Relationship of early life stress and psychological functioning to adult C-reactive protein in the coronary artery risk development in young adults study.

BACKGROUND: Low socioeconomic status (SES) and a harsh family environment in childhood have been linked to mental and physical health disorders in adulthood. The objective of the present investigation was to evaluate a developmental model of pathways that may help explain these links and to relate them to C-reactive protein (CRP) in the Coronary Artery Risk Development in Young Adults (CARDIA) dataset. METHODS: Participants (n = 3248) in the CARDIA study, age 32 to 47 years, completed measures of childhood SES (CSES), early family environment (risky families [RF]), adult psychosocial functioning (PsyF, a latent factor measured by depression, mastery, and positive and negative social contacts), body mass index (BMI), and C-reactive protein. RESULTS: Structural equation modeling indicated that CSES and RF are associated with C-reactive protein via their association with PsyF (standardized path coefficients: CSES to RF, RF to PsyF, PsyF to CRP, CSES to CRP, all p < .05), with good overall model fit. The association between PsyF and CRP was partially mediated by BMI (PsyF to BMI, BMI to CRP, both p < .05). CONCLUSIONS: Low childhood SES and a harsh early family environment appear to be related to elevated C-reactive protein in adulthood through pathways involving psychosocial dysfunction and high body mass index.     

Hospital responses to a data-driven statewide quality improvement project

BACKGROUND: The overall success of any continuous quality improvement (CQI) project lies in the ability to measure changes resulting from the project and to show that changes have resulted n improved care. METHOD: A software tool was developed to categorize hospital responses and activities implemented by hospitals as a result of the Cooperative Cardiovascular Project CCP). Information was captured regarding the hospital's acceptance of data and the educational/interventional strategies implemented. Hospital size, number of acute myocardial infarction patients treated, indicator performances, and type of presentation given (on-site versus regional visit) was entered to allow analysis of factors affecting the response. RESULT: sixty-one of 107 hospitals responded to the peer review organization. Of those, 49% planned further educational activities and 75% planned to implement some form of CQI activity. Comparison of responses in relation to the type of presentation received suggested that on-site presentations are associated with higher response rates and more intense quality improvement efforts. This also could be attributed to other factors such as hospital size, teaching environment, or number of acute myocardial infarction patients treated. CONCLUSION: The system developed allowed us to collate hospital improvement efforts as a result of CCP. The system is limited in its ability to identify those activities taking place before CCP. Further development and refinement of the tool is warranted to document quality improvement efforts and determine best strategies for peer review organization intervention.     

Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain

CONTEXT: Although chest pain is widely considered a key symptom in the diagnosis of myocardial infarction (MI), not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown. OBJECTIVES: To determine the frequency with which patients with MI present without chest pain and to examine their subsequent management and outcome. DESIGN: Prospective observational study. SETTING AND PATIENTS: A total of 434,877 patients with confirmed MI enrolled June 1994 to March 1998 in the National Registry of Myocardial Infarction 2, which includes 1674 hospitals in the United States. MAIN OUTCOME MEASURES: Prevalence of presentation without chest pain; clinical characteristics, treatment, and mortality among MI patients without chest pain vs those with chest pain. RESULTS: Of all patients diagnosed as having MI, 142,445 (33%) did not have chest pain on presentation to the hospital. This group of MI patients was, on average, 7 years older than those with chest pain (74.2 vs 66.9 years), with a higher proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6% vs 25. 4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3 hours), were less likely to be diagnosed as having confirmed MI at the time of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), beta-blockers (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients without chest pain had a 23.3% in-hospital mortality rate compared with 9.3% among patients with chest pain (adjusted odds ratio for mortality, 2. 21 [95% confidence interval, 2.17-2.26]). CONCLUSIONS: Our results suggest that patients without chest pain on presentation represent a large segment of the MI population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality. JAMA. 2000;283:3223-3229     

Secular Trends in Occurrence of Acute Venous Thromboembolism: The Worcester VTE Study (1985-2009)

Background

The clinical epidemiology of venous thromboembolism has changed recently because of advances in identification, prophylaxis, and treatment. We sought to describe secular trends in the occurrence of venous thromboembolism among residents of the Worcester, Massachusetts, metropolitan statistical area.

Methods

Population-based methods were used to monitor trends in event rates of first-time or recurrent venous thromboembolism in 5025 Worcester, Massachusetts, metropolitan statistical area residents who were diagnosed with acute pulmonary embolism or lower-extremity deep vein thrombosis during 9 annual periods between 1985 and 2009. Medical records were reviewed by abstractors and validated by clinicians.

Results

Age- and sex-adjusted annual event rates for first-time venous thromboembolism increased from 73 (95% confidence interval [CI], 64-82) per 100,000 in 1985/1986 to 133 (CI, 122-143) in 2009, primarily because of an increase in pulmonary embolism. The rate of recurrent venous thromboembolism decreased from 39 (CI, 32-45) in 1985/1986 to 19 (CI, 15-23) in 2003, and then increased to 35 (CI, 29-40) in 2009. There was an increasing trend in using noninvasive diagnostic testing, with approximately half of tests being invasive in 1985/1986 and almost all noninvasive by 2009.

Conclusions

Despite advances in identification, prophylaxis, and treatment between 1985 and 2009, the annual event rate of venous thromboembolism has increased and remains high. Although these increases partially may be due to increased sensitivity of diagnostic methods, especially for pulmonary embolism, they also may imply that current prevention and treatment strategies are less than optimal.     

The Importance of Measuring Competency-Based Outcomes: Standard Evaluation Measures Are Not Surrogates for Clinical Performance of Internal Medicine Residents

Background: Despite recent emphasis on educational outcomes, program directors still rely on standard evaluation techniques such as tests of knowledge and subjective ratings. Purposes: To assess the correlation of standard internal medicine (IM) residency evaluation scores (attending global evaluations, In-Training examination, and Mini-Clinical Examination Exercise) with documented performance of preventive measures for continuity clinic patients. Methods: Cross-sectional study of 132 IM residents attending an IM teaching clinic, July 2000 to June 2003, comparing standard evaluations with chart audit. Results: Mean resident performance ranged from 53% (SD = 24) through 89% (SD = 20) across the 6 preventive measures abstracted from 1,102 patient charts. We found weak and mostly not significant correlations between standard measures and performance of preventive services. Conclusions: Standard measures are not adequate surrogates for measuring clinical outcomes. This supports the Accreditation Council for Graduate Medical Education's recommendations to incorporate novel Toolbox measures, like chart audit, into residency evaluations.     

The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative

BACKGROUND: Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. METHODS: Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. RESULTS: Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. CONCLUSIONS: In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.     

A curriculum for training quality scholars to improve the health and health care of veterans and the community at large

In 1998, the Veterans Health Administration invested in the creation of the Veterans Administration National Quality Scholars Fellowship Program (VAQS) to train physicians in new ways to improve the quality of health care. We describe the curriculum for this program and the lessons learned from our experience to date. The VAQS Fellowship program has developed a core improvement curriculum to train postresidency physicians in the scholarship, research, and teaching of the improvement of health care. The curriculum covers seven domains of knowledge related to improvement: health care as a process; variation and measurement; customer/beneficiary knowledge; leading, following, and making changes in health care; collaboration; social context and accountability; and developing new, locally useful knowledge. We combine specific knowledge about the improvement of health care with the use of adult learning strategies, interactive video, and development of learner competencies. Our program provides insights for medical education to better prepare physicians to participate in and lead the improvement of health care.     

Validity of self-reports of reasons for hospitalization by young adults and risk factors for discordance with medical records: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

This research focused on the validity of young adults' (mean age=33 years; standard deviation, 3.9) self-reports of reasons for hospitalization and factors affecting validity in a longitudinal cohort study of over 5,000 young adults in four US cities (1985-1998). Self-reported reasons were considered discordant if they differed from those in medical records. Of the 321 self-reported hospitalizations, overall concordance was 92.5%; concordance ranged from 80% for infections to 100% for injuries/fractures and procedures/surgeries. There were no significant differences among mail, telephone, or face-to-face methods of collecting self-reports. In generalized estimating equations analyses, Black race (odds ratio=4.23, 95% confidence interval: 1.72, 10.40; p=0.002) and intravenous drug use (odds ratio=6.06, 95% confidence interval: 1.17, 31.22; p=0.03) were positively associated with discordance. Nonetheless, self-reports by Blacks were 90.0% concordant. Self-reports by Whites were 95.7% concordant. These results suggest that young adults' self-reported reasons for hospitalization are overwhelmingly concordant with medical records. This has important implications, since obtaining medical records has become more costly and logistically difficult.