Elderly patients receive less aggressive medical and invasive management of unstable angina: potential impact of practice guidelines

Development and validation of a scale to assess the belief that 'age causes illness'

OBJECTIVES

Self-directed ageism is the application of stereotypic age-related beliefs to oneself, and is known to negatively impact health-related motivation (Levy, 2003;  2022). This study focused on the specific self-directed stereotype that 'age causes illness' and aimed to develop and test a multi-item measure to assess this implicit, limiting belief.

METHODS AND MEASURES

Survey data was collected from N = 347 adults in southeastern Idaho (ages 45-65 years old, 60% female). A variety of measures were used to assess the discriminant, convergent and predictive validity of the Age Causes Illness scale including: socio-demographics (age, sex, education), psychosocial resources (personality, optimism, social support, depressive symptoms), health/aging expectations, and indicators of physical health.

RESULTS

The seven-item Age Causes Illness scale is reliable and shows an expected pattern of discriminant and convergent correlations with relevant socio-demographic, psychosocial, and aging-related measures. The belief that 'age causes illness,' as assessed with this new scale, is related to both objective and subjective indicators of physical health.

CONCLUSIONS

The Age Causes Illness scale is a brief screening tool, potentially applicable in behavioral health settings as an initial step toward discussion of the implicit, and often unchallenged, belief that age alone determines the onset, progression, and offset of illness.

Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care

In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.

Factors to improve quality for older patients in the emergency department: a qualitative study of patient trajectory

BACKGROUND

Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED.

METHODS

This is a qualitative study of some 450 h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient's trajectories, in particular those presenting with typically geriatric syndromes.

RESULTS

Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs.

CONCLUSIONS

The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people's specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors.

Patients 80 + have similar medication initiation rates to those aged 50-79 in Ontario FLS

Among individuals presenting to an Ontario FLS, we compared bone active medication initiation rates of patients 80 years and older with those 50-79 years old. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates between the two age groups INTRODUCTION: A Fracture Liaison Service (FLS) offers post-fracture services to individuals over the age of 50 years and could potentially address age inequities in pharmacotherapy often observed for older adults. Among individuals presenting to an Ontario FLS and classified as being at high risk for future fracture, our objective was to compare bone active medication initiation rates of patients 80 years and older with those 50-79 years old.

METHODS

In 39 FLS fracture clinics across Ontario, Canada, fracture prevention coordinators identified, assessed, and facilitated the referral of eligible patients for bone densitometry, fracture risk assessment, and implementation of pharmacotherapy in patients classified as high risk for future fracture. Variables assessed at baseline included age, sex, marital status, living location, fracture location, history of previous fracture, parent's history of hip fracture, history of falls, and fracture risk status. At 6 months, bone active medication initiation was assessed in patients classified as high risk for future fracture. The Chi-square test of independence was used to compare medication initiation rates between patients 80 + and those 50-79 years old.

RESULTS

Our sample size consisted of 808 patients aged 50-79 years and 346 aged 80 + years. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates of patients 50-79 and 80 + years old (76.9% versus 73.7%, p = 0.251).

CONCLUSION

A systematic approach to identifying patients at high risk for future fracture and tailoring treatment recommendations to these patients appeared to eliminate differences in treatment initiation rates based on older age.

Higher Frequency of Undetected Acute Coronary Syndrome in Elderly Patients with Chest Pain Who Visited the Emergency Department: A Large-Cohort Retrospective Study

Background

Acute coronary syndrome (ACS) is a critical disease encountered in the emergency department (ED). Despite the development of diagnostic tools, it may be difficult to diagnose ACS because of atypical symptoms and equivocal test results. We investigated the difference in the rates of revisit and undetected ACS between adult and elderly patients who visited the ED with chest pain.

Method

Data from 11,323 patients who visited the ED with chest pain at university hospitals in Korea were retrospectively analyzed. The cohort was categorized into two age groups: the adult (30–64 years) and elderly (>65 years). Baseline characteristic data (age, sex, vital signs, triage category, etc.) were obtained. We selected patients who revisited the ED within 30 d and investigated whether ACS was diagnosed.

Result

The revisit rate was higher in the elderly (12%) than in the adult group (8.3%). The rate of undetected ACS among the revisited patients was 2.91% (18/7,186) in adults and 6.08% (16/1,998) in elderly patients.

Conclusion

Elderly patients with chest pain had an increased rate of ED revisits and undetected ACS than adult patients. We recommend that old patients should be hospitalized to observe the progression of cardiac complaints or receive short-term follow-up.

Association of Hospital-level Neuraxial Anesthesia Use for Hip Fracture Surgery with Outcomes

Background

There is consistent and significant variation in neuraxial anesthesia use for hip fracture surgery across jurisdictions. We measured the association of hospital-level utilization of neuraxial anesthesia, independent of patient-level use, with 30-day survival (primary outcome) and length of stay and costs (secondary outcomes).

Methods

We conducted a population-based cohort study using linked administrative data in Ontario, Canada. We identified all hip fracture patients more than 65 yr of age from 2002 to 2014. For each patient, we measured the proportion of hip fracture patients at their hospital who received neuraxial anesthesia in the year before their surgery. Multilevel, multivariable regression was used to measure the association of log-transformed hospital-level neuraxial anesthetic-use proportion with outcomes, controlling for patient-level anesthesia type and confounders.

Results

Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic; utilization varied from 0 to 100% between hospitals. In total, 9,122 (8.5%) of patients died within 30 days of surgery. Survival independently improved as hospital-level neuraxial use increased (P = 0.009). Primary and sensitivity analyses demonstrated that most of the survival benefit was realized with increase in hospital-level neuraxial use above 20 to 25%; there did not appear to be a substantial increase in survival above this point. No significant associations between hospital neuraxial anesthesia-use and other outcomes existed.

Conclusions

Hip fracture surgery patients at hospitals that use more than 20 to 25% neuraxial anesthesia have improved survival independent of patient-level anesthesia type and other confounders. The underlying causal mechanism for this association requires a prospective study to guide improvements in perioperative care and outcomes of hip fracture patients.

Patterns of scheduled follow-up appointments following hospitalization for heart failure: insights from an urban medical center in the United States

Objectives

Although postdischarge outpatient follow-up appointments after a hospitalization for heart failure represent a potentially effective strategy to prevent heart failure readmissions, patterns of scheduled follow-up appointments upon discharge are poorly described. We aimed to characterize real-world patterns of scheduled follow-up appointments among adult patients with heart failure upon hospital discharge.

Patients and methods

This was a retrospective cohort study performed at a large urban academic center in the United States among adults hospitalized with a principal diagnosis of congestive heart failure between January 1, 2013, and December 31, 2014. Patient demographics, administrative data, clinical parameters, echocardiographic indices, and scheduled postdischarge outpatient follow-up appointments were collected.

Results

Of the 796 patients hospitalized for heart failure, just over half of the cohort had a scheduled follow-up appointment upon discharge. Follow-up appointments were less likely among patients who were white and had heart failure with preserved ejection fraction and more likely among patients with Medicaid and chronic obstructive pulmonary disease. In an adjusted multivariable regression model, age ≥65 years was inversely associated with a scheduled follow-up appointment upon hospital discharge, despite higher rates of several cardiovascular and noncardiovascular comorbidities.

Conclusion

Just half of the patients discharged home following a hospitalization for heart failure had a follow-up appointment scheduled, representing a missed opportunity to provide a recommended care transition intervention. Despite a greater burden of both cardiovascular and noncardiovascular comorbidities, older adults (age ≥65 years) were less likely to have a follow-up appointment scheduled upon discharge compared with younger adults, revealing a disparity that warrants further investigation.

Rates and timing of central venous cannulation among patients with sepsis and respiratory arrest admitted by the emergency department*

OBJECTIVES

Clinical guidelines for the acute management of emergency department patients with severe sepsis encourage the placement of central venous catheters. Data examining the timing of central venous catheter insertion among critically ill patients admitted from the emergency department are limited. We examined the hypothesis that prompt central venous catheter insertion during hospitalization among patients admitted from the emergency department acts as a surrogate marker for early aggressive care in the management of critically ill patients.

DESIGN

Retrospective cross-sectional analysis of emergency department visits using 2003-2006 discharge data from California, State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

SETTING

General medical or general surgical hospitals (n = 310).

PATIENTS

Patient hospitalizations beginning in the emergency department with the two most common diagnoses associated with central venous catheter (sepsis and respiratory arrest).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified the occurrence and timing of central venous catheter using International Classification of Diseases, 9th Revision, Clinical Modifications procedure codes. The primary outcomes measured were annual central venous catheters per 1,000 hospitalizations that began in the emergency department occurring emergently (procedure day 0), urgently (procedure day 1-2), or late (procedure day 3 or later). A total of 129,288 hospital discharges had evidence of central venous catheter. In 2003, 5,759 central venous catheters were placed emergently compared with 10,469 in 2006. The rate of emergent central venous catheter/1,000 increased annually from 228 in 2003, 239 in 2004, 257 in 2005, up to 269 in 2006. Urgent and late central venous catheter rates trended down (p < 0.001). In a multilevel model, the odds of undergoing emergent central venous catheter relative to 2003 increased annually: 1.08 (95% CI, 1.03-1.12) in 2004, 1.19 (95% CI, 1.14-1.23) in 2005, and 1.28 (95% CI, 1.23-1.33) in 2006.

CONCLUSIONS

Central venous catheters are inserted earlier and more frequently among critically ill patients admitted from the emergency department. Earlier central venous catheter insertion may require systematic changes to meet increasing utilization and enhanced mechanisms to measure central venous catheter outcomes.

An iatrogenic metabolic encephalopathy in a nonagenarian: The dilemma of a critical miss as a possible social dismissal

Here we posit for discussion the example of a reversible metabolic encephalopthy in a very elderly male that was missed clinically. A metabolic encephalopathy in extrememly elderly patients may be confused with delerium or inattention. A reversible cause of cognative dysfunction in the aged may be missed by practitioners because the aged may be assumed to have some level of impaired cognition; this may lead to a “social dismissal” of mental status changes. We highlight the need for engaged physicians in the care of the aged and vigilance against a professional bias toward the elderly patient that is dismissive.

Trends in outcomes among older patients with non-ST-segment elevation myocardial infarction

OBJECTIVES

The objective of this study is to assess trends in evidence-based therapy use and short- and long-term mortality over time among older patients with non-ST-segment elevation myocardial infarction (NSTEMI).

BACKGROUND

With the prevalence of national quality improvement efforts, the use of evidence-based therapies has improved over time among patients with NSTEMI, yet it is unclear whether these improvements have been associated with significant change in short- and long-term mortality for older patients.

METHODS

We linked detailed clinical data for 28,603 NSTEMI patients aged ≥65 years at 171 hospitals in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines Registry with longitudinal Centers for Medicare & Medicaid claims data and compared trends in annual unadjusted and risk-adjusted inhospital and long-term mortality from 2003 to 2006.

RESULTS

The median age of our NSTEMI study population was 77 years, 48% were female, and 87% were white. Overall, inhospital and 1-year mortality rates were 6.0% and 24.5%, respectively. When compared with patients treated in 2003, NSTEMI patients treated in 2006 were more likely to receive guideline-recommended inhospital medications and early invasive treatment. Inhospital mortality decreased significantly over the study period (5.5% vs 7.2% [adjusted odds ratio 0.82, 95% CI 0.67-1.00, P = .045] for 2006 vs 2003), but there was no significant change in 1-year mortality from the index admission (24.0% vs 26.0% [adjusted hazard ratio 0.99, 95% CI 0.90-1.08] for 2006 vs 2003).

CONCLUSIONS

Between 2003 and 2006, there was a significant reduction in inhospital mortality that corresponded to an increase in the use of evidence-based NSTEMI care. Nevertheless, long-term outcomes have not changed over time, suggesting a need for improved care transition and longitudinal secondary prevention.

Balancing the risk of mortality and major bleeding in the treatment of NSTEMI patients - a report from the National Cardiovascular Data Registry

OBJECTIVES

We sought to describe real-world patterns of care in NSTEMI patients across different risk profiles for bleeding and mortality.

BACKGROUND

The NCDR ACTION Registry-GWTG in-hospital mortality and major bleeding risk scores were developed to assess patient risk and optimize treatment decisions. However, little is known about the alignment of contemporary clinical management patterns with these risk estimates.

METHODS

We studied 61,366 NSTEMI patients in the NCDR ACTION-Registry-GWTG from January 2007 to March 2009, stratifying them into four groups based on estimated risk of mortality and major bleeding.

RESULTS

There were 24,709 (40.3%) patients in each of the concordant risk groups (low:low; high:high) and 5974 (9.7%) in each of the discordant risk groups (low:high; high:low). Subjects at high estimated risk for both mortality and major bleeding were least likely to receive guideline-based adjunctive pharmacotherapy or to undergo angiography within 48 hours but most likely to receive an excess dose of an antithrombotic agent. Patients at low estimated risk for mortality and bleeding received the most intensive adjunctive therapy and were most likely to undergo invasive angiography.

CONCLUSION

There are significant differences in contemporary patterns of care across varying risk profiles of mortality and major bleeding. Despite practice patterns which seem to emphasize avoiding harm with reduced use of antithrombotic therapy, patients at high risk for major bleeding continue to receive excess doses of antithrombotic therapy. Additional performance improvement efforts are needed to optimize outcomes in NSTEMI patients with high risk for both bleeding and mortality.

Therapy Students’ Recommendations of Physical Activity for Managing Persistent Low Back Pain in Older Adults

Negative views of older adults can lead to suboptimal care. For older adults with persistent low back pain (LBP), promotion of physical activity by health care professionals is important. Health care professionals’ views of older adults are influenced by their training. This study aimed to compare recommendations for physical activity for managing persistent LBP offered by students in physiotherapy and occupational therapy to an older person vs. a younger person. In a cross-sectional online survey, participants (N = 77) randomly received a vignette of either a 40-yr-old or 70-yr-old patient with persistent LBP. Other than age, the vignettes were identical. There was no difference between the younger and older vignettes in the likelihood of participants making overall appropriate physical activity recommendations—63% vs. 59%, OR (95%CI) = 1.19 (0.48–2.99), p = .71—although there was a trend toward age bias on recommendations specific to daily activity. Postqualification education may be where ageist views need to be addressed.

Attributing illness to 'old age:' consequences of a self-directed stereotype for health and mortality

Stereotypic beliefs about older adults and the aging process have led to endorsement of the myth that 'to be old is to be ill.' This study examined community-dwelling older adults' (N = 105, age 80+) beliefs about the causes of their chronic illness (ie, heart disease, cancer, diabetes, etc.), and tested the hypothesis that attributing the onset of illness to 'old age' is associated with negative health outcomes. A series of multiple regressions (controlling for chronological age, gender, income, severity of chronic conditions, functional status and health locus of control) demonstrated that 'old age' attributions were associated with more frequent perceived health symptoms, poorer health maintenance behaviours and a greater likelihood of mortality at 2-year follow-up. The probability of death was more than double among participants who strongly endorsed the 'old age' attribution as compared to those who did not (36% vs. 14%). Findings are framed in the context of self-directed stereotypes and implications for potential interventions are considered.

Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment

BACKGROUND

Geriatric adults represent an increasing proportion of emergency department (ED) users and can be particularly vulnerable to acute illnesses. Health care providers have recently begun to focus on the development of quality indicators (QIs) to define a minimal standard of care.

OBJECTIVES

The original objective of this project was to develop additional ED-specific QIs for older patients within the domains of medication management, screening and prevention, and functional assessment, but the quantity and quality of evidence were insufficient to justify unequivocal minimal standards of care for these three domains. Accordingly, the authors modified the project objectives to identify key research opportunities within these three domains that can be used to develop QIs in the future.

METHODS

Each domain was assigned one or two content experts who created potential QIs based on a systematic review of the literature, supplemented by expert opinion. Candidate QIs were then reviewed by four groups: the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, the SAEM Geriatric Interest Group, and audiences at the 2008 SAEM Annual Meeting and the 2009 American Geriatrics Society Annual Meeting, using anonymous audience response system technology as well as verbal and written feedback.

RESULTS

High-quality evidence based on patient-oriented outcomes was insufficient or nonexistent for all three domains. The participatory audiences did not reach a consensus on any of the proposed QIs. Key research questions for medication management (three), screening and prevention (two), and functional assessment (three) are presented based on proposed QIs that the majority of participants accepted.

CONCLUSIONS

In assessing a minimal standard of care by which to systematically derive geriatric QIs for medication management, screening and prevention, and functional assessment, compelling clinical research evidence is lacking. Patient-oriented research questions that are essential to justify and characterize future QIs within these domains are described.

Influence of updated guidelines on short- and long-term mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS)

AIM

In 2002 the ACC/AHA guidelines for the management of patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) were updated. We aimed to answer whether the implementation of updated guidelines was capable of influencing short- and long-term mortality in these patients.

METHODS

We analyzed data on 812 consecutive patients who were admitted with either UA or NSTEMI between 2001 and 2004. Patients admitted in the two years before the implementation of updated guidelines (UA(01/02) group and NSTEMI(01/02) group) were compared to patients admitted in the two years thereafter (UA(03/04) group and NSTEMI(03/04) group). Yearly follow-up concerning all-cause mortality was obtained up to four years.

RESULTS

The rate of revascularizations, the percentage of procedures performed within 48 h of admission, and the administration of clopidogrel increased significantly. However, still many - especially high-risk - patients did not receive revascularization. Patients of both UA groups had an identical in-hospital mortality rate. Differences in mortality between groups gained statistical significance over time (four-year mortality; 15.1% for the UA(03/04) group vs. 26.5% for the UA(01/02) group, p=0.014; HR 0.49 95% CI 0.28-0.87). In patients with NSTEMI in-hospital mortality decreased from 18.4% in the NSTEMI(01/02) group to 9.6% in the NSTEMI(03/04) group (p=0.011; HR 0.47 95% CI 0.26-0.84), and 1-year mortality from 34.7% to 25.1% (p=0.038; HR 0.63 95% CI 0.41-0.98), respectively. Mortality rates beyond one year were still lower in the NSTEMI(03/04) group as compared to the NSTEMI(01/02) group but it did not reach statistical significance. Multivariate Cox-regression analysis revealed furthermore that also patients with higher age and/or renal dysfunction benefit from an early invasive strategy.

CONCLUSION

The implementation of updated guidelines for NSTE-ACS had significant impact on short- and long-term mortality. However, an early invasive strategy is still withheld to a significant number of high-risk patients, who would benefit from an invasive treatment.

Survival and changes in physical ability after coronary revascularization for octa-nonagenerian patients with acute coronary syndrome

Elderly populations are increasingly represented among patients with acute coronary syndrome (ACS), and advanced age has been identified as an important risk factor for death and adverse outcome in patients with ACS treated invasively. Although considerable data have demonstrated a prognostic benefit of early revascularization in ACS particularly in high-risk patients, elderly patients with ACS are treated invasively less often than younger patients because older age is thought to be an independent predictor of mortality after percutaneous coronary intervention (PCI) in ACS. Over the past 5 years, a total of 54 ACS patients over 85 years old were treated. The 6-month survival rate was around 50% in the non-PCI group (n = 12) and around 80% in the PCI group (n = 42) (P < 0.05). Cardiac death occurred in 6 patients in the PCI group and in 6 patients in the non-PCI group. The rates of both cardiac death and all-cause death were significantly lower in the PCI group. The change in ADL score before and 6 months after the procedure was from 1.57 to 1.59 in the PCI group and from 2.25 to 2.20 in the non-PCI group. PCI for elderly patients with ACS is safe and life saving, and does not reduce the ability to perform activities of daily living. PCI should be recommended even for octo-nonagenerians with ACS.

Physicians' impression on the elders' functionality influences decision making for emergency care

BACKGROUND AND AIMS

This study analyzes the elements that compose the emergency physicians' criterion for selecting elderly patients for intensive care treatment. This issue has not been studied in-depth.

METHODS

A cross-sectional study was conducted at 4 university teaching hospitals, covering 101 randomly selected elderly patients admitted to emergency department and their respective physicians. Physicians were asked to forecast their plans for treatment or therapeutic abstention, in the event that patients might require aggressive measures (cardiopulmonary resuscitation or admission to critical care units). Data were collected on physicians' reasons for taking such decisions and their patients' functional capacity and cognitive status (Katz index and Informant Questionnaire on Cognitive Decline in the Elderly). A logistic regression model was constructed taking physicians' decisions as the dependent variables and adjusting for patient factors and physician impressions.

RESULTS

The functional status reported by reliable informants and the mental status measured by validated instruments were not coincident with the physicians' perception (functional status κ, 0.47; mental status κ, 0.26). A multivariate analysis showed that the age and the functional and mental status of patients, as perceived by the physicians, were the variables that better explained the physicians' decisions.

CONCLUSIONS

Physicians' impressions on the functional and mental status of their patients significantly influenced their selection of patients for high-intensity treatments despite the fact that some of these impressions were not correct.

Optimal medical therapy with or without percutaneous coronary intervention in older patients with stable coronary disease: a pre-specified subset analysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial

OBJECTIVES

Our aim was to access clinical effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) in older patients with stable coronary artery disease (CAD).

BACKGROUND

While older patients with CAD are at increased risk for cardiac events compared with younger patients, it is unclear whether PCI may mitigate this risk more effectively than OMT alone or, alternatively, may be associated with more complications.

METHODS

We conducted a pre-specified analysis of outcomes in stable CAD patients stratified by age and randomized to PCI+OMT or OMT alone in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial.

RESULTS

A total of 1,381 patients (60%) were <65 years of age (mean 56+/-6 years) and 904 patients (40%) were >or=65 years of age (mean 72+/-5 years). Achieved treatment targets for blood pressure, low-density lipoprotein cholesterol, adherence to diet and exercise, and angina-free status did not differ by age or treatment assignment. Among older patients, there was a 2- to 3-fold higher death rate, but similar rates of myocardial infarction, stroke, and major cardiac events compared with younger patients. The addition of PCI to OMT did not improve or worsen clinical outcomes in patients>or=65 years of age during a median 4.6 year follow-up.

CONCLUSIONS

These data support adherence to American College of Cardiology/American Heart Association clinical practice guidelines that advocate OMT as an appropriate initial management strategy, regardless of age. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657).

Antiplatelet therapy in older adults with non-ST-segment elevation acute coronary syndrome: considering risks and benefits

Antiplatelet agents play an important role in the treatment of non-ST-segment elevation acute coronary syndromes (NSTE ACS), particularly for those at high risk, such as older adults (aged > or =75 years) where treatment may yield the greatest benefits. Paradoxically, older adults are also at higher risk from bleeding complications. Most randomized trials have enrolled few older persons, so data are sparse with which to guide clinical practice. In this review, we highlight the relevant trial evidence for antiplatelet therapy (aspirin, P2Y(12) inhibitors, and small molecule glycoprotein IIb/IIIa inhibitors) in NSTE ACS in relation to age, taking into consideration the risks and benefits, dose, concomitant therapy, and duration of use. Given greater potential benefits from primary and secondary prevention strategies in cardiovascular care, it is important to apply guideline recommendations in older adults. However, given their complexity, it is important to further consider the application of existing and new therapies and strategies of care in "real-world" settings.

Global aging: challenges for community psychology

Older persons are among the major marginalized, disenfranchised citizens worldwide, yet this group has generally been ignored in the community psychology literature. In this paper, we trace the demographic trends in aging worldwide, and draw the field's attention to the United Nations Program on Aging, which structures its policy recommendations in terms of concepts that are familiar to community psychologists. A central theme of the paper is that community psychology can have a role in producing the conceptual shifts needed to change societal attitudes now dominated by negative age stereotypes.

Patterns of transfer for patients with non-ST-segment elevation acute coronary syndrome from community to tertiary care hospitals

BACKGROUND

Practice guidelines for non-ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management (cardiac catheterization and revascularization within 48 hours of hospital presentation) for high-risk patients, but interhospital transfer is necessary to provide rapid access to revascularization procedures for patients who present to community hospitals without revascularization capabilities.

METHODS

We analyzed patterns and factors associated with interhospital transfer among 19,238 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) from 124 community hospitals without revascularization capabilities in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines quality improvement initiative from January 2001 through June 2004.

RESULTS

Less than half of the patients (46.3%) admitted to community hospitals were transferred to tertiary hospitals, and fewer (20%) were transferred early (within 48 hours of presentation). Early transfer rates increased by 16% over 10 quarters in patients with a predicted low or moderate risk of inhospital mortality, compared with 5% in high-risk patients. By the last quarter of the analysis, 41.4% of low-risk patients were transferred early versus 12.5% of high-risk patients. Factors significantly associated with early transfer included younger age, lack of prior heart failure, cardiology inpatient care, and ischemic ST-segment electrocardiographic changes. Among patients who were not transferred, 29% had no further risk stratification performed with stress testing, ejection fraction measurement, or diagnostic cardiac catheterization (at hospitals with catheterization laboratories).

CONCLUSIONS

Most patients with NSTE ACS presenting to community hospitals without revascularization capabilities are not rapidly transferred to tertiary hospitals, and lower-risk patients appear to be preferentially transferred early. Further investigation is needed to determine if improved risk-based triage at community hospitals can optimize transfer decision making for high-risk patients with NSTE ACS.

Abciximab in elderly with acute coronary syndrome invasively treated: effect on outcome

Older age is an independent predictor of mortality after percutaneous coronary intervention (PCI) in patients with Non-ST elevation Acute Coronary Syndrome (ACS). GPIIb/IIIa inhibitors are proved to improve outcome in high risk patients, but conflicting data are available about the effects of these inhibitors in elderly. Accordingly, we studied a consecutive population of elderly patients undergoing PCI for Non-ST elevation ACS. A total of 500 patients were divided in: GPI group (247 pts; mean age 77+/-1.9 years) treated by stenting plus abciximab and, no GPI group (253 pts; mean age 77+/-2.4 years) treated by stenting alone. Propensity analysis was used to account for the nonrandomized use of GPIIb/IIIa inhibitors. During hospitalization, incidence of death was similar among groups (3.2% vs 4.6%) without difference regarding incidence of major (1.6% vs 1.1%) and minor bleedings (4% vs 3%). At long-term follow-up the rate of death was significantly lower in GPI group (4.5% vs 12.3%; p=0.002) as well as the rate of acute myocardial infarction (2.8% vs 11.1%; p=0.0001), and pre-PCI (5.7% vs 13.4%; p=0.003). Cox regression analysis identified abciximab use as an independent predictor of lower long-term major adverse cardiac event (MACE) after adjustment for propensity score (Exp (B) 0.620, 95%CI 0.394-0.976, p=0.039). Our results suggest that addition of abciximab to stenting improves outcome in elderly patients with Non-ST elevation ACS, leading to an absolute benefit for reduction of death and MACE, with an acceptable rate of major and minor bleedings.

Outcomes in elderly patients with acute coronary syndromes randomized to enoxaparin vs. unfractionated heparin: results from the SYNERGY trial

AIMS

Elderly patients are at high risk from non-ST-segment elevation acute coronary syndromes (NSTE ACS) as well as from treatment-related complications. Age-associated changes in physiology may alter the risk and benefit expected from therapy. The SYNERGY database was used to study the influence of age on treatment outcomes with enoxaparin vs. unfractionated heparin (UFH) in patients with high-risk NSTE ACS.

METHODS AND RESULTS

Age was analysed as a continuous and categorical variable (<65, 65-74, and >or=75 years, and <75 and >or=75 years) for descriptive purposes. Logistic regression was used to adjust the outcomes of 30-day death, death or myocardial infarction (MI), and major bleeding for baseline characteristics. Odds ratios compared outcomes by age and by treatment within age groups. Model interaction terms were used to test for statistically different outcomes by treatment and age. Overall, 9977 randomized patients had age information, of whom 25.5% (2540) were >or=75 years of age. Elderly patients (>or=75 years) had more cardiovascular risk factors, prior cardiac disease, and higher acuity at presentation. After adjustment, advanced age (per 10 years) was associated with 30-day death or MI [risk odds ratios (ROR): 1.14, P = 0.002], 30-day death (ROR: 1.54, P < 0.0001), and 1-year death (ROR: 1.47, P < 0.0001), as well with TIMI major bleeding (ROR: 1.21, P = 0.001), GUSTO severe bleeding (ROR: 1.20, P = 0.047), and transfusion (ROR: 1.04, P = 0.324). Although there was a higher rate of GUSTO severe bleeding noted with enoxaparin in elderly patients, the overall relationships between treatment (UFH or enoxaparin) and outcomes did not vary significantly as a function of the patient's age.

CONCLUSION

Although higher rates of adverse events are seen in the oldest subgroup (age >or=75 years) treated with enoxaparin, statistical comparisons confirm similar efficacy and safety of enoxaparin and UFH across age subgroups as was demonstrated overall in SYNERGY.

Assessment of attitudes of intensive care unit staff toward clinical practice guidelines

Although studies on the implementation and adherence to specific practice guidelines have been proliferating, research examining the attitude of healthcare workers toward practice guidelines in general has been lacking. This study is a secondary analysis of data collected from 39 volunteer hospitals participating in the National Nosocomial Infection Surveillance System on attitudes of intensive care unit staff regarding practice guidelines in general. Age, profession, type of intensive care unit, and race were identified as significant predictors of attitude scores in this study. Understanding the differences in perceived barriers is important for the adherence to practice guidelines.

The elderly in the emergency department: a critical review of problems and solutions

The elderly are an ever increasing population in overcrowded emergency departments (EDs) in many countries. They have multiple health problems and consume more time and resources than younger patients. They are more frequently admitted and experience adverse outcomes after they are discharged from the ED. These frail patients could require specific skills, instruments and organisational models of emergency care in order to look after their complex needs. As such, several approaches have been tried and tested to improve emergency care for them. This article analyses the epidemiological load and problems faced when confronted with elder ED patients. We critically review organisational models, clinical approaches and methodologies in order to reduce ED physicians' difficulties and to improve quality of care and outcomes for elder patients. Triage, clinical assessment and discharge are identified as critical moments during an emergency care process, and interesting and useful instruments are proposed as possible solutions.

Attitudes toward practice guidelines among intensive care unit personnel: a cross-sectional anonymous survey

OBJECTIVES

The study assessed attitudes of intensive care unit (ICU) staff members toward practice guidelines in general and toward a specific guideline, The Centers for Disease Control and Prevention's Guideline for Hand Hygiene in Healthcare Settings; correlated these attitudes with staff and hospital characteristics; and examined the impact of staff attitudes toward the Hand Hygiene Guideline on self-reported implementation of the Guideline.

METHODS

We performed a cross-sectional survey of staff in 70 ICUs in 39 U.S. hospitals, members of The National Nosocomial Infection Surveillance System. A survey, "Attitudes Regarding Practice Guidelines," was administered anonymously to all willing staff during a site visit at each hospital. A total of 1359 ICU personnel responded: 1003 nurses (74%), 228 physicians (17%), and 128 others (10%).

RESULTS

Significantly more positive attitudes toward practice guidelines were found among staff in pediatric compared with adult ICUs (P < .001). Nurses and other staff when compared with physicians had more positive attitudes toward guidelines in general but not toward the specific Hand Hygiene Guideline. Those with more positive attitudes were significantly more likely to report that they had implemented recommendations of the Guideline (P < .001) and used an alcohol product for hand hygiene (P = .002).

CONCLUSIONS

The majority of staff members were familiar with the Centers for Disease Control and Prevention Hand Hygiene Guideline. Staff attitudes toward practice guidelines varied by type of ICU and by profession, and more positive attitudes were associated with significantly better self-reported guideline implementation. Because differences in staff attitudes might hinder or facilitate their acceptance and adoption of evidence-based practice guidelines, these results may have important implications for the education and/or socialization of ICU staff.

"Oldest old" patients in intensive care: prognosis and therapeutic activity

OBJECTIVE

In view of ethical considerations and the limited resources in intensive care medicine, the present investigation aims to give a descriptive overview of the prognosis and therapeutic activity for the oldest age group of elderly patients admitted to an intensive care unit (ICU) in comparison with younger ICU patients.

PATIENTS AND METHODS

3069 patients admitted to the ICU during a seven-year period were categorized into four age groups: under 65 years (48%), 65 to 74 years (26%), 75 to 85 years (22%) and 85 years or older (5%). Type and reason for ICU admission, length of ICU stay, severity of illness as measured by the simplified acute physiology score (SAPS)-II, level of provided care as measured by the simplified therapeutic intervention scoring system (TISS)-28, and vital status at the date of ICU discharge were recorded.

RESULTS

The ICU mortality rate of patients aged 85 years or older was significantly higher than in patients under 65 (OR of mortality: 1.8, p < 0.001). Non-survivors had higher SAPS II levels (even when excluding age points) in all age groups, but higher daily average TISS points only in patients under 85. The daily average TISS score was negatively correlated to age (r = -0.03; p < 0.001) and was significantly lower in the oldest group when compared with all the younger groups (p < 0.001). The oldest patients had a significantly shorter length of stay (median: 2; interquartile range [IQR] 1-3, p < 0.001) than the younger patient groups.

CONCLUSIONS

Within the very elderly population, age is an important and independent predictor of mortality, but acute severity of illness is even more strongly associated with mortality. Consequently, age alone may be an inappropriate criterion for allocation of ICU resources.

Risk Stratification and Prognosis in Octogenarians Undergoing Stress Echocardiographic Study

BACKGROUND

The prognostic value of stress echocardiography (SE) for the diagnosis and risk stratification of coronary artery disease in octogenarians is not well defined.

METHODS

Follow-up of 5 years (mean 2.9 +/- 1.0 years) for confirmed nonfatal myocardial infarction (n = 17) and cardiac death (n = 37) was obtained in 335 patients, age > or =80 years (mean age 84 +/- 3 years, 44% male), undergoing SE (33% treadmill, 67% dobutamine). Left ventricular (LV) regional wall motion was assessed by a consensus of two echocardiographers and scored as per standard five-point scale, 16-segment model of wall motion analysis. Ischemic LV wall segment was defined as deterioration in the thickening and excursion during stress (increase in wall-motion score index (WMSI) > or =1).

RESULTS

By univariate analysis, inducible ischemia (chi-square = 38.4, P < 0.001), left ventricular ejection fraction (chi-square = 41.2, P < 0.001), a history of previous myocardial infarction (chi-square = 22.3, P < 0.01), hypertension (chi-square = 33, P < 0.01), and age (chi-square = 27.7, P < 0.01) were significant predictors of future cardiac events. WMSI, an index of inducible ischemia, provided incremental prognostic information when forced into a multivariable model where clinical and rest echocardiography variables were entered first. WMSI effectively stratified octogenarians into low- and high-risk groups (annualized event rates of 1.2 versus 5.8%/year, P < 0.001).

CONCLUSIONS

Stress echocardiography yields incremental prognostic information in octogenarians and effectively stratifies them into low- and high-risk groups. Precise therapeutic decision making in very elderly patients should incorporate combined clinical and stress echocardiography data.

The elder patient with suspected acute coronary syndromes in the emergency department

OBJECTIVES

To describe the evaluation and outcomes of elder patients with suspected acute coronary syndromes (ACS) presenting to the emergency department (ED).

METHODS

This was a post hoc analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS) registry, which had 17,713 ED visits for suspected ACS. First visits from the United States with nonmissing patient demographics, 12-lead electrocardiogram results, and clinical history were included in the analysis. Those who used cocaine or amphetamines or left the ED against medical advice were excluded. Elder was defined as age 75 years or older. ACS was defined by 30-day revascularization, Diagnosis-related Group codes, or death within 30 days with positive cardiac biomarkers at index hospitalization. Multivariable logistic regression analyses were performed to determine the association between being elder and 1) 30-day all-cause mortality, 2) ACS, 3) diagnostic tests ordered, and 4) disposition. Multivariable logistic regression was also performed to determine which clinical variables were associated with ACS in elder and nonelder patients.

RESULTS

A total of 10,126 patients with suspected ACS presenting to the ED were analyzed. For patients presenting to the ED, being elder was independently associated with ACS and all-cause 30-day mortality, with adjusted odds ratios of 1.8 (95% confidence interval [CI] = 1.5 to 2.2) and 2.6 (95% CI = 1.6 to 4.3), respectively. Elder patients were more likely to be admitted to the hospital (adjusted odds ratio, 2.2; 95% CI = 1.8 to 2.6), but there were no differences in the rates of cardiac catheterization and noninvasive stress cardiac imaging. Different clinical variables were associated with ACS in elder and nonelder patients. Chest pain as chief complaint, typical chest pain, and previous history of coronary artery disease were significantly associated with ACS in nonelder patients but were not associated with ACS in elder patients. Male gender and left arm pain were associated with ACS in both elder and nonelder patients.

CONCLUSIONS

Elder patients who present to the ED with suspected ACS represent a population at high risk for ACS and 30-day mortality. Elders are more likely to be admitted to the hospital, but despite an increased risk for adverse events, they have similar odds of receiving a diagnostic test, such as stress cardiac imaging or cardiac catheterization, compared with nonelder patients. Different clinical variables are associated with ACS, and clinical prediction rules utilizing presenting symptoms should consider the effect modification of age.

Use of evidence-based medicine for acute coronary syndromes in the elderly and very elderly: insights from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes trials

BACKGROUND

Evidence-based medications (EBM) are underused in older patients despite potentially larger absolute benefits. Little is known about factors influencing prescribing in the elderly with acute coronary syndromes.

METHODS

Among the 15,904 patients from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) and second SYMPHONY trials, we examined the rates of use of EBM according to age (< 75 or > or = 75 years, and 3 subgroups of 5 year increments among patients > or = 75 years).

RESULTS

Ninety-day mortality increased with age (< 75 years, 1.3%; > or = 75 to < 80 years, 4.4%; > or = 80 to < 85 years, 6.0%; > or = 85 years, 9.6%). Compared with subjects < 75 years (n = 14,043), acute EBM use was lower among patients > or = 75 years (n = 1794): aspirin (83% vs 85%), heparin (73% vs 78%), and beta-blockers (70% vs 76%). Similarly, discharge use of beta-blockers (69% vs 76%) and statins (28% vs 40%) was lower, although this was not the case for angiotensin-converting enzyme inhibitors (44% vs 41%). These patterns persisted among eligible patients. Beyond the age of 75 years, EBM use was not further influenced by age except for statins and angiotensin-converting enzyme inhibitors, which were used less frequently in those > or = 85 years. Among patients aged > or = 75 years, prediction for use of each EBM in multivariable modeling was modest (C indices, approximately 0.7); except for statins, increasing age did not predict lower EBM use.

CONCLUSIONS

Despite higher mortality risk, EBM use was lower among older patients even considering eligibility. Among those aged > or = 75 years, age was no longer the major factor predicting EBM use. The modest C indices suggest other factors are associated with prescribing, underscoring the need for treatment algorithms and quality assurance measures in older patients.

Outcome of older critically ill patients: a matched cohort study

BACKGROUND

Admission of older patients to intensive care units is a controversial issue.

OBJECTIVE

To estimate age-associated mortality of critically ill patients.

METHODS

A prospective matched cohort study in the Medical-Surgical Intensive Care Unit of a tertiary hospital was conducted. We included 100 consecutive patients older than 70 years admitted to the intensive care unit (cases) and 100 patients younger than 70 years (controls). The matching criterion was the severity of illness at admission to the intensive care unit as estimated by the simplified acute physiological score (SAPS II) without including age in its calculation.

RESULTS

Mortality in the intensive care unit was higher, but not statistically significant, in the older group: 26% vs. 19% (p = 0.23). Patients older than 70 years had a longer duration of mechanical ventilation (median 7 vs. 3 days) and longer stay in the intensive care unit (median 8 vs. 5 days). There were no differences in organ dysfunctions, except for a higher incidence of respiratory failure in the older group (p < 0.001). The use of invasive procedures was similar in both groups. There were more orders for the withholding/withdrawal of treatment in patients older than 70 years (9 vs. 3%, p = 0.07).

CONCLUSION

In our study, age was not related with a significant higher mortality. In the older patients included in our study the survival was greater than 70% with a similar resource utilization except for a longer stay in the intensive care unit.

Comparison of long-term mortality across the spectrum of acute coronary syndromes

BACKGROUND

Data are sparse regarding comparative long-term mortality across the spectrum of patients presenting with acute coronary syndrome (ACS).

METHODS

We identified all patients hospitalized with suspected myocardial ischemia in an urban academic hospital from 1991 to 1992. We compared presenting characteristics, treatment, and long-term mortality between patients with unstable angina (UA), minor myocardial damage (MMD), definite non-ST-elevation myocardial infarction (NSTEMI), and STEMI.

RESULTS

Of 760 patients (mean age 68 years, 35% women), 22% had UA, 35% had MMD, 26% had NSTEMI, and 17% had STEMI. During a mean follow-up of 9.5 years, unadjusted mortality was highest in patients with MMD and NSTEMI (mortality for UA 43%, MMD 68%, NSTEMI 62%, STEMI 44%; P < .001). Patients with MMD and NSTEMI were older than patients with STEMI or UA, had more comorbid conditions (diabetes, prior myocardial infarction, congestive heart failure), and were less likely to receive aspirin, unfractionated heparin, or revascularization therapies during the index hospitalization. After multivariable adjustment for all significant covariates, mortality increased sequentially along the spectrum of ACS (hazards ratios for UA 1.0 [referent], MMD 1.12 [95% CI 0.84-1.49], NSTEMI 1.28 [0.95-1.72], and STEMI 1.52 [1.06-2.19]).

CONCLUSIONS

Patients presenting with MMD and definite NSTEMI had a worse unadjusted long-term prognosis up to 10 years after index hospitalization than patients with STEMI. This mortality excess for MMD/NSTEMI was associated with more comorbid conditions and decreased use of basic therapies for ACS. After controlling for baseline differences, STEMI patients had the highest mortality.

Uncomplicated acute renal failure and hospital resource utilization: a retrospective multicenter analysis

BACKGROUND

Although acute renal failure (ARF) complicating nonrenal organ dysfunction in the intensive care unit is associated with significant mortality and hospital costs, hospital resource utilization attributed to uncomplicated ARF is not well known. The goal of this study is to characterize the costs and lengths of stay (LOSs) incurred by hospitalized patients with uncomplicated ARF and their important determining factors.

METHODS

We obtained hospital case-mix data sets from 23 Massachusetts hospitals for a 2-year period (1999 to 2000) from the Massachusetts Division of Health Care Finance and Policy. A total of 2,252 records of patients hospitalized with uncomplicated ARF were identified. Patient records of other common medical diagnoses were studied for comparison.

RESULTS

Patients hospitalized with uncomplicated ARF incurred median direct hospital costs of 2,600 dollars, median hospital LOS of 5 days, and mortality of 8%. Dialysis was independently associated with significantly greater hospital costs and LOSs for patients with uncomplicated ARF (P < 0.05). Male sex and nonwhite race were associated with significantly lower hospital costs and LOSs, whereas type of hospital had opposing effects on these 2 resource utilization outcomes (P < 0.05). Unadjusted aggregate resource utilization associated with uncomplicated ARF exceeded that of many other common illnesses.

CONCLUSION

Demographic and hospital factors, as well as dialysis therapy, are significant determinants of hospital resource utilization for patients with uncomplicated ARF. Uncomplicated ARF appears to incur greater hospital costs and longer LOSs compared with other common medical conditions. Greater focus should be directed toward further understanding of the factors influencing resource utilization for ARF.

Age-related differences in the management and outcome of patients with acute coronary syndromes

BACKGROUND

Age-related differences in patients with an acute coronary syndrome (ACS) have not been well characterized in prior observational studies that often included only certain age groups or subjects with myocardial infarction (MI).

METHODS

We stratified 4627 patients admitted with an ACS across 9 provinces between 1999 and 2001 enrolled in the Canadian ACS Registry into 3 age groups (< 65, 65-74, and > or = 75 years) to evaluate differences in clinical characteristics, management, and 1-year outcome.

RESULTS

Older patients more frequently had previous angina, MI, or heart failure and were less likely to have positive cardiac markers, ST elevation, and Q-wave MI or to receive thrombolytics, beta-blockers, and cholesterol-lowering and antiplatelet agents in hospital, at discharge, and at 1 year. In multivariable analyses controlling for patient factors, every decade increase in age was independently associated with reduced use of coronary angiography (odds ratio [OR] 0.79, 95% CI 0.74-0.84, P < .001) and percutaneous coronary intervention (OR 0.88, 95% CI 0.81-0.95, P = .001). When adjusted for validated clinical prognosticators and differences in management, every decade of age increment independently predicted an increased risk of death at 1 year (OR 1.87, 95% CI 1.66-2.12, P < .001).

CONCLUSIONS

Across the broad spectrum of ACS, elderly patients had more complex comorbidities and worse outcome, yet they were less likely to undergo revascularization or to receive acute and long-term evidence-based medications. Our findings emphasize the ongoing need to better define and promote optimal therapeutic regimens for elderly patients with ACS.

Moving from Evidence to Practice in the Care of Patients Who Have Acute Coronary Syndrome

Both acute management and secondary prevention for patients presenting with the spectrum of ACS have evolved greatly during the last decade, as evidenced by the multitude of clinical trials and the development of CPGs. The goal of the next decade is to ensure the accurate, equal,and timely application of these therapies and management strategies in clinical practice. In the emergency department, initiation of guideline-based management is especially challenging given the dynamic process of risk stratification that must take place to ensure properly directed care. It is clear, however, that application of such therapies leads to improved outcomes. Lessons learned from previous and ongoing quality improvement initiatives will provide the tools needed to ensure that widespread adoption of guideline-based therapy is complete.

Evolution in Cardiovascular Care for Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

OBJECTIVES

This study evaluated the impact of age on care and outcomes for non-ST-segment elevation acute coronary syndromes (NSTE ACS).

BACKGROUND

Recent clinical trials have expanded treatment options for NSTE ACS, now reflected in guidelines. Elderly patients are at highest risk, yet have previously been shown to receive less care than younger patients.

METHODS

In 56,963 patients with NSTE ACS at 443 U.S. hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative from January 2001 to June 2003, we compared use of guidelines-recommended care across four age groups: <65, 65 to 74, 75 to 84, and > or =85 years. A multivariate model tested for age-related differences in treatments and outcomes after adjusting for patient, provider, and hospital factors.

RESULTS

Of the study population, 35% were > or =75 years old, and 11% were > or =85 years old. Use of acute anti-platelet and anti-thrombin therapy within the first 24 h decreased with age. Elderly patients were also less likely to undergo early catheterization or revascularization. Whereas use of many discharge medications was similar in young and old patients, clopidogrel and lipid-lowering therapy remained less commonly prescribed in elderly patients. In-hospital mortality and complication rates increased with advancing age, but those receiving more recommended therapies had lower mortality even after adjustment than those who did not.

CONCLUSIONS

Age impacts use of guidelines-recommended care for newer agents and early in-hospital care. Further improvements in outcomes for elderly patients by optimizing the safe and early use of therapies are likely.

Influence of clinical trial enrollment on the quality of care and outcomes for patients with non-ST-segment elevation acute coronary syndromes

BACKGROUND

Clinical trials provide evidence that is formulated into recommendations for practice guidelines, but it remains uncertain whether patients enrolled in trials are similar to those treated in routine practice and whether trial enrollment influences inhospital treatments and outcomes.

METHODS

Using data from the CRUSADE quality improvement initiative, we evaluated predictors of trial enrollment, treatment patterns, and clinical outcomes among high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) who were and were not enrolled in a clinical trial during hospitalization.

RESULTS

Among 55,172 high-risk patients presenting with NSTE ACS at 443 US hospitals, 1397 (2.5%) patients were enrolled in a clinical trial during index hospitalization. Significant predictors of trial enrollment included male sex, lack of renal insufficiency, and absence of congestive heart failure on presentation. Acute (<24 hours) and discharge secondary prevention interventions recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS were used more commonly in patients enrolled in clinical trials. Cardiac catheterization (84.5% vs 65.8%, P < .0001), percutaneous coronary intervention (48.2% vs 36.3%, P < .0001), and bypass surgery (19.1% vs 11.3%, P < .0001) were also performed more frequently in trial patients. The adjusted risk of inhospital mortality was similar in trial versus nontrial patients (odds ratio 0.86, 95% CI 0.60-1.24).

CONCLUSIONS

Patients with NSTE ACS participating in clinical trials are more likely to receive beneficial therapies and interventions throughout hospitalization, but preferential recruitment of patients with lower-risk features may limit the external validity of trial results.

Use of a computerized guideline for glucose regulation in the intensive care unit improved both guideline adherence and glucose regulation

OBJECTIVE

To measure the impact of a computerized guideline for glucose regulation in an ICU.

DESIGN

A randomized, controlled trial with an off-on-off design.

METHODS

We implemented a glucose regulation guideline in an intensive care unit in paper form during the first study period. During the second period, the guideline was randomly applied in either paper or computerized form. In the third period, the guideline was available only in paper form.

MEASUREMENTS AND RESULTS

We analyzed data for 484 patients. During the intervention period, the control group included 54 patients and the computerized intervention group included 66 patients. The two guideline-related outcome measures consisted of compliance with: (a) glucose measurement timing recommendations and (b) insulin dose advice. We measured clinical impact as the proportion of time that glucose levels fell within target range. In the first (paper-based) study period, 29.0% of samples occurred with optimal timing; during the second period, this increased to 35.5% for paper-based and to 40.2% for computerized protocols. The third study period timeliness scores reverted to the first period rates. Late (suboptimal) sampling occurred for 66% of glucose measurements in the first study period, for 42% of paper-based and 28% of computer-based protocol samples in the second period, and for 50.0% of samples in the third study period. In the first study period, insulin-dosing guideline compliance was 56.3%; in the second period, it was 64.2% for paper-based and 77.3% for computer-based protocols, and it fell to 42.4% in the third period. For the second study period, the time that a patient's glucose values fell within target range improved for both the control (52.9%) and the computerized groups (54.2%) compared with the first study period (44.3%) and the third period (42.3%).

CONCLUSION

Implementing a computerized version of a guideline significantly improved timeliness of measurements and glucose level regulation for critically ill patients compared with implementing a paper-based version of the guideline.