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Little is known about whether sex differences in acute coronary syndrome (ACS) presentation exist in younger patients. Khan and coauthors surveyed 1015 patients (30% women) 55 years or younger with ACS using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey. They found that while chest pain was the most common symptom for both sexes, women were more likely to present without chest pain compared with men, and women reported more symptoms in general than did men. Patients without chest pain did not differ significantly from those with chest pain in terms of ACS type, troponin level elevation, or coronary stenosis. An Editorial from Akinkuolie and Mora accompanies the study.
Informing patients and providers of the likelihood of survival after in-hospital cardiac arrest, neurologically intact or with minimal deficits, may be useful when discussing do-not-attempt-resuscitation orders. Ebell and coauthors used data from a large national registry to develop and internally validate a simple point score to predict the outcome of in-hospital cardiopulmonary resuscitation (the Good Outcomes Following Attempted Resuscitation [GO FAR] score). Using only variables knowable prior to arrest, the model identified more than one-quarter of patients as having a low (1.0%) or very low (1.4%) likelihood of survival to discharge, neurologically intact or with minimal deficits. Covinsky provides an Editor’s Note.
Editor’s Note, Related Article
Continuing Medical Education
Preventable hospitalizations are common among older adults for reasons that are not well understood. Nyweide and coauthors used survival analysis to measure continuity of care according to 2 separate continuity metrics up to the point of an index preventable hospitalization, death, or end of the patient’s 24-month observation period. They found that visit patterns indicative of higher continuity were associated with a 2% reduction in the rate of preventable hospitalization for every 0.1 increase in either continuity metric after adjustment for beneficiary characteristics and illness burden as well as market-level characteristics. This reduction amounts to approximately a 20% reduction in rate of preventable hospitalization for patients with the highest compared with the lowest continuity of care. Gupta and Bodenheimer make practical suggestions for primary care providers in an Invited Commentary.
Intensive care interventions that prolong life without achieving an effect that the patient can appreciate as a benefit are often considered “futile” by health care providers. Huynh and coauthors examined the prevalence and cost of futile treatment, as assessed by the critical care physician, in the intensive care units of 1 academic health system. Over a 3-month period, they found that 904 patients (80%) never received futile treatment, 98 (8.6%) received probably futile treatment, and 123 (11%) received futile treatment; the cost of futile treatment in critical care was estimated to be $2.6 million for this 3-month period at 1 academic health system. In an Invited Commentary, Truog and White assess the clinical implications of this study.
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Clinical trials of glucose regulation have provided inconsistent results with respect to cardiovascular outcomes. De Mulder and coauthors conducted a single-center, prospective, open-label, randomized clinical trial (BIOMarker Study to Identify the Acute Risk of a Coronary Syndrome–2 Glucose trial) of 294 patients in a large teaching hospital. They found that intensive glucose regulation did not reduce infarct size in hyperglycemic patients with acute coronary syndrome treated with percutaneous coronary intervention and was associated with harm. Dandona and Boden consider the state of the evidence base in an Invited Commentary.
Advocates have promoted the patient-centered medical home, but the effects on health care utilization and quality of care are not known. Rosenthal and coauthors evaluated the Rhode Island patient-centered medical home pilot compared with practices without patient-centered medical home programs and found that the pilot was associated with substantial increases in medical home recognition scores, but the effects on quality and utilization were modest after 2 years. In an Invited Commentary, Grumbach calls for widespread primary care reform.
Highlights. JAMA Intern Med. 2013;173(20):1853-1855. doi:10.1001/jamainternmed.2013.6333