general population. At 5 years, the rates ran 49%, 44%, and 24%, respectively.

The difference between poststroke and post-MI patients showed up in several types of hospitalizations. Poststroke patients had substantially more rehospitalizations for a subsequent stroke: an 18% rate over 5 years, compared with 7% in the post-MI patients. But the post-MI patients held a decided edge in the rate of a subsequent MI: 25% over 5 years, compared with a 6% rate among the poststroke patients during the 5 years following their index event. The post-MI patients also had similarly large and statistically significant increases in their rate of heart failure and dysrhythmias. The overall, 5-year rate of hospitalization for any vascular cause ran 38% in the poststroke patients, 49% in patients who had an initial MI, and 19% in the general elderly population.

The 5-year rate of hospitalization for pneumonia reached the highest level in the stroke patients, at 20%, which was significantly greater than the 10% rate in the general population, but not a statistically significant difference over the 15% rate in patients with a history of MI. Poststroke patients also showed a high 5-year rate of hospitalization for hip fracture of 10%, which is twice the U.S. rate among women aged 65 years or older (based on published data) and also double the general Medicare population’s rate in Dr. Lakshminarayan’s study. At 5 years, 4% of the post-MI patients had a hip fracture.

Dr. Lakshminarayan said that she had no disclosures.

LOS ANGELES – During the first 5 years following a stroke, elderly patients have a unique pattern of comorbidity and hospitalization. This pattern sets them apart from similarly aged people who didn’t experience a stroke as well as from elderly patients who have had acute myocardial infarction, based on a review of more than 5,700 age- and gender-matched Medicare beneficiaries.

Following a stroke, Medicare patients showed a substantially higher rate of hospitalizations for hip fracture or pneumonia, compared with matched people without a history of stroke. These findings indicate that these excess events in stroke survivors "are not just due to age or the effects of acute hospitalization," Dr. Kamakshi Lakshminarayan said at the International Stroke Conference.

The analysis also showed that during the first year following a stroke or MI, the rate of any acute care hospitalization reached 49% in the poststroke patients and 55% in the post-MI patients, strikingly higher than the 20% rate among the matched elderly people with no history of either event.

The first year following a stroke or MI is when the rate of acute care hospitalization "peels away from the general Medicare population. This is where we need to intervene" to reduce the incidence of the complications that lead to hospitalizations, said Dr. Lakshminarayan, a stroke epidemiologist at the University of Minnesota in Minneapolis.

She and her associates studied 823 Medicare patients aged 65-84 years who had a validated, acute ischemic stroke during 2000 that led to hospitalization at any of 19 Minnesota hospitals. The researchers assembled two comparison groups of Medicare beneficiaries who matched the stroke group by age, sex, and race, including 823 patients with an acute MI treated at the same 19 hospitals, and 4,115 matched people from Minnesota with no history of stroke or recent MI.

The stroke and MI patients matched up fairly closely for their cumulative 30-day, 1-year, and 5-year mortality, although the stroke patients had significantly higher rates of death following hospital discharge at both 1 year and 5 years after the initial hospitalization. Cumulative mortality in both postevent groups dwarfed the rate among the people who had neither a stroke nor MI. At 1 year, cumulative mortality ran 24% in the stroke patients, 22% in the MI patients, and 4% in the general population. At 5 years, the rates ran 49%, 44%, and 24%, respectively.

The difference between poststroke and post-MI patients showed up in several types of hospitalizations. Poststroke patients had substantially more rehospitalizations for a subsequent stroke: an 18% rate over 5 years, compared with 7% in the post-MI patients. But the post-MI patients held a decided edge in the rate of a subsequent MI: 25% over 5 years, compared with a 6% rate among the poststroke patients during the 5 years following their index event. The post-MI patients also had similarly large and statistically significant increases in their rate of heart failure and dysrhythmias. The overall, 5-year rate of hospitalization for any vascular cause ran 38% in the poststroke patients, 49% in patients who had an initial MI, and 19% in the general elderly population.

The 5-year rate of hospitalization for pneumonia reached the highest level in the stroke patients, at 20%, which was significantly greater than the 10% rate in the general population, but not a statistically significant difference over the 15% rate in patients with a history of MI. Poststroke patients also showed a high 5-year rate of hospitalization for hip fracture of 10%, which is twice the U.S. rate among women aged 65 years or older (based on published data) and also double the general Medicare population’s rate in Dr. Lakshminarayan’s study. At 5 years, 4% of the post-MI patients had a hip fracture.

Dr. Lakshminarayan said that she had no disclosures.

LOS ANGELES – During the first 5 years following a stroke, elderly patients have a unique pattern of comorbidity and hospitalization. This pattern sets them apart from similarly aged people who didn’t experience a stroke as well as from elderly patients who have had acute myocardial infarction, based on a review of more than 5,700 age- and gender-matched Medicare beneficiaries.

Following a stroke, Medicare patients showed a substantially higher rate of hospitalizations for hip fracture or pneumonia, compared with matched people without a history of stroke. These findings indicate that these excess events in stroke survivors "are not just due to age or the effects of acute hospitalization," Dr. Kamakshi Lakshminarayan said at the International Stroke Conference.

The analysis also showed that during the first year following a stroke or MI, the rate of any acute care hospitalization reached 49% in the poststroke patients and 55% in the post-MI patients, strikingly higher than the 20% rate among the matched elderly people with no history of either event.

The first year following a stroke or MI is when the rate of acute care hospitalization "peels away from the general Medicare population. This is where we need to intervene" to reduce the incidence of the complications that lead to hospitalizations, said Dr. Lakshminarayan, a stroke epidemiologist at the University of Minnesota in Minneapolis.

She and her associates studied 823 Medicare patients aged 65-84 years who had a validated, acute ischemic stroke during 2000 that led to hospitalization at any of 19 Minnesota hospitals. The researchers assembled two comparison groups of Medicare beneficiaries who matched the stroke group by age, sex, and race, including 823 patients with an acute MI treated at the same 19 hospitals, and 4,115 matched people from Minnesota with no history of stroke or recent MI.

The stroke and MI patients matched up fairly closely for their cumulative 30-day, 1-year, and 5-year mortality, although the stroke patients had significantly higher rates of death following hospital discharge at both 1 year and 5 years after the initial hospitalization. Cumulative mortality in both postevent groups dwarfed the rate among the people who had neither a stroke nor MI. At 1 year, cumulative mortality ran 24% in the stroke patients, 22% in the MI patients, and 4% in the general population. At 5 years, the rates ran 49%, 44%, and 24%, respectively.

The difference between poststroke and post-MI patients showed up in several types of hospitalizations. Poststroke patients had substantially more rehospitalizations for a subsequent stroke: an 18% rate over 5 years, compared with 7% in the post-MI patients. But the post-MI patients held a decided edge in the rate of a subsequent MI: 25% over 5 years, compared with a 6% rate among the poststroke patients during the 5 years following their index event. The post-MI patients also had similarly large and statistically significant increases in their rate of heart failure and dysrhythmias. The overall, 5-year rate of hospitalization for any vascular cause ran 38% in the poststroke patients, 49% in patients who had an initial MI, and 19% in the general elderly population.

The 5-year rate of hospitalization for pneumonia reached the highest level in the stroke patients, at 20%, which was significantly greater than the 10% rate in the general population, but not a statistically significant difference over the 15% rate in patients with a history of MI. Poststroke patients also showed a high 5-year rate of hospitalization for hip fracture of 10%, which is twice the U.S. rate among women aged 65 years or older (based on published data) and also double the general Medicare population’s rate in Dr. Lakshminarayan’s study. At 5 years, 4% of the post-MI patients had a hip fracture.

Dr. Lakshminarayan said that she had no disclosures.

LOS ANGELES – During the first 5 years following a stroke, elderly patients have a unique pattern of comorbidity and hospitalization. This pattern sets them apart from similarly aged people who didn’t experience a stroke as well as from elderly patients who have had acute myocardial infarction, based on a review of more than 5,700 age- and gender-matched Medicare beneficiaries.

Following a stroke, Medicare patients showed a substantially higher rate of hospitalizations for hip fracture or pneumonia, compared with matched people without a history of stroke. These findings indicate that these excess events in stroke survivors "are not just due to age or the effects of acute hospitalization," Dr. Kamakshi Lakshminarayan said at the International Stroke Conference.

The analysis also showed that during the first year following a stroke or MI, the rate of any acute care hospitalization reached 49% in the poststroke patients and 55% in the post-MI patients, strikingly higher than the 20% rate among the matched elderly people with no history of either event.

The first year following a stroke or MI is when the rate of acute care hospitalization "peels away from the general Medicare population. This is where we need to intervene" to reduce the incidence of the complications that lead to hospitalizations, said Dr. Lakshminarayan, a stroke epidemiologist at the University of Minnesota in Minneapolis.

She and her associates studied 823 Medicare patients aged 65-84 years who had a validated, acute ischemic stroke during 2000 that led to hospitalization at any of 19 Minnesota hospitals. The researchers assembled two comparison groups of Medicare beneficiaries who matched the stroke group by age, sex, and race, including 823 patients with an acute MI treated at the same 19 hospitals, and 4,115 matched people from Minnesota with no history of stroke or recent MI.

The stroke and MI patients matched up fairly closely for their cumulative 30-day, 1-year, and 5-year mortality, although the stroke patients had significantly higher rates of death following hospital discharge at both 1 year and 5 years after the initial hospitalization. Cumulative mortality in both postevent groups dwarfed the rate among the people who had neither a stroke nor MI. At 1 year, cumulative mortality ran 24% in the stroke patients, 22% in the MI patients, and 4% in the general population. At 5 years, the rates ran 49%, 44%, and 24%, respectively.

The difference between poststroke and post-MI patients showed up in several types of hospitalizations. Poststroke patients had substantially more rehospitalizations for a subsequent stroke: an 18% rate over 5 years, compared with 7% in the post-MI patients. But the post-MI patients held a decided edge in the rate of a subsequent MI: 25% over 5 years, compared with a 6% rate among the poststroke patients during the 5 years following their index event. The post-MI patients also had similarly large and statistically significant increases in their rate of heart failure and dysrhythmias. The overall, 5-year rate of hospitalization for any vascular cause ran 38% in the poststroke patients, 49% in patients who had an initial MI, and 19% in the general elderly population.

The 5-year rate of hospitalization for pneumonia reached the highest level in the stroke patients, at 20%, which was significantly greater than the 10% rate in the general population, but not a statistically significant difference over the 15% rate in patients with a history of MI. Poststroke patients also showed a high 5-year rate of hospitalization for hip fracture of 10%, which is twice the U.S. rate among women aged 65 years or older (based on published data) and also double the general Medicare population’s rate in Dr. Lakshminarayan’s study. At 5 years, 4% of the post-MI patients had a hip fracture.

Dr. Lakshminarayan said that she had no disclosures.

LOS ANGELES – During the first 5 years following a stroke, elderly patients have a unique pattern of comorbidity and hospitalization. This pattern sets them apart from similarly aged people who didn’t experience a stroke as well as from elderly patients who have had acute myocardial infarction, based on a review of more than 5,700 age- and gender-matched Medicare beneficiaries.

Following a stroke, Medicare patients showed a substantially higher rate of hospitalizations for hip fracture or pneumonia, compared with matched people without a history of stroke. These findings indicate that these excess events in stroke survivors "are not just due to age or the effects of acute hospitalization," Dr. Kamakshi Lakshminarayan said at the International Stroke Conference.

The analysis also showed that during the first year following a stroke or MI, the rate of any acute care hospitalization reached 49% in the poststroke patients and 55% in the post-MI patients, strikingly higher than the 20% rate among the matched elderly people with no history of either event.

The first year following a stroke or MI is when the rate of acute care hospitalization "peels away from the general Medicare population. This is where we need to intervene" to reduce the incidence of the complications that lead to hospitalizations, said Dr. Lakshminarayan, a stroke epidemiologist at the University of Minnesota in Minneapolis.

She and her associates studied 823 Medicare patients aged 65-84 years who had a validated, acute ischemic stroke during 2000 that led to hospitalization at any of 19 Minnesota hospitals. The researchers assembled two comparison groups of Medicare beneficiaries who matched the stroke group by age, sex, and race, including 823 patients with an acute MI treated at the same 19 hospitals, and 4,115 matched people from Minnesota with no history of stroke or recent MI.

The stroke and MI patients matched up fairly closely for their cumulative 30-day, 1-year, and 5-year mortality, although the stroke patients had significantly higher rates of death following hospital discharge at both 1 year and 5 years after the initial hospitalization. Cumulative mortality in both postevent groups dwarfed the rate among the people who had neither a stroke nor MI. At 1 year, cumulative mortality ran 24% in the stroke patients, 22% in the MI patients, and 4% in the general population. At 5 years, the rates ran 49%, 44%, and 24%, respectively.

The difference between poststroke and post-MI patients showed up in several types of hospitalizations. Poststroke patients had substantially more rehospitalizations for a subsequent stroke: an 18% rate over 5 years, compared with 7% in the post-MI patients. But the post-MI patients held a decided edge in the rate of a subsequent MI: 25% over 5 years, compared with a 6% rate among the poststroke patients during the 5 years following their index event. The post-MI patients also had similarly large and statistically significant increases in their rate of heart failure and dysrhythmias. The overall, 5-year rate of hospitalization for any vascular cause ran 38% in the poststroke patients, 49% in patients who had an initial MI, and 19% in the general elderly population.

The 5-year rate of hospitalization for pneumonia reached the highest level in the stroke patients, at 20%, which was significantly greater than the 10% rate in the general population, but not a statistically significant difference over the 15% rate in patients with a history of MI. Poststroke patients also showed a high 5-year rate of hospitalization for hip fracture of 10%, which is twice the U.S. rate among women aged 65 years or older (based on published data) and also double the general Medicare population’s rate in Dr. Lakshminarayan’s study. At 5 years, 4% of the post-MI patients had a hip fracture.

Dr. Lakshminarayan said that she had no disclosures.

LOS ANGELES – During the first 5 years following a stroke, elderly patients have a unique pattern of comorbidity and hospitalization. This pattern sets them apart from similarly aged people who didn’t experience a stroke as well as from elderly patients who have had acute myocardial infarction, based on a review of more than 5,700 age- and gender-matched Medicare beneficiaries.

Following a stroke, Medicare patients showed a substantially higher rate of hospitalizations for hip fracture or pneumonia, compared with matched people without a history of stroke. These findings indicate that these excess events in stroke survivors "are not just due to age or the effects of acute hospitalization," Dr. Kamakshi Lakshminarayan said at the International Stroke Conference.

The analysis also showed that during the first year following a stroke or MI, the rate of any acute care hospitalization reached 49% in the poststroke patients and 55% in the post-MI patients, strikingly higher than the 20% rate among the matched elderly people with no history of either event.

The first year following a stroke or MI is when the rate of acute care hospitalization "peels away from the general Medicare population. This is where we need to intervene" to reduce the incidence of the complications that lead to hospitalizations, said Dr. Lakshminarayan, a stroke epidemiologist at the University of Minnesota in Minneapolis.

She and her associates studied 823 Medicare patients aged 65-84 years who had a validated, acute ischemic stroke during 2000 that led to hospitalization at any of 19 Minnesota hospitals. The researchers assembled two comparison groups of Medicare beneficiaries who matched the stroke group by age, sex, and race, including 823 patients with an acute MI treated at the same 19 hospitals, and 4,115 matched people from Minnesota with no history of stroke or recent MI.

The stroke and MI patients matched up fairly closely for their cumulative 30-day, 1-year, and 5-year mortality, although the stroke patients had significantly higher rates of death following hospital discharge at both 1 year and 5 years after the initial hospitalization. Cumulative mortality in both postevent groups dwarfed the rate among the people who had neither a stroke nor MI. At 1 year, cumulative mortality ran 24% in the stroke patients, 22% in the MI patients, and 4% in the general population. At 5 years, the rates ran 49%, 44%, and 24%, respectively.

The difference between poststroke and post-MI patients showed up in several types of hospitalizations. Poststroke patients had substantially more rehospitalizations for a subsequent stroke: an 18% rate over 5 years, compared with 7% in the post-MI patients. But the post-MI patients held a decided edge in the rate of a subsequent MI: 25% over 5 years, compared with a 6% rate among the poststroke patients during the 5 years following their index event. The post-MI patients also had similarly large and statistically significant increases in their rate of heart failure and dysrhythmias. The overall, 5-year rate of hospitalization for any vascular cause ran 38% in the poststroke patients, 49% in patients who had an initial MI, and 19% in the general elderly population.

The 5-year rate of hospitalization for pneumonia reached the highest level in the stroke patients, at 20%, which was significantly greater than the 10% rate in the general population, but not a statistically significant difference over the 15% rate in patients with a history of MI. Poststroke patients also showed a high 5-year rate of hospitalization for hip fracture of 10%, which is twice the U.S. rate among women aged 65 years or older (based on published data) and also double the general Medicare population’s rate in Dr. Lakshminarayan’s study. At 5 years, 4% of the post-MI patients had a hip fracture.

Dr. Lakshminarayan said that she had no disclosures.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

Photo credit: (c) Anetta/Fotolia

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

Photo credit: this text is superscript.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

Photo credit: (c) Anetta/Fotolia

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

Photo credit: this text is superscript.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

Photo credit: (c) Anetta/Fotolia

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

Photo credit: this text is superscript.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don’t expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said at the American Diabetes Association's annual advanced postgraduate course.

"We’re at the early stages of using computerized ordering." Automated systems "make it easier for nonendocrinologists to do the right thing" when administering insulin to hospitalized patients, said Dr. Korytkowski, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.

Setting up computerized order templates for insulin management is complicated because there is "no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we’re working on it. We don’t have it yet, but it’s worth doing," she said in an interview.

The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients. This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67). Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140-200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).

A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. "A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital," Dr. Korytkowski said.

Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said. The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians. Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet.

The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).

Dr. Korytkowski said that she has been a consultant to Eli Lilly.

LOS ANGELES – Physicians using angioplasty and stenting to treat intracranial stenosis need to identify the best patients to receive these interventions, and make sure that the procedures are cost effective, Dr. Adnan I. Qureshi said at the International Stroke Conference.

During 2005-2007, a large sample of U.S. hospital data showed that out of an estimated 1.8 million patients with acute or chronic intracranial arterial disease, roughly 1,600 patients underwent intracranial angioplasty or received a stent in an intracranial artery, said Dr. Qureshi, professor and associate head of the neurology department at the University of Minnesota, Minneapolis. The sample, which included diagnostic- and procedure-code information on nearly 371,000 U.S. patients with a primary diagnosis of stroke or transient ischemic attack, also showed that the small number of patients who underwent intracranial angioplasty or received a stent had substantially higher hospital charges than did medically treated patients.

Stenting also produced generally good outcomes, with 76% of patients going home after their hospital discharge, 20% going on to a care facility, and 4% dying in hospital. Patients who underwent intracranial angioplasty had worse outcomes, with a 17% mortality rate and a 39% rate of discharge to a care facility, with 45% going home from the hospital (total is 101% due to rounding).

But the administrative database that supplied these data included no information on patients’ disease severity, making meaningful outcome comparisons impossible, Dr. Qureshi stressed.

"The data do not allow us to compare patients with similar disease severity. Worse outcomes may not be related to the procedure but to where these patients started from. The challenge is to apply these treatments to the patients who are most likely to benefit," he said in an interview. Until now, "technology has been the main focus. Other factors that play into outcomes, like patient selection and timely administration of the treatment, have taken a back seat.

"We need to closely monitor the outcomes of patients who undergo [intracranial stenting and angioplasty] because that is the only way we’ll find out whether patients truly benefit. Endovascular treatments are being used today without good evidence of who to use them on and when. The message we don’t want to come from our analysis is that intracranial angioplasty and stent placement don’t work. What muddies the picture is when you apply [these treatments] to patients who don’t benefit. We need to focus on treating the patients who will benefit. I think our data are a wake-up call for us to be sure we are properly [focused] on patient selection and on cost being offset by the benefit that patients receive."

Dr. Qureshi’s analysis used data collected in the Nationwide Inpatient Sample by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. During 2005-2007, of the 370,993 patients in the sample with a primary diagnostic code of stroke or transient ischemic attack, 158 patients underwent intracranial angioplasty and 169 received an intracranial stent. Those numbers extrapolate to nationwide levels of about 1,822,000 cases, with 791 patients undergoing angioplasty and 837 receiving an intracranial stent, Dr. Qureshi said at the meeting, sponsored by the American Heart Association.

Further analysis showed that intracranial interventions occurred primarily at large teaching hospitals. Hospitalization charges for patients undergoing primary intracranial angioplasty only averaged $88,000; and for patients undergoing angioplasty plus stenting, the charges averaged almost $61,000. In contrast, for the remaining patients in the database hospitalization charges averaged about $24,000. Among patients who underwent an intracranial intervention, the concurrent presence of heart failure, pneumonia, urinary tract infection, or an intracranial hemorrhage was linked with a significantly increased rate of death or disability.

"In today’s world, most patients who get this procedure had an ischemic event in the brain related to the stenosis, and most had already been tried on maximal medical therapy. The challenge is, at what point do you decide that you have exhausted the medical options and move to [an intervention]. The strategy of how these patients are managed has changed, but their outcomes have not shifted as much as we would like. We need to closely monitor outcomes," Dr. Qureshi said.

Dr. Qureshi said that he had no disclosures.

LOS ANGELES – Physicians using angioplasty and stenting to treat intracranial stenosis need to identify the best patients to receive these interventions, and make sure that the procedures are cost effective, Dr. Adnan I. Qureshi said at the International Stroke Conference.

During 2005-2007, a large sample of U.S. hospital data showed that out of an estimated 1.8 million patients with acute or chronic intracranial arterial disease, roughly 1,600 patients underwent intracranial angioplasty or received a stent in an intracranial artery, said Dr. Qureshi, professor and associate head of the neurology department at the University of Minnesota, Minneapolis. The sample, which included diagnostic- and procedure-code information on nearly 371,000 U.S. patients with a primary diagnosis of stroke or transient ischemic attack, also showed that the small number of patients who underwent intracranial angioplasty or received a stent had substantially higher hospital charges than did medically treated patients.

Stenting also produced generally good outcomes, with 76% of patients going home after their hospital discharge, 20% going on to a care facility, and 4% dying in hospital. Patients who underwent intracranial angioplasty had worse outcomes, with a 17% mortality rate and a 39% rate of discharge to a care facility, with 45% going home from the hospital (total is 101% due to rounding).

But the administrative database that supplied these data included no information on patients’ disease severity, making meaningful outcome comparisons impossible, Dr. Qureshi stressed.

"The data do not allow us to compare patients with similar disease severity. Worse outcomes may not be related to the procedure but to where these patients started from. The challenge is to apply these treatments to the patients who are most likely to benefit," he said in an interview. Until now, "technology has been the main focus. Other factors that play into outcomes, like patient selection and timely administration of the treatment, have taken a back seat.

"We need to closely monitor the outcomes of patients who undergo [intracranial stenting and angioplasty] because that is the only way we’ll find out whether patients truly benefit. Endovascular treatments are being used today without good evidence of who to use them on and when. The message we don’t want to come from our analysis is that intracranial angioplasty and stent placement don’t work. What muddies the picture is when you apply [these treatments] to patients who don’t benefit. We need to focus on treating the patients who will benefit. I think our data are a wake-up call for us to be sure we are properly [focused] on patient selection and on cost being offset by the benefit that patients receive."

Dr. Qureshi’s analysis used data collected in the Nationwide Inpatient Sample by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. During 2005-2007, of the 370,993 patients in the sample with a primary diagnostic code of stroke or transient ischemic attack, 158 patients underwent intracranial angioplasty and 169 received an intracranial stent. Those numbers extrapolate to nationwide levels of about 1,822,000 cases, with 791 patients undergoing angioplasty and 837 receiving an intracranial stent, Dr. Qureshi said at the meeting, sponsored by the American Heart Association.

Further analysis showed that intracranial interventions occurred primarily at large teaching hospitals. Hospitalization charges for patients undergoing primary intracranial angioplasty only averaged $88,000; and for patients undergoing angioplasty plus stenting, the charges averaged almost $61,000. In contrast, for the remaining patients in the database hospitalization charges averaged about $24,000. Among patients who underwent an intracranial intervention, the concurrent presence of heart failure, pneumonia, urinary tract infection, or an intracranial hemorrhage was linked with a significantly increased rate of death or disability.

"In today’s world, most patients who get this procedure had an ischemic event in the brain related to the stenosis, and most had already been tried on maximal medical therapy. The challenge is, at what point do you decide that you have exhausted the medical options and move to [an intervention]. The strategy of how these patients are managed has changed, but their outcomes have not shifted as much as we would like. We need to closely monitor outcomes," Dr. Qureshi said.

Dr. Qureshi said that he had no disclosures.

LOS ANGELES – Physicians using angioplasty and stenting to treat intracranial stenosis need to identify the best patients to receive these interventions, and make sure that the procedures are cost effective, Dr. Adnan I. Qureshi said at the International Stroke Conference.

During 2005-2007, a large sample of U.S. hospital data showed that out of an estimated 1.8 million patients with acute or chronic intracranial arterial disease, roughly 1,600 patients underwent intracranial angioplasty or received a stent in an intracranial artery, said Dr. Qureshi, professor and associate head of the neurology department at the University of Minnesota, Minneapolis. The sample, which included diagnostic- and procedure-code information on nearly 371,000 U.S. patients with a primary diagnosis of stroke or transient ischemic attack, also showed that the small number of patients who underwent intracranial angioplasty or received a stent had substantially higher hospital charges than did medically treated patients.

Stenting also produced generally good outcomes, with 76% of patients going home after their hospital discharge, 20% going on to a care facility, and 4% dying in hospital. Patients who underwent intracranial angioplasty had worse outcomes, with a 17% mortality rate and a 39% rate of discharge to a care facility, with 45% going home from the hospital (total is 101% due to rounding).

But the administrative database that supplied these data included no information on patients’ disease severity, making meaningful outcome comparisons impossible, Dr. Qureshi stressed.

"The data do not allow us to compare patients with similar disease severity. Worse outcomes may not be related to the procedure but to where these patients started from. The challenge is to apply these treatments to the patients who are most likely to benefit," he said in an interview. Until now, "technology has been the main focus. Other factors that play into outcomes, like patient selection and timely administration of the treatment, have taken a back seat.

"We need to closely monitor the outcomes of patients who undergo [intracranial stenting and angioplasty] because that is the only way we’ll find out whether patients truly benefit. Endovascular treatments are being used today without good evidence of who to use them on and when. The message we don’t want to come from our analysis is that intracranial angioplasty and stent placement don’t work. What muddies the picture is when you apply [these treatments] to patients who don’t benefit. We need to focus on treating the patients who will benefit. I think our data are a wake-up call for us to be sure we are properly [focused] on patient selection and on cost being offset by the benefit that patients receive."

Dr. Qureshi’s analysis used data collected in the Nationwide Inpatient Sample by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. During 2005-2007, of the 370,993 patients in the sample with a primary diagnostic code of stroke or transient ischemic attack, 158 patients underwent intracranial angioplasty and 169 received an intracranial stent. Those numbers extrapolate to nationwide levels of about 1,822,000 cases, with 791 patients undergoing angioplasty and 837 receiving an intracranial stent, Dr. Qureshi said at the meeting, sponsored by the American Heart Association.

Further analysis showed that intracranial interventions occurred primarily at large teaching hospitals. Hospitalization charges for patients undergoing primary intracranial angioplasty only averaged $88,000; and for patients undergoing angioplasty plus stenting, the charges averaged almost $61,000. In contrast, for the remaining patients in the database hospitalization charges averaged about $24,000. Among patients who underwent an intracranial intervention, the concurrent presence of heart failure, pneumonia, urinary tract infection, or an intracranial hemorrhage was linked with a significantly increased rate of death or disability.

"In today’s world, most patients who get this procedure had an ischemic event in the brain related to the stenosis, and most had already been tried on maximal medical therapy. The challenge is, at what point do you decide that you have exhausted the medical options and move to [an intervention]. The strategy of how these patients are managed has changed, but their outcomes have not shifted as much as we would like. We need to closely monitor outcomes," Dr. Qureshi said.

Dr. Qureshi said that he had no disclosures.