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Walling et al applied quality indicators from the Assessing Care of Vulnerable Elders (ACOVE) set to measure the quality of care provided to an adult decedent cohort at a quaternary care university hospital recognized for providing aggressive care toward the end of life. This study showed that most patients are required to have life-sustaining treatments withheld or withdrawn prior to death, with one-third of patients removed from mechanical ventilation in anticipation of death. Overall, patients received recommended care for 70% of measures, but goals of care were addressed in a timely fashion for patients admitted to the intensive care unit approximately half of the time. Deficits in communication, dyspnea assessment, automatic implantable cardioverter/defibrillator deactivation, and bowel regimens for patients were identified as targets for quality improvement.
Practice guidelines recommend treating low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) to attain low-risk factor targets for patients with diabetes. Timbie et al simulated the net benefit of “treating to targets” for a nationally representative sample of patients with diabetes using a battery of treatments. The authors found that the majority of the benefit was limited to the first few steps of medication intensification or to tight control for a limited group of very-high-risk patients. Because of treatment-related disutility, intensifying beyond the first step (LDL-C) or third step (BP) resulted in either limited benefit or net harm for patients with below-average risk.
As physicians determine treatment, educate patients, manage adverse effects, and influence patient knowledge and motivation, their medical management and communication abilities may play an important role in treatment persistence with antihypertensive treatment. Tamblyn et al, in a population-based study of 645 physicians and 13 205 newly treated patients with hypertension, found that physicians with better management decision-making and communication skills on national licensing examinations had lower rates of nonpersistence, as did patients with early treatment changes, more follow-up visits, and nondiuretics as the initial choice of therapy. Overall, 22.2% of patients stopped taking all antihypertensive medications in the first 6 months, and improving physicians' medical management abilities could prevent 15.8% of these cases.
In this population-based, nested case-control study, Antoniou et al evaluated the risk of hyperkalemia-associated hospitalization among elderly patients treated with trimethoprim-sulfamethoxazole in combination with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Compared with controls, case patients were almost 7 times more likely to have received a prescription for trimethoprim-sulfamethoxazole than for amoxicillin in the 14 days preceding hospitalization. No such risk was observed with comparator antibiotics. This study highlights a major increase in the risk of hyperkalemia-associated hospitalization among continuous users of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers who receive treatment with trimethoprim-sulfamethoxazole.
In a large 16-year prospective cohort study of premenopausal women in the Nurses' Health Study II, an increase in time spent bicycling was associated with a significantly lower change in weight, and this inverse relationship was stronger among women with excess weight. For women who did not bicycle at baseline (1989), less weight gain was evident for even a small increase to 5 min/d or less in 2005. Conversely, women who bicycled for 15 min/d or more in 1989 were at a higher risk of weight gain if they decreased or stopped bicycling in 2005. Although bicycling—similar to brisk walking and unlike slow walking—was associated with less weight gain, fewer women brisk walked (39% of the women) and more women slow walked (50%) or bicycled (48%). Nevertheless, the time spent bicycling was the least (4.6 min/d) compared with time spent brisk walking (8.5 min/d) or slow walking (7.8 min/d). In promoting physical activity, physicians should consider brisk walking, rather than just walking, and also bicycling for a longer time.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2010;170(12):1006. doi:10.1001/archinternmed.2010.170