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Technology and your Health

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Regionalization and the Underuse of Angiography in the Veterans Affairs Health Care System as Compared with a Fee-for-Service System

Laura A. Petersen, M.D., M.P.H., et al

Volume 348:2209-2217 May 29, 2003

Background Policies to concentrate or regionalize invasive procedures at high-volume medical centers are under active consideration. Such policies could improve outcomes among those who undergo procedures while increasing their underuse among those who never reach such centers. We compared the underuse of needed angiography after acute myocardial infarction in a traditional Medicare fee-for-service system with underuse in the regionalized Department of Veterans Affairs (VA) health care system.

Methods We studied 1665 veterans from 81 VA hospitals and 19,305 Medicare patients from 1530 non-VA hospitals, all of whom were elderly men. We compared adjusted angiography use and one-year mortality among patients for whom angiography was rated as clinically needed. We compared underuse in models before and after controlling for the on-site availability of cardiac procedures.

Results After adjustment for the need for angiography, underuse was present in both groups, but VA patients remained significantly less likely than Medicare patients to undergo angiography (43.9 percent vs. 51.0 percent; odds ratio, 0.75; 95 percent confidence interval, 0.57 to 0.96). After also controlling for on-site availability of cardiac procedures at the admitting hospital, we found no significant difference in the underuse of angiography among VA patients as compared with Medicare patients (odds ratio, 1.02; 95 percent confidence interval, 0.82 to 1.26) or in one-year mortality (odds ratio, 1.08; 95 percent confidence interval, 0.89 to 1.28).

Conclusions There is underuse of needed angiography after acute myocardial infarction in both the VA and Medicare systems, but the rate of underuse is significantly higher in the VA. These differences appear to be associated with limited on-site availability of cardiac procedures in the regionalized VA health care system. Further work should focus on how regionalization policies could be improved with effective referral and triage processes.

Comment: I am troubled by this data which shows a 30 mortality rate in the Medicare patients of 7.0% vs 6% in the VA and a 1 year mortality rate of 20.3 vs 18.9 for Medicare vs VA.  While they are not a lot higher in the Medicare patients, they are higher enough to raise the question of whether we are doing too many procedures, rather than not enough.  Perhaps the “guidelines” should be revisited. GLE

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Personal Behaviors

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Actual Causes of Death in the United States, 2000

Ali H. Mokdad, PhD et al  JAMA. 2004;291:1238-1245.

Context  Modifiable behavioral risk factors are leading causes of mortality in the United States. Quantifying these will provide insight into the effects of recent trends and the implications of missed prevention opportunities.

Main Outcome Measures  Actual causes of death.

Results  The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400 000 deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%). Other actual causes of death were microbial agents (75 000), toxic agents (55 000), motor vehicle crashes (43 000), incidents involving firearms (29 000), sexual behaviors (20 000), and illicit use of drugs (17 000).

Conclusions  These analyses show that smoking remains the leading cause of mortality. However, poor diet and physical inactivity may soon overtake tobacco as the leading cause of death.

Comment: Sad to know that we are our own worst enemies.  HeartVentures wants to help you live a longer and healthier life.  GLE

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You are what you eat…

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International Prevalence, Recognition, and Treatment of Cardiovascular Risk Factors in Outpatients With Atherothrombosis

Deepak L. Bhatt, MD; et al for the REACH Registry Investigators

JAMA. 2006;295:180-189.  Vol. 295 No. 2, January 11, 06

Atherothrombosis is the leading cause of cardiovascular morbidity and mortality around the globe. We set out to determine whether atherosclerosis risk factor prevalence and treatment would demonstrate comparable patterns in many countries around the world.

The Reduction of Atherothrombosis for Continued Health (REACH) Registry collected data on atherosclerosis risk factors and treatment. A total of 67 888 patients aged 45 years or older from 5473 physician practices in 44 countries had either established arterial disease (coronary artery disease; cerebrovascular disease; peripheral arterial disease or 3 or more risk factors for atherothrombosis between 2003 and 2004.

Baseline prevalence of atherosclerosis risk factors, medication use, and degree of risk factor control.

Results  Atherothrombotic patients throughout the world had similar risk factor profiles: a high proportion with hypertension (81.8%), hypercholesterolemia (72.4%), and diabetes (44.3%). The prevalence of overweight (39.8%), obesity (26.6%), and morbid obesity (3.6%) were similar in most geographic locales, but was highest in North America (overweight: 37.1%, obese: 36.5%, and morbidly obese: 5.8%; P<.001 vs other regions). Patients were generally undertreated with statins (69.4% overall; range: 56.4% for cerebrovascular disease to 76.2% for CAD), antiplatelet agents (78.6% overall; range: 53.9% for  3 risk factors to 85.6% for CAD), and other evidence-based risk reduction therapies. Current tobacco use in patients with established vascular disease was substantial (14.4%). Undertreated hypertension (50.0% with elevated blood pressure at baseline), undiagnosed hyperglycemia (4.9%), and impaired fasting glucose (36.5% in those not known to be diabetic) were common. Among those with symptomatic atherothrombosis, 15.9% had symptomatic polyvascular disease.

Conclusion  This large, international, contemporary database shows that classic cardiovascular risk factors are consistent and common but are largely undertreated and undercontrolled in many regions of the world.

Comment:  This is true in the U.S. as well where adequacy of Rx and compliance are poor.  It behooves us all to take better care of ourselves; preferably with healthy eating and exercise.

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Type 2 Diabetes

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Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin

Diabetes Prevention Program Research Group Volume NEJM 346;2002:393-403

ABSTRACT

We randomly assigned 3234 nondiabetic persons with elevated fasting and post-load plasma glucose concentrations to placebo, metformin (850 mg twice daily), or a lifestyle-modification program with the goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week. The mean age of the participants was 51 years, and the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 34.0; 68 percent were women, and 45 percent were members of minority groups.

Results The average follow-up was 2.8 years. The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively. The lifestyle intervention reduced the incidence by 58 percent (95 percent confidence interval, 48 to 66 percent) and metformin by 31 percent (95 percent confidence interval, 17 to 43 percent), as compared with placebo; the lifestyle intervention was significantly more effective than metformin.

Comment:  Lifestyle change much more effective than Rx at preventing diabetes. GLE

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Blood Pressures Going UP

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Recent data gathered by the federal government indicates the incidence of high blood pressure has increased from 50 million in 1988-1994 to 65 million in 1999-2000. This is believed to reflect the increase in obesity which now effects two-thirds of all Americans. This data indicates that 31% of all Americans have high blood pressure; half of them are men - half women.

Published August 2004 in the journal Hypertension.

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