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Permanente
Abstracts
Abstracts
of articles authored or coauthored by Permanente clinicians.
Click
here for a pdf copy of these Abstracts >>
From Northern California:
Glycemic control and heart failure among adult patients with diabetes
Iribarren C,
Karter AJ, Go AS, et al. Circulation 2001 Jun 5;103(22):2668-73
to
article >>
From Northern California:
Self-monitoring
of blood glucose levels and glycemic control: the Northern California
Kaiser Permanente Diabetes Registry
Karter AJ, Ackerson LM,
Darbinian JA, et al. Am J Med 2001 Jul;111(1):1-9
to
article >>
From Georgia:
Prevalence of clinical and isolated subclinical cardiovascular
disease in older adults with glucose disorders: the Cardiovascular Health
Study
Barzilay JI, Spiekerman
CF, Kuller LH, et al. Diabetes Care 2001 Jul;24(7):1233-9
to
article >>
From Northern California:
Emergency
department right upper quadrant ultrasound is associated with a reduced
time to diagnosis and treatment of ruptured ectopic pregnancies
Rodgerson JD, Heegaard WG,
Plummer D, Hicks J, Clinton J, Sterner S. Acad Emerg Med 2001 Apr;8(4):331-6
to
article >>
From Northern California:
Prevalence and determinants of osteoporosis drug prescription among
patients with high exposure to glucocorticoid drugs
Ettinger B, Chidambaran
P, Pressman A. Am J Manag Care 2001 Jun;7(6):597-605
to
article >>
From Northern California:
Variation in clinician recommendations for multiple injections
during adoption of inactivated polio vaccine
Lieu TA, Davis RL, Capra
AM, et al. Pediatrics 2001 Apr;107(4):E49
to
article >>
From The Northwest:
Variations in pharmacotherapy for attention deficit hyperactivity
disorder in managed care
Boles M, Lynch FL, DeBar
LL. J Child Adolesc Psychopharmacol 2001 Spring;11(1):43-52
to
article >>
From Northern California
and Group Health, Northwest:
Targeted testing of children for tuberculosis: validation of a
risk assessment questionnaire
Froehlich H, Ackerson LM,
Morozumi PA. Pediatrics 2001 Apr;107(4):E54
to
article >>
From Ohio:
Osteoporosis screening outreach trial: the role of the primary
care physician
Binstock
M. Obstet Gynecol 2001 Apr;97(4 Suppl 1):S26
to
article >>
From Northern California:
Prevalence of diagnosed atrial fibrillation in adults: national
implications for rhythm management and stroke prevention: the Anticoagulation
and Risk Factors in Atrial Fibrillation (ATRIA) Study
Go AS,
Hylek EM, Phillips KA, et al. JAMA 2001 May 9;285(18):2370-5
to
article >>
From Northern California:
Comparison
of quality and cost-effectiveness in the evaluation of symptomatic cholelithiasis
with different approaches to ultrasound availability in the ED
Durston W, Carl ML, Guerra
W, et al. Am J Emerg Med 2001 Jul;19(4):260-9
to
article >>
Permanente
Abstracts
Abstracts
of articles authored or coauthored by Permanente clinicians.
Click
here for a pdf copy of these Abstracts >>
As Robert Aquinas McNally
mentions in his article "Something in the Genes," p 15, when
Henry Kaiser and Sidney Garfield, MD, created what is today Kaiser Permanente
(KP), their vision "... extended to bridging the institutional gap
separating medical research from clinical medicine." As our founders
recognized the importance of independent research, and as KP continues
this legacy today, The Permanente Journal has recognized the important
work of Permanente researchers and promotes this work by reprinting abstracts
in each issue. To further bridge this gap, we are now inviting the authors
to briefly describe how his or her research can be embedded into daily
practice. Beginning with this issue there will be a number of "Clinical
Implications" boxes adjoining the related abstract from which you
can glean the basic relevance of the abstract to your practice.
From Northern California:
Glycemic control and heart failure among adult
patients with diabetes
Iribarren C,
Karter AJ, Go AS, et al. Circulation 2001 Jun 5;103(22):2668-73
background:
Glycemic control is associated with microvascular events, but its effect
on the risk of heart failure is not well understood. We examined the association
between hemoglobin (HbA1c) and the risk of heart failure hospitalization
and/or death in a population-based sample of adult patients with diabetes
and assessed whether this association differed by patient sex, heart failure
pathogenesis, and hypertension status.
methods
and results: A cohort design was used with baseline between January
1, 1995, and June 30, 1996, and follow-up through December 31, 1997 (median
2.2 years). Participants were 25,958 men and 22,900 women with (predominantly
type 2) diabetes, > 19 years old, with no known history of heart
failure. There were a total of 935 events (516 among men; 419 among women).
After adjustment for age, sex, race/ethnicity, education level, cigarette
smoking, alcohol consumption, hypertension, obesity, use of beta-blockers
and ACE inhibitors, type and duration of diabetes, and incidence of interim
myocardial infarction, each 1% increase in HbA1c was associated with an
8% increased risk of heart failure (95% CI 5% to 12%). An HbA1c >
10, relative to HbA1c <7, was associated with 1.56-fold (95% CI 1.26
to 1.93) greater risk of heart failure. Although the association was stronger
in men than in women, no differences existed by heart failure pathogenesis
or hypertension status.
conclusions: These results confirm previous evidence that poor glycemic
control may be associated with an increased risk of heart failure among
adult patients with diabetes.
| clinical
implications:
These data show apparently linearly progressive increase in the risk
of heart failure with progressively worse glycemic control (8% increased
heart failure risk for each 1% increase in HbA1c). The 22% of the
cohort judged to have poor glycemic control had a 56% higher risk
of heart failure than subjects who had the best glycemic control.
Thus, I hope that our study increases the awareness of potential cardiac
complications of diabetes at the macro- and micro-vascular levels
and emphasizes the importance of tight glycemic control. In order
to encourage patients to maintain glycemic control, I would first
stress behavioral modifications such as losing weight through exercise
and a healthy diet appropriate for diabetes. Second, I would suggest
compliance with instructions for home self-monitoring of blood glucose
level. And third, I would recommend adherence to the prescribed insulin
and/or oral hypoglycemic therapy. --CI |
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list of abstracts >>
From Northern California:
Self-monitoring
of blood glucose levels and glycemic control: the Northern California
Kaiser Permanente Diabetes Registry
Karter AJ, Ackerson LM,
Darbinian JA, et al. Am J Med 2001 Jul;111(1):1-9
purpose:
We sought to evaluate the effectiveness of self-monitoring blood glucose
levels to improve glycemic control.
subjects
and methods: A cohort design was used to assess the relation between
self-monitoring frequency (1996 average daily glucometer strip utilization)
and the first glycosylated hemoglobin (HbA1c) level measured in 1997.
The study sample included 24,312 adult patients with diabetes who were
members of a large, group model, managed care organization. We estimated
the difference between HbA1c levels in patients who self-monitored at
frequencies recommended by the American Diabetes Association compared
with those who monitored less frequently or not at all. Models were adjusted
for age, sex, race, education, occupation, income, duration of diabetes,
medication refill adherence, clinic appointment "no show" rate,
annual eye exam attendance, use of nonpharmacological (diet and exercise)
diabetes therapy, smoking, alcohol consumption, hospitalization and emergency
room visits, and the number of daily insulin injections.
results:
Self-monitoring among patients with type 1 diabetes (> 3 times
daily) and pharmacologically treated type 2 diabetes (at least daily)
was associated with lower HbA1c levels (1.0 percentage points lower in
type 1 diabetes and 0.6 points lower in type 2 diabetes) than was less
frequent monitoring (p < 0.0001). Although there are no specific recommendations
for patients with nonpharmacologically treated type 2 diabetes, those
who practiced self-monitoring (at any frequency) had a 0.4 point lower
HbA1c level than those not practicing at all (p < 0.0001).
conclusion:
More frequent self-monitoring of blood glucose levels was associated with
clinically and statistically better glycemic control regardless of diabetes
type or therapy. These findings support the clinical recommendations suggested
by the American Diabetes Association.
Reprinted
from American Journal of Medicine, Vol 111, No. 1, Karter AJ, Ackerson
LM, Darbinian JA, et al, Self-monitoring of blood glucose levels and glycemic
control: the Northern California Kaiser Permanente Diabetes registry,
1-9. Copyright 2001, with permission from Excerpta Medica Inc.
To
list of abstracts >>
From Georgia:
Prevalence of clinical and isolated subclinical
cardiovascular disease in older adults with glucose disorders: the Cardiovascular
Health Study
Barzilay JI, Spiekerman
CF, Kuller LH, et al. Diabetes Care 2001 Jul;24(7):1233-9
objective:
Clinical cardiovascular disease (CVD) is highly prevalent among people
with diabetes. However, there is little information regarding the prevalence
of subclinical CVD and its relation to clinical CVD in diabetes and in
the glucose disorders that precede diabetes.
research design and methods: Participants in the Cardiovascular Health
Study, aged > 65 years (n = 5888), underwent vascular and metabolic
testing. Individuals with known disease in the coronary, cerebral, or
peripheral circulations were considered to have clinical disease. Those
without any clinical disease in whom CVD was detected by ultrasonography,
electrocardiography, or ankle arm index in any of the three vascular beds
were considered to have isolated subclinical disease.
results: Approximately 30% of the cohort had clinical disease, and
approximately 60% of the remainder had isolated subclinical disease. In
those with normal glucose status, isolated subclinical disease made up
most of the total CVD. With increasing glucose severity, the proportion
of total CVD that was clinical disease increased; 75% of men and 66% of
women with normal fasting glucose status had either clinical or subclinical
CVD. Among those with known diabetes, the prevalence was approximately
88% (odds ratio [OR] 2.46 for men and 4.22 for women, p < 0.0001).
There were intermediate prevalences and ORs for those with impaired fasting
glucose status and newly diagnosed diabetes.
conclusions: Isolated subclinical CVD is common among older adults.
Glucose disorders are associated with an increased prevalence of total
CVD and an increased proportion of clinical disease relative to subclinical
disease.
Copyright by the American Diabetes Association.
| clinical
implications:
Subclinical cardiovascular disease (CVD) is highly prevalent in the
glucose disorders that precede known diabetes mellitus. It is upon
this background that clinical CVD prevalence is high in the stage
of known diabetes mellitus. It therefore behooves the practicing physician
to identify those with early glucose disorders in order to take appropriate
measures (aspirin, lowering blood pressure and lipids) to prevent
the progression of subclinical to clinical CVD. --JB |
To
list of abstracts >>
From Northern California:
Emergency
department right upper quadrant ultrasound is associated with a reduced
time to diagnosis and treatment of ruptured ectopic pregnancies
Rodgerson JD, Heegaard WG,
Plummer D, Hicks J, Clinton J, Sterner S. Acad Emerg Med 2001 Apr;8(4):331-6
objective:
To determine whether the time to diagnosis and treatment of patients with
ruptured ectopic pregnancy is significantly less for patients who had
emergency department (ED) right upper quadrant (RUQ) ultrasound (US) compared
with those who had US in the radiology department.
methods: The authors conducted a retrospective review of eligible
patients presenting to an urban ED between January 1990 and December 1998.
Patients were included in the study if they were seen in the ED, had a
discharge diagnosis of ruptured ectopic pregnancy, were brought immediately
to the operating room after a definitive diagnosis of ectopic pregnancy
rupture was made, and had more than 400 mL of intraperitoneal blood found
at the time of surgery. The ED, hospital, radiology, and operative records
were reviewed to determine presenting vital signs, intraperitoneal blood
loss, time to diagnosis, time to treatment, and type of US performed.
results: There were 37 patients enrolled; 16 received ED RUQ US (group
I) and 21 had a formal US in radiology (group II). The ages, pulses, systolic
blood pressures, and volumes of hemoperitoneum were similar between the
two groups. The average time to diagnosis from ED arrival was 58 minutes
for group I (SD = 57; 95% CI = 28 to 87) and 197 minutes for group II
(SD = 82; 95% CI = 162 to 232) (p < 0.0001). The average time
to operative treatment was 111 minutes (group I) (SD = 86; 95% CI = 69
to 153) and 322 minutes (group II) (SD = 107; 95% CI = 270 to 364) (p
< 0.0001), respectively.
conclusions: Patients with ruptured ectopic pregnancy, who were selected
to have RUQ US performed in the ED by emergency physicians, had an average
decrease in time to diagnosis of two and a quarter hours, and an average
decrease in time to treatment of three and a half hours, compared with
those having a formal pelvic US in the radiology department. Further prospective
investigation is needed to determine whether ED RUQ US can safely expedite
care of patients with suspected ectopic pregnancy.
To
list of abstracts >>
From Northern California:
Prevalence and determinants of osteoporosis
drug prescription among patients with high exposure to glucocorticoid
drugs
Ettinger B, Chidambaran
P, Pressman A. Am J Manag Care 2001 Jun;7(6):597-605
objective:
To investigate use of osteoporosis drugs among patients with high exposure
to glucocorticoid drugs.
study
design: Retrospective review of pharmacy records.
methods:
We identified patients aged > 20 years who received prescriptions
for > 2 g of prednisone (or equivalent) during any 12-month
period between January 1, 1998, and December 31, 1999, and who initiated
use of osteoporosis-specific drugs (alendronate sodium, etidronate disodium,
and calcitonin) during that period.
results:
Among 8807 patients who met study criteria, 772 (8.8%) received prescriptions
for osteoporosis drugs. Prevalence of osteoporosis drug prescriptions
increased linearly during the study and differed markedly by patient sex,
age, and exposure to glucocorticoid drugs. Osteoporosis drugs were prescribed
for 16.3% of women aged > 65 years, for 6.1% of women aged <
50 years, for 6.5% of men aged > 65 years, and for 2.2% of men
aged < 50 years. Higher glucocorticoid exposure was also associated
with higher rate of osteoporosis drug prescription (11.2% of patients
exposed to > 4 g/year and 5.6% exposed to 2 to 3 g/year received such
therapies). Osteoporosis drugs were 50% more likely to be prescribed by
clinicians who prescribed glucocorticoid drugs to > 18 patients than
by providers who prescribed glucocorticoid drugs to < 4 patients.
conclusions:
Despite ready availability of bone-specific osteoporosis drugs, few patients
with high exposure to glucocorticoid drugs received such therapy. Likelihood
of an osteoporosis drug being prescribed for such patients strongly depends
on patient sex, age, and exposure to glucocorticoid drugs and on level
of practitioner experience in prescribing glucocorticoid drugs.
To
list of abstracts >>
From Northern California:
Variation in clinician recommendations for
multiple injections during adoption of inactivated polio vaccine
Lieu TA, Davis RL, Capra
AM, et al. Pediatrics 2001 Apr;107(4):E49
objectives:
To describe variation in clinician recommendations for multiple injections
during the adoption of inactivated poliovirus vaccine (IPV) in two large
health maintenance organizations (HMOs), and to test the hypothesis that
variation in recommendations would be associated with variation in immunization
coverage rates.
design:
Cross-sectional study based on a survey of clinician practices one year
after IPV was recommended and computerized immunization data from these
clinicians' patients.
study
settings: Two large West Coast HMOs: Kaiser Permanente in Northern
California and Group Health Cooperative of Puget Sound.
outcome
measures: Immunization status of 8-month-olds and 24-month-olds cared
for by the clinicians during the study.
results:
More clinicians at Group Health (82%), where a central guideline was
issued, had adopted the IPV/oral poliovirus vaccine (OPV) sequential schedule
than at Kaiser (65%), where no central guideline was issued. Clinicians
at both HMOs said that if multiple injections fell due at a visit and
they elected to defer some vaccines, they would be most likely to defer
the hepatitis B vaccine (HBV) for infants (40%). At Kaiser, IPV users
were more likely than OPV users to recommend the first HBV at birth (64%
vs 28%) or if they did not, to defer the third HBV to eight months or
later (62% vs 39%). In multivariate analyses, patients whose clinicians
used IPV were as likely to be fully immunized at eight months old as those
whose clinicians used all OPV. At Kaiser, where there was variability
in the maximum number of injections clinicians recommended at infant visits,
providers who routinely recommended three or four injections at a visit
had similar immunization coverage rates as those who recommended one or
two. At both HMOs, clinicians who strongly recommended all possible injections
at a visit had higher immunization coverage rates at eight months than
those who offered parents the choice of deferring some vaccines to a subsequent
visit (at Kaiser, odds ratio [OR]: 1.2; 95% confidence interval [CI]:
1.0-1.5; at Group Health, OR: 1.8; 95% CI: 1.1-2.8).
conclusions:
Neither IPV adoption nor the use of multiple injections at infant visits
were associated with reductions in immunization coverage. However, at
the HMO without centralized immunization guidelines, IPV adoption was
associated with changes in the timing of the first and third HBV. Clinical
policymakers should continue to monitor practice variation as future vaccines
are added to the infant immunization schedule.
To
list of abstracts >>
From The Northwest:
Variations in pharmacotherapy for attention
deficit hyperactivity disorder in managed care
Boles M, Lynch FL, DeBar
LL. J Child Adolesc Psychopharmacol 2001 Spring;11(1):43-52
The purpose
of this study was to identify the patterns of pharmacotherapy in the treatment
of children diagnosed with attention deficit hyperactivity disorder (ADHD)
in a large, non-profit, group-model managed care organization from January
1997 through July 1998. We sought to determine whether children with uncomplicated
ADHD use different drug therapies when compared to children with ADHD
and psychiatric comorbidity. We also examined the relationships between
the use of specialty mental health services and the use of various psychotropic
medications for treatment of ADHD. We found that children with ADHD and
psychiatric comorbidity were less likely to use psychostimulants (odds
ratio [OR] = 0.71, 95% confidence interval [CI] = 0.55-0.93, p = 0.01)
but more likely to use antidepressants (OR = 2.74, 95% CI = 1.95-3.86,
p < 0.01), alpha adrenergic agonists (OR = 2.63, 95% CI = 1.93-3.57,
p < 0.01), and other psychotropic medications (OR = 2.40, 95% CI =
1.27-4.50, p < 0.01) than children with uncomplicated ADHD (who were
more likely to use stimulants only). Additionally, children with psychiatric
comorbidity were more likely to use multiple psychotropic drugs (p <
0.01). The results of this study indicate that children with potentially
more complex mental health needs are being treated with more varied drug
therapy and/or specialty mental health care services.
To
list of abstracts >>
From Northern California
and Group Health, Northwest:
Targeted testing of children for tuberculosis:
validation of a risk assessment questionnaire
Froehlich H, Ackerson LM,
Morozumi PA. Pediatrics 2001 Apr;107(4):E54
objective:
Given the directive of the American Academy of Pediatrics to test children
for tuberculosis (TB) only if they are at high risk for the disease, we
sought to determine how well a risk assessment questionnaire can predict
a positive tuberculin skin test (TST) result among children seen in a
medical office setting.
methods:
In a prospective observational study, we identified 31,926 children who
received well-child care in 18 pediatric offices of the Kaiser Permanente
Northern California Region from August 1996 through
November 1998 and who were due to receive a routine TST (Mantoux method)
as part of universal screening. Parents were asked to complete a questionnaire
about risk factors for TB infection that included demographic information.
The TST result at 48 to 72 hours was compared with questionnaire responses
to identify responses that were most highly associated with a positive
TST result at both the 10-mm and 15-mm cutoffs. A concurrent study was
conducted to determine whether parents can recognize induration.
results:
This population was diverse in age (range: 0-18 years), race/ethnicity
(white: 37%; Hispanic: 26.4%; Asian: 15.0%; black: 11.8%; other: 8.4%;
not stated by parent: 1.6%), and household annual income (range: $10,524-$175,282).
Overall incidence of positive TST results was 1.0% at the 10-mm cutoff
and 0.5% at the 15-mm cutoff. Positive predictive value of selected individual
risk factors at the 10-mm cutoff were: child born outside the United States,
10.4%; history of receiving bacille Calmette-Guerin vaccine, 5.5%; and
child having lived outside the United States, 5.3%. Using multivariate
analysis, we selected a subset of risk factors that were independently
and significantly associated with a positive TST result > 10
mm: history of receiving bacille Calmette-Guerin vaccine (odds ratio [OR]:
2.31; 95% confidence interval [CI]: 1.70-3.13); household member with
history of positive TST result or TB disease (OR: 1.53; 95% CI: 1.14-2.04);
child born outside the United States (OR: 8.63; 95% CI: 6.16-12.09); child
having lived outside the United States (OR: 2.06; 95% CI: 1.49-2.85);
and race/ethnicity reported by parent as Asian (OR: 2.28; 95% CI: 1.59-3.27)
or Hispanic (OR: 1.57; 95% CI: 1.09-2.26). Several factors were not statistically
significant predictors of a positive TST result: age, sex, household annual
income, household member infected with human immunodeficiency virus or
who had stayed in a homeless shelter, and being an adopted or foster child.
Overall sensitivity of the nine main items on the questionnaire was 80.9%;
when a subset of four of these questions plus the race/ethnicity questions
were used, sensitivity of responses was 83.5%. Parents failed to recognize
positive TST results at a rate of 9.9% (for the 10-mm cutoff) and 5.9%
(at the 15-mm cutoff).
conclusion:
A five-question risk assessment questionnaire completed by parents can
be used to accurately identify risk factors associated with TB infection
in children. In our population, some risk factors suggested by the American
Academy of Pediatrics could not be validated. Parents cannot be relied
on to read TST results accurately. Screening for TB can be enabled by
using a standardized, validated questionnaire to identify children who
should be given tuberculin skin testing.
To
list of abstracts >>
From Ohio:
Osteoporosis screening outreach trial: the
role of the primary care physician
Binstock
M. Obstet Gynecol 2001 Apr;97(4 Suppl 1):S26
objective:
Screening and treatment rates for osteoporosis are low despite high prevalence
and morbidity. The purpose of this study was to determine the impact of
primary care physician (PCP) review and signature on a letter outreach
campaign to promote densitometry (DXA) in a group of high-risk postmenopausal
females.
methods:
Computerized records of more than 35,000 women aged 55 years and older
were obtained. Inclusion criteria were weight less than 127 pounds and
current cigarette smoking. Exclusion criteria were prior DXA or having
received a bone-protective drug during the past three months. Women with
an odd record number had their letter sent to their PCP to review for
clinical appropriateness and signature. Those with an even number were
sent a letter with the name of the chief at the bottom.
results:
DXA was done in 10% (37/364) of the PCP group and 20% (67/339) of
the non-PCP group. The DXA results (PCP versus non-PCP) were: osteoporosis
(54%, 41%), osteopenia (37%, 39%), and normal (8%, 19%). Among patients
with osteoporosis, treatment was dispensed to 40% of the PCP patients
versus 53% of the non-PCP patients.
Among patients with osteopenia, treatment was dispensed to 36% of the
PCP patients versus 42% of the non-PCP patients. Thirty-seven patients
in both groups were dispensed bone-protective drugs (almost exclusively
estrogen) despite not undergoing DXA.
conclusion:
Screening rates were low but consistent with prior outreach campaigns.
Involving the PCP substantially reduced the response rate. Treatment rates
were low in both groups, but higher in the non-PCP group. Many women in
both groups began bone-protective drug therapy following the letter despite
not having DXA.
Reprinted
with permission from the American College of Obstetricians and Gynecologists
(Obstetrics and Gynecology, 2001 Apr;97(4 Suppl 1):S26.
To
list of abstracts >>
From Northern California:
Prevalence of diagnosed atrial fibrillation
in adults: national implications for rhythm management and stroke prevention:
the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study
Go AS,
Hylek EM, Phillips KA, et al. JAMA 2001 May 9;285(18):2370-5
context:
Atrial fibrillation is the most common arrhythmia in elderly persons and
a potent risk factor for stroke. However, recent prevalence and projected
future numbers of persons with atrial fibrillation are not well described.
objective: To estimate prevalence of atrial fibrillation and US national
projections of the numbers of persons with atrial fibrillation through
the year 2050.
design, setting, and patients: Cross-sectional study of adults aged
20 years or older who were enrolled in a large health maintenance organization
in California and who had atrial fibrillation diagnosed between July 1,
1996, and December 31, 1997.
main outcome measures: Prevalence of atrial fibrillation in the study
population of 1.89 million; projected number of persons in the United
States with atrial fibrillation between 1995-2050.
results: A total of 17,974 adults with diagnosed atrial fibrillation
were identified during the study period; 45% were aged 75 years or older.
The prevalence of atrial fibrillation was 0.95% (95% confidence interval,
0.94%-0.96%). Atrial fibrillation was more common in men than in women
(1.1% vs 0.8%; p < .001). Prevalence increased from 0.1% among adults
younger than 55 years to 9.0% in persons aged 80 years or older. Among
persons aged 50 years or older, prevalence of atrial fibrillation was
higher in whites than in blacks (2.2% vs 1.5%; p < .001). We estimate
approximately 2.3 million US adults currently have atrial fibrillation.
We project that this will increase to more than 5.6 million (lower bound,
5.0; upper bound, 6.3) by the year 2050, with more than 50% of affected
individuals aged 80 years or older.
conclusions: Our study confirms that atrial fibrillation is common
among older adults and provides a contemporary basis for estimates of
prevalence in the United States. The number of patients with atrial fibrillation
is likely to increase 2.5-fold during the next 50 years, reflecting the
growing proportion of elderly individuals. Coordinated efforts are needed
to face the increasing challenge of optimal stroke prevention and rhythm
management in patients with atrial fibrillation.
Copyrighted 2001, American Medical Association
| clinical
implications:
Clinicians should recognize that the burden of atrial fibrillation
and associated complications of ischemic stroke, arrhythmia-related
symptoms, and effects on cardiac function are substantial now but
will grow rapidly over the coming decades as the US population ages.
Our study demonstrates that the occurrence of atrial fibrillation
is tightly linked with increasing age, with about 1 in 25 patients
age 60 years or older and 1 in 10 patients age 80 years or older having
this arrhythmia, often without overt symptoms. Atrial fibrillation
increases the annual risk of stroke by fivefold, and this effect persists
throughout older age. In particular, early identification and risk
stratification of older patients with atrial fibrillation would facilitate
better targeting of persons who are most likely to benefit from chronic
anticoagulation with warfarin therapy to prevent ischemic stroke and
other systemic thromboembolism. --AG |
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list of abstracts >>
From Northern California:
Comparison
of quality and cost-effectiveness in the evaluation of symptomatic cholelithiasis
with different approaches to ultrasound availability in the ED
Durston W, Carl ML, Guerra
W, et al. Am J Emerg Med 2001 Jul;19(4):260-9
Ultrasound
is the imaging study of choice for the detection of gallstones, but ultrasound
through medical imaging departments (MI Sono) is not readily available
on an immediate basis in many emergency departments (EDs). Several studies
have shown that emergency physicians can perform ultrasound themselves
(ED Sono) to rule out gallstones with acceptable accuracy after relatively
brief training periods, but there have been no studies to date specifically
addressing the effect of ED Sono of the gallbladder on quality and cost-effectiveness
in the ED. In this study, we investigated measures of quality and cost-effectiveness
in evaluating patients with suspected symptomatic cholelithiasis during
three different years with distinctly different approaches to ultrasound
availability. The study retrospectively identified a total of 418 patients
who were admitted for cholecystectomy or for a complication of cholelithiasis
within six months of an ED visit for possible biliary colic. The percentage
of patients who had gallstones documented at the first ED visit improved
from 28% in 1993, when there was limited availability of ultrasound through
the Medical Imaging Department (MI Sono), to 56% in 1995, when MI Sono
was readily available, to 70% in 1997, when both MI Sono and ED Sono were
readily available (p < .001). There were also significant differences
over the three years in the mean number of days from the first ED visit
to documentation of gallstones (19.7 in 1993, 10.7 in 1995, 7.4 in 1997,
p < .001); the mean number of return visits for possible biliary colic
before documentation of gallstones (1.67 in 1993, 1.24 in 1995, and 1.25
in 1997, p < .001); and the incidence of complications of cholelithiasis
in the interval between the first ED visit
for possible biliary colic and the date of documentation of cholelithiasis
(6.8% in 1993, 5.9% in 1995, 1.5% in 1997, p = .049). The number of MI
Sonos ordered by emergency physicians per case of symptomatic cholelithiasis
identified increased from 1.7 in 1993 to 2.5 in 1995 and dropped back
to 1.7 in 1997, when 4.2 ED Sonos per study case were also done. The cost
of ED Sonos was more than offset by savings in avoiding calling in ultrasound
technicians after regular Medical Imaging Department hours. The indeterminate
rate for ED Sonos was 18%. Excluding indeterminates, the sensitivity of
ED Sono for detection of gallstones was 88.6% (95% CI 83.1-92.8%), the
specificity 98.2% (95% CI 96.0-99.3%), and the accuracy 94.8% (95% CI
92.5-96.5%). We conclude that greater availability of MI Sono in the ED
was associated with improved quality in the evaluation of patients with
suspected symptomatic cholelithiasis but also with increased ultrasound
costs. The availability of ED Sono in addition to readily available MI
Sono was associated with further improved quality and decreased costs.
The indeterminate rate for ED Sono was relatively high, but excluding
indeterminates, the accuracy of ED Sono was comparable with published
reports of MI Sono.
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