This study draws from nationally representative surveys of chronically disabled community-dwelling older adults and their primary caregivers to examine the experiences of family and friends providing end-of-life care. Nearly three quarters of chronically disabled older adults in the last year of life were found to be receiving help from family and friends. End-of-life primary informal caregivers provided an average of 43 hours of help per week and 85% helped daily; supportive services were infrequently used. Compared with primary informal caregivers of persons who survived the following 12 months, end-of-life caregivers provided significantly higher levels of assistance and reported more challenges and strains but were no less likely to endorse rewards related to their helping role.
Several small studies suggest that weight loss reduces C-reactive protein level; however, the consistency and magnitude of this effect has not been well characterized. In this issue, Selvin et al provide results from their systematic review of the literature on weight loss interventions and change in C-reactive protein level. The authors summarize the results from lifestyle and surgical weight loss intervention studies. By pooling the results from 33 studies, the authors demonstrate that weight loss is associated with a decline in C-reactive protein level across the spectrum of weight loss interventions. The largest changes in C-reactive protein level were observed in those interventions that achieved the largest reductions in weight, particularly surgical interventions. These results suggest that weight loss may be an effective nonpharmacologic strategy for lowering C-reactive protein level.
Smetana et al systematically reviewed the literature describing outcomes for single medical conditions among patients who receive care from generalists or specialists. Among 49 eligible studies of diagnoses within the narrow area of the specialist's domain, 24 favored specialty care, 13 found no difference in outcomes, 7 varied by individual outcome, 1 depended on physician experience, and 4 favored generalist care. Selection bias was adequately addressed in 58% of studies that favored specialty care and in 71% of studies that found no difference or favored generalist care (P = .52). The authors found more methodologic flaws among studies that favored specialty care than among those that favored generalist care or found no difference. Studies that favored specialty care were less likely to address these key methodologic factors than those that favored generalist care or found no difference in outcomes.
Perlroth et al used a Markov model and clinical estimates from the literature to examine the cost-effectiveness analysis of alteplase in hemodynamically stable patients with pulmonary embolism and right ventricular dysfunction. Their base-case results showed that alteplase was associated with marginally higher total lifetime health care costs ($42 500 vs $41 900) and was slightly less effective (6.35 vs 6.40 quality-adjusted life-years) than treatment with heparin alone. This analysis does not support the routine use of thrombolysis in patients with submassive pulmonary embolism. However, thrombolysis was more effective and cost less than $50 000 per quality-adjusted life-year gained when it was assumed that the baseline risk of death in the heparin group was 3 times higher than the base-case estimate and that alteplase reduced the relative risk of death by at least 10%. Thus, thrombolysis may prove to be cost-effective in selected subgroups of hemodynamically stable patients in whom the risk of death is higher.
Spaude et al explored the possibility that annual receipt of influenza vaccination might have protective effects beyond prevention of the flu. They evaluated outcomes in all individuals hospitalized with pneumonia at 34 hospitals during 4 influenza seasons between 1999 and 2003. Study subjects who had received influenza vaccination during the current flu season, but who had developed pneumonia nonetheless, had a risk of in-hospital death between 22% and 43% lower than hospitalized individuals who had not been vaccinated. Flu shots were beneficial even after controlling for other characteristics likely to be more common among those who do not get vaccinated.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2007;167(1):7. doi:10.1001/archinte.167.1.7