Physical Sciences and Mathematics Commons^™

Effects Of Cost Sharing On Seeking Care For Serious And Minor Symptoms. Results Of A Randomized Controlled Trial, Martin Shapiro, John Ware, Cathy Sherbourne

Martin Shapiro

To estimate the effect of cost sharing on seeking care for serious and minor symptoms, we analyzed data for 3539 persons aged 17 to 61 from the Rand Health Insurance Experiment. Participants were randomly assigned to a free-care group or to insurance plans requiring them to pay part of the costs (cost-sharing group). Annual surveys were administered to determine if participants had serious and minor symptoms during the preceding month and whether they saw a physician. Serious symptoms were judged by a panel of physicians to warrant care in most instances; minor symptoms were judged neither to be severe nor …

Leukoaraiosis Predicts Poor 90-Day Outcome After Acute Large Cerebral Artery Occlusion, Nils Henninger, Eugene Lin, Stephen Baker, Ajay Wakhloo, Deepak Takhtani, Majaz Moonis

Nils Henninger

BACKGROUND: To date limited information regarding outcome-modifying factors in patients with acute intracranial large artery occlusion (ILAO) in the anterior circulation is available. Leukoaraiosis (LA) is a common finding among patients with ischemic stroke and has been associated with poor post-stroke outcomes but its association with ILAO remains poorly characterized. This study sought to clarify the contribution of baseline LA and other common risk factors to 90-day outcome (modified Rankin Scale, mRS) after stroke due to acute anterior circulation ILAO. METHODS: We retrospectively analyzed 1,153 consecutive patients with imaging-confirmed ischemic stroke during a 4-year period (2007-2010) at a single academic …

Trends In The Prevalence And Mortality Of Cognitive Impairment In The United States: Is There Evidence Of A Compression Of Cognitive Morbidity, Kenneth Langa, Eric Larson, Jason Karlawish, David Cutler, Mohammed Kabeto, Scott Kim, Allison Rosen

Jason Karlawish

BACKGROUND: Recent medical, demographic, and social trends might have had an important impact on the cognitive health of older adults. To assess the impact of these multiple trends, we compared the prevalence and 2-year mortality of cognitive impairment (CI) consistent with dementia in the United States in 1993 to 1995 and 2002 to 2004. METHODS: We used data from the Health and Retirement Study (HRS), a nationally representative population-based longitudinal survey of U.S. adults. Individuals aged 70 years or older from the 1993 (N = 7,406) and 2002 (N = 7,104) waves of the HRS were included. CI was determined …

Striving For Cultural Competence In An Hiv Program: The Transformative Impact Of A Microsystem In A Larger Health Network, Judith N Sabino, Timothy Friel, Lynn Deitrick, Debbie Salas-Lopez

Debbie Salas-Lopez MD, MPH

No abstract provided.

Managed Care, Hospice Use, Site Of Death, And Medical Expenditures In The Last Year Of Life, Ezekiel Emanuel, Arlene Ash, Wei Yu, Gail Gazelle, Norman Levinsky, Olga Saynina, Mark Mcclellan, Mark Moskowitz

wei yu

BACKGROUND: We examined deaths of Medicare beneficiaries in Massachusetts and California to evaluate the effect of managed care on the use of hospice and site of death and to determine how hospice affects the expenditures for the last year of life.

METHODS: Medicare data for beneficiaries in Massachusetts (n = 37 933) and California (n = 27 685) who died in 1996 were merged with each state's death certificate files to determine site and cause of death. Expenditure data were Health Care Financing Administration payments and were divided into 30-day periods from the date of death back 12 months.

RESULTS: …

Racial And Ethnic Differences In Hospice Use Among Patients With Heart Failure, Jane Givens, Jennifer Tjia, Chao Zhou, Ezekiel Emanuel, Arlene Ash

Jennifer Tjia

BACKGROUND: Heart failure is the leading noncancer diagnosis for patients in hospice care and the leading cause of hospitalization among Medicare beneficiaries. Racial and ethnic differences in hospice patients are well documented for patients with cancer but poorly described for those with heart failure.

METHODS: On the basis of a national sample of 98 258 Medicare beneficiaries 66 years and older on January 1, 2001, with a diagnosis of heart failure who had at least 1 physician or hospital encounter and who were not enrolled in hospice care between January 1 and December 31, 2000, we determined the effect of …

Disparities In Combination Drug Therapy Use In Older Adults With Coronary Heart Disease: A Cross-Sectional Time-Series In A Nationally Representative Us Sample, Jennifer Tjia, Becky Briesacher, Dawei Xie, Jason Fu, Robert Goldberg

Jennifer Tjia

BACKGROUND: Despite evidence of effective combination drug therapy for secondary prevention of coronary heart disease (CHD), older adults with this condition remain undertreated.

OBJECTIVE: To describe time trends (1992-2003) in the adoption of combination cardiac drug therapies (beta-blockers [beta-adrenoceptor antagonists], ACE inhibitors or angiotensin II type 1 receptor antagonists [angiotensin receptor blockers; ARBs], and lipid-lowering agents) among older adults in the US with CHD and to identify factors associated with not using combination therapy.

METHODS: The study took the form of a cross-sectional time-series. The study population consisted of a nationally representative sample of adults aged >or=65 years with CHD …

Trends And Outcomes Associated With Angiotensin-Converting Enzyme Inhibitors, Chyke Doubeni, Carol Bigelow, Darleen Lessard, Frederick Spencer, Jorge Yarzebski, Joel Gore, Jerry Gurwitz, Robert Goldberg

Chyke A. Doubeni

BACKGROUND: Limited recent data are available describing the patterns of use of angiotensin converting enzyme inhibitor (ACEI) therapy in patients with acute myocardial infarction (AMI), particularly from the more generalizable population-based setting. The purpose of this study was to examine trends in the receipt of ACEIs and associated short-term outcomes in patients hospitalized with AMI in a large Northeastern community.

METHODS: We conducted a community-wide study of 7991 patients hospitalized with AMI in all metropolitan Worcester, Massachusetts, medical centers during 8 annual periods between 1990 and 2003.

RESULTS: Among all patients, 44% received ACEI therapy during their acute hospitalization. There …

Treatment Practices And Outcomes Of Patients With Established Peripheral Arterial Disease Hospitalized With Acute Myocardial Infarction In A Community Setting, Frederick Spencer, Darleen Lessard, Chyke Doubeni, Jorge Yarzebski, Joel Gore, Robert Goldberg

Chyke A. Doubeni

BACKGROUND: There are little contemporary data available describing the hospital and long-term outcomes of patients with peripheral arterial disease (PAD) who are hospitalized with acute myocardial infarction (AMI). The objectives of our population-based study were to examine the hospital and long-term outcomes, as well as the use of different treatment practices, among patients with established PAD who were hospitalized with AMI. METHODS: The study sample consisted of 4480 patients hospitalized with AMI at all Worcester, Mass, medical centers in 4 alternate years between 1997 and 2003. RESULTS: Among the metropolitan Worcester residents hospitalized with AMI, 13.5% had a history of …

Adjusting Medicare Capitation Payments Using Prior Hospitalization Data, Arlene Ash, Frank Porell, Leonard Gruenberg, Eric Sawitz, Alexa Beiser

Frank Porell

The diagnostic cost group approach to a reimbursement model for health maintenance organizations is presented. Diagnostic information about previous hospitalizations is used to create empirically determined risk groups, using only diagnoses involving little or no discretion in the decision to hospitalize. Diagnostic cost group and other models (including Medicare's current formula and other prior-use models) are tested for their ability to predict future costs, using R2 values and new measures of predictive performance. The diagnostic cost group models perform relatively well with respect to a range of criteria, including administrative feasibility, resistance to provider manipulation, and statistical accuracy.

30-Year Trends In Heart Failure In Patients Hospitalized With Acute Myocardial Infarction, David Mcmanus, Marcello Chinali, Jane Saczynski, Joel Gore, Jorge Yarzebski, Frederick Spencer, Darleen Lessard, Robert Goldberg

Jorge L. Yarzebski

Despite significant advances in its treatment, acute myocardial infarction (AMI) remains an important cause of heart failure (HF). Contemporary data remain lacking, however, describing long-term trends in incidence rates, demographic and clinical profiles, and outcomes of patients who develop HF as a complication of AMI. Our study sample consisted of 11,061 residents of the Worcester (Massachusetts) metropolitan area hospitalized with AMI at all greater Worcester hospitals in 15 annual study periods from 1975 to 2005. Overall, 32.4% of patients (n = 3,582) with AMI developed new-onset HF during their acute hospitalization. Patients who developed HF were generally older, more likely …

Recent Trends In The Incidence, Treatment, And Outcomes Of Patients With Stemi And Nstemi, David Mcmanus, Joel Gore, Jorge Yarzebski, Frederick Spencer, Darleen Lessard, Robert Goldberg

Jorge L. Yarzebski

BACKGROUND: despite the widespread use of electrocardiographic changes to characterize patients presenting with acute myocardial infarction, little is known about recent trends in the incidence rates, treatment, and outcomes of patients admitted for acute myocardial infarction further classified according to the presence of ST-segment elevation. The objectives of this population-based study were to examine recent trends in the incidence and death rates associated with the 2 major types of acute myocardial infarction in residents of a large central Massachusetts metropolitan area. METHODS: We reviewed the medical records of 5383 residents of the Worcester (MA) metropolitan area hospitalized for either ST-segment …

Declining Length Of Stay For Patients Hospitalized With Ami: Impact On Mortality And Readmissions, Jane Saczynski, Darleen Lessard, Frederick Spencer, Jerry Gurwitz, Joel Gore, Jorge Yarzebski, Robert Goldberg

Jorge L. Yarzebski

BACKGROUND: Length of hospital stay after acute myocardial infarction decreased significantly in the 1980s and 1990s. Whether length of stay has continued to decrease during the 2000s, and the impact of decreasing length of stay on rehospitalization and mortality, is unclear. We describe decade-long (1995-2005) trends in length of stay after acute myocardial infarction, and examine whether declining length of stay has impacted early rehospitalization and postdischarge mortality in a population-based sample of hospitalized patients.

METHODS: The study sample consisted of 4184 patients hospitalized with acute myocardial infarction in a central New England metropolitan area during 6 annual periods (1995, …

Management And Outcomes Of Renal Disease And Acute Myocardial Infarction, Paul Santolucito, Dennis Tighe, David Mcmanus, Jorge Yarzebski, Darleen Lessard, Joel Gore, Robert Goldberg

Jorge L. Yarzebski

BACKGROUND: Contemporary trends in the management and outcomes of chronic kidney disease patients who develop an acute myocardial infarction have not been adequately described, particularly from the more generalizable perspective of a population-based investigation. METHODS: The study population consisted of 6219 residents of the Worcester, Massachusetts, metropolitan area who were hospitalized with acute myocardial infarction in 6 annual periods between 1995 and 2005. Patients were categorized as having preserved kidney function (n=3154), mild to moderate chronic kidney disease (n=2313), or severe chronic kidney disease (n=752) at the time of hospital admission. RESULTS: Patients with chronic kidney disease were more likely …

Body Mass Index, Treatment Practices, And Mortality In Patients With Acute Heart Failure, Timothy Fitzgibbons, Olga Hardy, Darleen Lessard, Joel Gore, Jorge Yarzebski, Robert Goldberg

Jorge L. Yarzebski

OBJECTIVES: Obesity is associated with an increased risk of heart failure (HF). Among patients presenting with acute HF, however, differences in clinical characteristics, treatment regimens, and short-term prognosis of varying weights are largely unknown, particularly from a broader population-based perspective. METHODS: A total of 3722 patients admitted with acute HF to 11 greater Worcester (Massachusetts, USA) hospitals during 1995 and 2000 were categorized as being lean (n = 216), normal weight (n = 1465), overweight (n = 1007), or obese (n = 1034) at the time of hospitalization. RESULTS: Obese patients with decompensated HF were significantly younger (mean age = …

Changes Over Time In The Use Of Aspirin In Patients Hospitalized With Acute Myocardial Infarction (1975 To 1997): A Population-Based Perspective, Elizabeth Jackson, Ramya Sivasubramian, Frederick Spencer, Jorge Yarzebski, Darleen Lessard, Joel Gore, Robert Goldberg

Jorge L. Yarzebski

OBJECTIVE: The purpose of this study was to examine 2 decade-long trends in the use of aspirin and associated outcomes in patients hospitalized with acute myocardial infarction. BACKGROUND: Aspirin has been shown to be beneficial in the secondary prevention of AMI. However, little is known about changes over time in the use of aspirin in patients hospitalized with AMI and associated outcomes, particularly from a more generalizable population-based perspective. METHODS: We examined trends in aspirin use and hospital and long-term outcomes in 9336 metropolitan Worcester, Mass, residents hospitalized with validated AMI in all area hospitals between 1975 and 1997. RESULTS: …

Thirty-Year Trends (1975-2005) In The Magnitude, Patient Characteristics, And Hospital Outcomes Of Patients With Acute Myocardial Infarction Complicated By Ventricular Fibrillation, Robert Goldberg, Jorge Yarzebski, Frederick Spencer, Juan Zevallos, Darleen Lessard, Joel Gore

Jorge L. Yarzebski

Limited contemporary data are available describing the incidence rates, hospital prognosis, and factors associated with the occurrence of ventricular fibrillation (VF) in patients hospitalized with acute myocardial infarction (AMI). The objectives of our study were to examine 3-decade-long trends (1975 to 2005) in the magnitude, predictors, and hospital case-fatality rates associated with VF in residents of a large New England metropolitan area hospitalized at all area medical centers with an uncomplicated AMI. The study population consisted of 7,472 residents of the Worcester (Massachusetts) metropolitan area hospitalized with an uncomplicated AMI in 15 annual periods from 1975 to 2005. The overall …

Temporal Trends (1975 Through 1990) In The Incidence And Case-Fatality Rates Of Primary Ventricular Fibrillation Complicating Acute Myocardial Infarction. A Communitywide Perspective, David Chiriboga, Jorge Yarzebski, Robert Goldberg, Joel Gore, Joseph Alpert

Jorge L. Yarzebski

BACKGROUND: As part of a population-based study of acute myocardial infarction, we examined changes over time in the incidence and in-hospital case-fatality rates of primary ventricular fibrillation complicating acute myocardial infarction. METHODS AND RESULTS: Patients with validated acute myocardial infarction hospitalized at 16 hospitals in the Worcester, Mass, metropolitan area between 1975 and 1990 comprised the study sample. During the 15-year study period, 5.1% of patients developed primary ventricular fibrillation in the setting of uncomplicated acute myocardial infarction, with this rate remaining relatively constant over time. Both age- and multivariable-adjusted analyses showed no significant trend in the incidence rates of …

Coronary Heart Disease: Epidemiology, Risk Factors, And Temporal Trends, Robert Goldberg, Jorge Yarzebski

Jorge L. Yarzebski

Citation: Goldberg RJ, Yarzebski JL. Coronary Heart Disease: Epidemiology, Risk Factors, and Temporal Trends. Chapter 1, pp. 3 24. In Lifestyle Medicine. Rippe JM (Ed.). 1999. Blackwell Science Publishers.

Decade-Long Trends (1986 To 1997) In The Medical Treatment Of Patients With Acute Myocardial Infarction: A Community-Wide Perspective, Frederick Spencer, George Scleparis, Robert Goldberg, Jorge Yarzebski, Darleen Lessard, Joel Gore

Jorge L. Yarzebski

BACKGROUND: Although there are an increasing number and variety of medications available for the treatment of patients with acute myocardial infarction (AMI), few data are available describing recent, and changes over time in, use of different cardiac medications in patients with AMI from a more generalizable, community-wide perspective. Moreover, it is unclear whether the demographic and clinical profile of patients receiving these agents is similar or varies according to the type of agent prescribed. METHODS AND RESULTS: The purpose of this study was to examine recent patterns and changes over a decade-long period (1986 to 1997) in the use of …

Temporal Trends And Associated Factors Of Inpatient Cardiac Rehabilitation In Patients With Acute Myocardial Infarction: A Community-Wide Perspective, Frederick Spencer, Bobak Salami, Jorge Yarzebski, Darleen Lessard, Joel Gore, Robert Goldberg

Jorge L. Yarzebski

PURPOSE: Cardiac rehabilitation (CR) has been shown to be an important therapeutic intervention after the development of acute myocardial infarction (AMI), but historically has been underused. Inpatient CR often represents cardiac patients' first exposure to risk factor modification education and acts as a gateway to outpatient programs. METHODS: The authors performed a longitudinal study of the use of inpatient CR in 5204 Worcester residents hospitalized with validated AMI in seven 1-year periods between 1986 and 1997. RESULTS: The overall rate of referral to inpatient CR was 68%, with a slight decline in use to less than 60% in the authors' …

Communitywide Trends In The Use And Outcomes Associated With Beta-Blockers In Patients With Acute Myocardial Infarction: The Worcester Heart Attack Study, Helme Silvet, Frederick Spencer, Jorge Yarzebski, Darleen Lessard, Joel Gore, Robert Goldberg

Jorge L. Yarzebski

BACKGROUND: Despite the benefits associated with beta-blocker therapy in patients with acute myocardial infarction (AMI), limited recent data are available describing the extent of use of this therapy and the associated hospital and long-term outcomes, particularly from the perspective of a population-based study. Data are also limited about the characteristics of patients with AMI who do not receive beta-blockers. This study examines more than 2 decades of trends in the use of beta-blockers in hospitalized patients with AMI. METHODS: Communitywide study of 10,374 patients hospitalized with confirmed AMI in all metropolitan Worcester hospitals during 12 annual periods between 1975 and …

The Impact Of The Stent Era On The Management Strategy For Acute Myocardial Infarction: A Population-Based Perspective, Harold Dauerman, Robert Goldberg, Jorge Yarzebski, Darleen Lessard, Joel Gore

Jorge L. Yarzebski

We determined trends in the use of invasive diagnostic and revascularization strategies from a multihospital community-wide perspective for patients suffering acute myocardial infarction (AMI). Comparing 3,824 patients treated in the prestent era (1986-1993) to 1,915 patients hospitalized during the stent era (1995-1997), there was a significant increase in the use of invasive procedures and revascularization techniques across a broad spectrum of AMI patients during their index hospitalization. This resulted in a higher-risk profile of patients referred for invasive management of AMI in the stent era. Cathet. Cardiovasc. Intervent. 51:255-258, 2000.

Symptom Presentation In Patients Hospitalized With Acute Heart Failure., Robert Goldberg, Frederick Spencer, Mariana Szklo-Coxe, Mayra Tisminetzky, Jorge Yarzebski, Darleen Lessard, Joel Gore, William Gaasch

Jorge L. Yarzebski

OBJECTIVES: The objectives of this study were to examine the type and frequency of symptoms in patients hospitalized with acute heart failure (HF) as well as the relationship between symptom patterns and patient characteristics, treatment practices, and hospital outcomes in patients hospitalized with decompensated HF.

METHODS: The study sample consisted of 4537 residents of the Worcester, MA metropolitan area hospitalized for decompensated HF at 11 greater Worcester medical centers in 1995 and 2000.

RESULTS: The average age of the study sample was 76 years; the majority (57%) were women, and three-quarters of our patient population had been previously diagnosed with …

Multidecade-Long Trends (1986-2005) In The Utilization Of Coronary Reperfusion And Revascularization Treatment Strategies In Patients Hospitalized With Acute Myocardial Infarction: A Community-Wide Perspective, Jared Wasser, Robert Goldberg, Frederick Spencer, Jorge Yarzebski, Joel Gore

Jorge L. Yarzebski

OBJECTIVES: The objectives of our community-wide investigation were to describe multidecade-long trends (1986-2005) in the utilization of thrombolytic therapy, percutaneous coronary interventions, and coronary artery bypass graft surgery in patients hospitalized with acute myocardial infarction (AMI). METHODS: The study sample consisted of 9422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 11 annual periods between 1986 and 2005. RESULTS: Increases in the utilization of percutaneous coronary interventions were observed between 1986 (2.0%) and 2005 (50.7%) with the most rapid increases beginning in the late 1990s. Utilization of coronary artery bypass graft surgery during …

Differential Symptoms Of Acute Myocardial Infarction In Patients With Kidney Disease: A Community-Wide Perspective, Jonathan Sosnov, Darleen Lessard, Robert Goldberg, Jorge Yarzebski, Joel Gore

Jorge L. Yarzebski

BACKGROUND: Patients seeking care for acute myocardial infarction (AMI) present with multiple symptoms. The objectives of our community-wide study are to examine the symptom profile of patients with, as compared with those without, kidney disease who present to the hospital with independently confirmed AMI. METHODS: The symptom profile of 4,482 patients from the Worcester, MA, metropolitan area hospitalized with independently validated AMI at all 11 area medical centers during the 4 study years of 1997, 1999, 2001, and 2003 was examined. Factor analysis was used to aggregate the relevant symptoms of AMI. Logistic regression analysis was used to examine differences …

Two-Decade-Long Trends (1975-1997) In The Incidence, Hospitalization, And Long-Term Death Rates Associated With Complete Heart Block Complicating Acute Myocardial Infarction: A Community-Wide Perspective, Frederick Spencer, Samer Jabbour, Darleen Lessard, Jorge Yarzebski, Shmuel Ravid, Virginia Zaleskas, Michael Hyder, Joel Gore, Robert Goldberg

Jorge L. Yarzebski

BACKGROUND: The purpose of this community-wide study was to describe a >2-decade-long experience (1975-97) in the incidence and death rates associated with complete heart block (CHB) in patients with acute myocardial infarction (AMI). Limited population-based data exist describing recent, and changes with time therein, incidence and case-fatality rates associated with CHB complicating AMI.

METHODS: We conducted an observational study of 9082 metropolitan Worcester, Mass, residents (1990 census = 437,000) hospitalized with validated AMI in all greater Worcester hospitals during 11 1-year periods between 1975 and 1997.

RESULTS: Overall, CHB developed in 5.0% of patients with AMI. The incidence rates of …

Use Of The Invasive Management Strategy For Patients With Non-Q-Wave Myocardial Infarction: An Observational Database Report From The Worcester Heart Attack Study, Harold Dauerman, Jorge Yarzebski, Joel Gore, Darleen Lessard, Robert Goldberg

Jorge L. Yarzebski

BACKGROUND: Recent randomized clinical trials have suggested a benefit of an invasive management strategy in patients with acute coronary syndromes. However, the broader use and impact of the invasive management approach has not been established for patients with acute coronary syndromes beyond the relatively narrow patient populations studied in randomized, clinical trials. METHODS: Residents of the Worcester, Mass, area who were hospitalized with non-Q-wave acute myocardial infarction (AMI) at all area hospitals in 5 annual periods between 1990 and 1997 comprised the sample of interest (n = 2436). We examined the extent of use of an invasive versus a conservative …

Trends In Atrial Fibrillation Complicating Acute Myocardial Infarction, Jane Saczynski, David Mcmanus, Zheng Zhou, Frederick Spencer, Jorge Yarzebski, Darleen Lessard, Joel Gore, Robert Goldberg

Jorge L. Yarzebski

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) and this arrhythmia is associated with increased morbidity and mortality in patients with AMI. Limited information is available, however, about changing, and contemporary, trends in the incidence and death rates associated with AF complicating AMI. We examined the magnitude and impact of AF and the risk of stroke and hospital and long-term death rates in a population-based study of patients hospitalized with AMI. The study population consisted of 7,513 residents of the Worcester, Massachusetts, metropolitan area hospitalized with AMI at all greater Worcester medical centers during 9 biennial …

Contemporary Trends In Evidence-Based Treatment For Acute Myocardial Infarction, Marco Fornasini, Jorge Yarzebski, David Chiriboga, Darleen Lessard, Frederick Spencer, Philip Aurigemma, Joel Gore, Robert Goldberg

Jorge L. Yarzebski

BACKGROUND: Guidelines for the management of patients with acute myocardial infarction recommend the routine use of 4 effective cardiac medications: angiotensin-converting enzyme inhibitors, aspirin, beta-blockers, and lipid-lowering agents. Limited data are available, however, about the contemporary and changing use of these therapies, particularly from a population-based perspective. The study describes differences in the use of these medications during hospitalization for acute myocardial infarction according to age, gender, and period of hospitalization.

METHODS: The study population consisted of 6334 women and men treated at 11 hospitals in the Worcester, Mass, metropolitan area for acute myocardial infarction in 6 annual periods between …