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In This Issue of Archives of Internal Medicine
February 14, 2011

Archives of Internal Medicine

Arch Intern Med. 2011;171(3):190. doi:10.1001/archinternmed.2010.523

Effect of Cardiac Rehabilitation Referral Strategies on Utilization Rates

To determine the optimal strategy to maximize cardiac rehabilitation use, a prospective evaluation of 4 referral strategies was conducted: (1) systematic via discharge order or electronic record, (2) liaison discussion at the bedside, (3) combined approach, vs (4) “usual” referral at the discretion of providers. A total of 2635 inpatients with coronary artery disease from 11 Ontario hospitals participated. Generalized estimating equations showed that automatic referral combined with a patient discussion resulted in the greatest cardiac rehabilitation use (OR, 8.41; 85.8% referral, 73.5% enrollment). Among those referred, degree of cardiac rehabilitation participation was higher than 80% regardless of referral strategy. Hospitals should be encouraged to adopt these strategies so more cardiac patients access and realize the mortality and morbidity benefits of cardiac rehabilitation.

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Cost-Utility of Aspirin and Proton Pump Inhibitors for Primary Prevention

Aspirin use is advocated for primary prevention of coronary heart disease in men. However, its cardiac benefits come at a risk of increased gastrointestinal tract (GI) bleeding. Proton pump inhibitors (PPIs) provide a protective effect for upper GI bleeding. Thus, combination use of these medications may give patients a better balance of clinical outcomes but at added cost. Earnshaw et al examined the economic and clinical outcomes associated with primary prevention using aspirin with or without a PPI. For men with varying coronary heart disease risks and ages, combination therapy (at over-the-counter PPI cost) is not cost-effective for most patients, except for those at high risk for GI bleeding. Clinicians using GI bleeding risk assessments can target PPI therapy and improve patient outcomes for low-dose aspirin users at acceptable costs.

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Hospice Use and High-Intensity Care in Men Dying of Prostate Cancer

Bergman et al characterized hospice use by men dying of prostate cancer and compared the use of high-intensity care between those who did and those who did not enroll in hospice. The authors used linked Surveillance, Epidemiology, and End Results–Medicare data and created 2 multivariable logistic regression models, one to identify factors associated with hospice use and one to determine the association of hospice use with the receipt of diagnostic and interventional procedures and physician visits at the end of life. Men dying of prostate cancer who enrolled in hospice were less likely to receive high-intensity care, including intensive care unit admissions, inpatient stays, and multiple emergency department visits.

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The Magnitude of Acute Serum Creatinine Increase After Cardiac Surgery and the Risk of Chronic Kidney Disease, Progression of Kidney Disease, and Death

Increases in creatinine level following cardiac surgery are common; however, it is unknown how these changes influence long-term outcomes. This study uses data on 29 388 veterans undergoing cardiac surgery to determine the association between the magnitude of creatinine level increase following cardiac surgery and incident chronic kidney disease (CKD), CKD progression, or death. Overall, the relative hazards for outcomes increased monotonically with greater increases in creatinine level. Creatinine level increases of 1% to 24%, 25% to 49%, 50% to 99%, or 100% or greater were associated at 3 months with a greater risk of incident CKD (hazard ratio [HR], 2.1, 4.0, 5.8, and 6.6, respectively; all P < .01), progression of CKD stage (HR, 2.5, 3.8, 4.4, and 8.0, respectively; all P < .01), and long-term mortality (HR, 1.4, 1.9, 2.8, and 5.0, respectively; all P < .01) compared with no increase in creatinine. Individuals with increases in creatinine level following cardiac surgery are at risk for long-term adverse outcomes.

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Lack of Follow-up After Fecal Occult Blood Testing in Older Adults

In a cohort of 2410 patients 70 years or older screened with fecal occult blood testing (FOBT) at 4 Department of Veterans Affairs (VA) facilities, Carlson et al found that many did not receive any follow-up after incomplete or positive screening results. Among 212 patients with positive FOBT results, only 42% received complete colon evaluation and follow-up was low regardless of whether patients were aged 70 to 74 years without comorbidity or 80 years or older with comorbidity. Instead, other factors, such as VA site, number of positive FOBT cards, and number of VA outpatient visits were predictive of receiving complete colon evaluation. Also, medical chart documentation indicated that patients who should not have been screened in the first place accounted for 38% of patients who did not receive complete colon evaluation within 1 year of positive FOBT results, and most (>75%) patients who did not receive complete colon evaluation in the first year never received complete follow-up, even during the next 5 years. Efforts to improve follow-up in older adults should address the full chain of decision making, including individualizing screening decisions and facilitating timely follow-up of positive FOBT results in patients whose comormibity and preferences make follow-up appropriate.

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