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May 23, 2011, Vol 171, No. 10, Pages 877-954

Original Investigation

ONLINE FIRST

Translating Weight Loss and Physical Activity Programs Into the Community to Preserve Mobility in Older, Obese Adults in Poor Cardiovascular Health

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Arch Intern Med. 2011;171(10):880-886. doi:10.1001/archinternmed.2010.522
BackgroundLimitations in mobility are common among older adults with cardiovascular and cardiometabolic disorders and have profound effects on health and well-being. With the growing population of older adults in the United States, effective and scalable public health approaches are needed to address this problem. Our goal was to determine the effects of a physical activity and weight loss intervention on 18-month change in mobility among overweight or obese older adults in poor cardiovascular health.MethodsThe study design was a translational, randomized controlled trial of physical activity (PA) and weight loss (WL) on mobility in overweight or obese older adults with cardiovascular disease (CVD) or at risk for CVD. The study was conducted within the community infrastructure of Cooperative Extension Centers. Participants were randomized to 1 of 3 interventions: PA, WL + PA, or a successful aging (SA) education control arm. The primary outcome was time to complete a 400-m walk in seconds (400MWT).ResultsA significant treatment effect (P = .002) and follow-up testing revealed that the WL + PA group improved their 400MWT (adjusted mean [SE], 323.3 [3.7] seconds) compared with both PA (336.3 [3.9] seconds; P = .02) and SA (341.3 [3.9] seconds; P < .001). Participants with poorer mobility at baseline benefited the most (P < .001).ConclusionExisting community infrastructures can be effective in delivering lifestyle interventions to enhance mobility in older adults in poor cardiovascular health with deficits in mobility; attention should be given to intervening on both weight and sedentary behavior since weight loss is critical to long-term improvement in mobility.Trial Registrationclinicaltrials.gov Identifier: NCT00119795

ONLINE FIRST

Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults

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Arch Intern Med. 2011;171(10):887-895. doi:10.1001/archinternmed.2010.535
BackgroundChronic insomnia is a common health problem with substantial consequences in older adults. Cognitive behavioral treatments are efficacious but not widely available. The aim of this study was to test the efficacy of brief behavioral treatment for insomnia (BBTI) vs an information control (IC) condition.MethodsA total of 79 older adults (mean age, 71.7 years; 54 women [70%]) with chronic insomnia and common comorbidities were recruited from the community and 1 primary care clinic. Participants were randomly assigned to either BBTI, consisting of individualized behavioral instructions delivered in 2 intervention sessions and 2 telephone calls, or IC, consisting of printed educational material. Both interventions were delivered by a nurse clinician. The primary outcome was categorically defined treatment response at 4 weeks, based on sleep questionnaires and diaries. Secondary outcomes included self-report symptom and health measures, sleep diaries, actigraphy, and polysomnography.ResultsCategorically defined response (67% [n = 26] vs 25% [n = 10]; χ2 = 13.8) (P < .001) and the proportion of participants without insomnia (55% [n = 21] vs 13% [n = 5]; χ2 = 15.5) (P < .001) were significantly higher for BBTI than for IC. The number needed to treat was 2.4 for each outcome. No differential effects were found for subgroups according to hypnotic or antidepressant use, sleep apnea, or recruitment source. The BBTI produced significantly better outcomes in self-reported sleep and health (group × time interaction, F5,73 = 5.99, P < .001), sleep diary (F8,70 = 4.32, P < .001), and actigraphy (F4,74 = 17.72, P < .001), but not polysomnography. Improvements were maintained at 6 months.ConclusionWe found that BBTI is a simple, efficacious, and durable intervention for chronic insomnia in older adults that has potential for dissemination across medical settings.Trial Registrationclinicaltrials.gov Identifier: NCT00177203

ONLINE FIRST

Electronic Health Records and Clinical Decision Support SystemsImpact on National Ambulatory Care Quality

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Arch Intern Med. 2011;171(10):897-903. doi:10.1001/archinternmed.2010.527
BackgroundElectronic health records (EHRs) are increasingly used by US outpatient physicians. They could improve clinical care via clinical decision support (CDS) and electronic guideline–based reminders and alerts. Using nationally representative data, we tested the hypothesis that a higher quality of care would be associated with EHRs and CDS.MethodsWe analyzed physician survey data on 255 402 ambulatory patient visits in nonfederal offices and hospitals from the 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Based on 20 previously developed quality indicators, we assessed the relationship of EHRs and CDS to the provision of guideline-concordant care using multivariable logistic regression.ResultsElectronic health records were used in 30% of an estimated 1.1 billion annual US patient visits. Clinical decision support was present in 57% of these EHR visits (17% of all visits). The use of EHRs and CDS was more likely in the West and in multiphysician settings than in solo practices. In only 1 of 20 indicators was quality greater in EHR visits than in non-EHR visits (diet counseling in high-risk adults, adjusted odds ratio, 1.65; 95% confidence interval, 1.21-2.26). Among the EHR visits, only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS (lack of routine electrocardiographic ordering in low-risk patients, adjusted odds ratio, 2.88; 95% confidence interval, 1.69-4.90). There were no other significant quality differences.ConclusionsOur findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

Health Care Reform

Colorectal Cancer Screening Among Ethnically Diverse, Low-Income PatientsA Randomized Controlled Trial

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Arch Intern Med. 2011;171(10):906-912. doi:10.1001/archinternmed.2011.201

Less Is More

Inhaled Anticholinergic Drug Therapy and the Risk of Acute Urinary Retention in Chronic Obstructive Pulmonary DiseaseA Population-Based Study

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Arch Intern Med. 2011;171(10):914-920. doi:10.1001/archinternmed.2011.170

ONLINE FIRST

Effects of Benefits and Harms on Older Persons' Willingness to Take Medication for Primary Cardiovascular Prevention

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Arch Intern Med. 2011;171(10):923-928. doi:10.1001/archinternmed.2011.32
BackgroundQuality-assurance initiatives encourage adherence to evidenced-based guidelines based on a consideration of treatment benefit. We examined older persons' willingness to take medication for primary cardiovascular disease prevention according to benefits and harms.MethodsIn-person interviews were performed with 356 community-living older persons. Participants were asked about their willingness to take medication for primary prevention of myocardial infarction (MI) with varying benefits in terms of absolute 5-year risk reduction and varying harms in terms of type and severity of adverse effects.ResultsMost (88%) would take medication, providing an absolute benefit of 6 fewer persons with MI out of 100, approximating the average risk reduction of currently available medications. Of participants who would not take it, 17% changed their preference if the absolute benefit was increased to 10 fewer persons with MI, and, of participants who would take it, 82% remained willing if the absolute benefit was decreased to 3 fewer persons with MI. In contrast, large proportions (48%-69%) were unwilling or uncertain about taking medication with average benefit causing mild fatigue, nausea, or fuzzy thinking, and only 3% would take medication with adverse effects severe enough to affect functioning.ConclusionsOlder persons' willingness to take medication for primary cardiovascular disease prevention is relatively insensitive to its benefit but highly sensitive to its adverse effects. These results suggest that clinical guidelines and decisions about prescribing these medications to older persons need to place emphasis on both benefits and harms.

ONLINE FIRST

Recovery Expectations and Long-term Prognosis of Patients With Coronary Heart Disease

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Arch Intern Med. 2011;171(10):929-935. doi:10.1001/archinternmed.2011.41
BackgroundExpectations of patients regarding their prospects for recovery have been shown to predict subsequent physical and social functioning. Evidence regarding the impact of expectations on clinical outcomes is limited.MethodsAt the inpatient service of a tertiary care hospital, we evaluated beliefs of patients undergoing coronary angiography about their prognosis as predictors of long-term survival and 1-year functional status. Baseline assessments, including a measure of expectations for recovery, were obtained during hospitalization with mortality follow-up for approximately 15 years. Patients with significant obstructive coronary artery disease were interviewed while in the hospital and enrolled in follow-up. Functional status was assessed at baseline and 1 year later with questionnaires reflecting physical capabilities. Analyses controlled for age, sex, disease severity, comorbidities, treatments, demographics, depressive symptoms, social support, and functional status. There were 1637 total deaths, 885 from cardiovascular causes, in the 2818 patients in these analyses. The outcomes were total mortality, cardiovascular mortality, and 1-year functional status.ResultsExpectations were positively associated with survival after controlling for background and clinical disease indicators. For a difference equivalent to an interquartile range of expectations, the hazard ratio (HR) for total mortality was 0.76 (95% confidence interval [CI], 0.71-0.82) and 0.76 (95% CI, 0.69-0.83) for cardiovascular mortality. The HRs were 0.83 (95% CI, 0.76-0.91) and 0.79 (95% CI, 0.70-0.89) with further adjustments for demographic and psychosocial covariates. Similar associations (P < .001) were observed for functional status.ConclusionRecovery expectations at baseline were positively associated with long-term survival and functioning in patients with coronary artery disease.
Invited Commentary

ONLINE FIRST

Time to Disseminate Cognitive Behavioral Treatment of InsomniaComment on “Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults”

Abstract Full Text
Arch Intern Med. 2011;171(10):895-896. doi:10.1001/archinternmed.2010.526

ONLINE FIRST

Clinical Decision Support and Rich Clinical Repositories: A Symbiotic RelationshipComment on “Electronic Health Records and Clinical Decision Support Systems”

Abstract Full Text
Arch Intern Med. 2011;171(10):903-905. doi:10.1001/archinternmed.2010.518

Building Blocks of the Patient-Centered Medical/Health HomeComment on “Colorectal Cancer Screening Among Ethnically Diverse, Low-Income Patients”

Abstract Full Text
Arch Intern Med. 2011;171(10):912-913. doi:10.1001/archinternmed.2011.210

Inhaled Anticholinergics for Chronic Obstructive Pulmonary DiseaseComment on “Inhaled Anticholinergic Drug Therapy and the Risk of Acute Urinary Retention in Chronic Obstructive Pulmonary Disease”

Abstract Full Text
Arch Intern Med. 2011;171(10):920-922. doi:10.1001/archinternmed.2011.171

ONLINE FIRST

Optimism Amid Serious Disease: Clinical Panacea or Ethical Conundrum?Comment on “Recovery Expectations and Long-term Prognosis of Patients With Coronary Heart Disease”

Abstract Full Text
Arch Intern Med. 2011;171(10):935-936. doi:10.1001/archinternmed.2011.40
Images From Our Readers

Autumn foliage reflected in Bronx River at Harsdale, New York

Abstract Full Text
Arch Intern Med. 2011;171(10):905. doi:10.1001/archinternmed.2011.186

Puente de la Exposicion (Puente Calatrava) footbridge in Valencia, Spain; architect: Santiago Calatrava

Abstract Full Text
Arch Intern Med. 2011;171(10):940. doi:10.1001/archinternmed.2011.187
In This Issue of Archives of Internal Medicine

In This Issue of Archives of Internal Medicine

Abstract Full Text
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Arch Intern Med. 2011;171(10):879. doi:10.1001/archinternmed.2011.177
Article

Error in Correspondence in: Considering Selection Bias When Developing a Search Strategy

Abstract Full Text
Arch Intern Med. 2011;171(10):886. doi:10.1001/archinternmed.2011.181
Special Article

Geriatric Drug EvaluationWhere Are We Now and Where Should We Be in the Future?

Abstract Full Text
Arch Intern Med. 2011;171(10):937-940. doi:10.1001/archinternmed.2011.152
Research Letters

Health Care Reform

A Quantitative Analysis of Adverse Events and “Overwarning” in Drug Labeling

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.182

One-Hour Glucose, Mortality, and Risk of Diabetes: A 44-Year Prospective Study in Men

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.183
Editor's Correspondence

EHRs and Health Care Quality: Correlation With Out-of-date, Differently Purposed Data Does Not Equate With Causality

Abstract Full Text
Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.188

Electronic Health Records, the PINNACLE Registry, and Quality Care

Abstract Full Text
Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.189

Electronic Health Records, the PINNACLE Registry, and Quality Care—Reply

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.190

Percutaneous Intervention for Non–ST-Segment Elevation Myocardial Infarction Within the Therapeutic Time Window for Acute Myocardial Infarction

Abstract Full Text
Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.191

Percutaneous Intervention for Non–ST-Segment Elevation Myocardial Infarction Within the Therapeutic Time Window for Acute Myocardial Infarction—Reply

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.192

Monacolin Levels in Red Yeast Rice: Methodological Questions

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.193

Monacolin Levels in Red Yeast Rice: Methodological Questions—Reply

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.194

Racial Disparities in End-of-Life Care

Abstract Full Text
Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.195

Racial Disparities in End-of-Life Care—Reply

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.196

Invited Commentary—Prescription Drug Label Adverse Events: A Call for PrioritizationComment on “A Quantitative Analysis of Adverse Events and ‘Overwarning’ in Drug Labeling”

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.200

Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures

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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.202

Less Is More

Incidence of Physician-Diagnosed Carpal Tunnel Syndrome in the General Population

Abstract Full Text
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Arch Intern Med. 2011;171(10):941-954. doi:10.1001/archinternmed.2011.203
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