The conceptualization of patient complexity is just beginning in clinical medicine.
This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach ...promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients.
The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare.
We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health.
Objective. Despite unknown risks, prescription opioid use (POU) for nonmalignant chronic pain has grown in the US over the last decade. The objective of this study was to examine associations between ...POU and coronary heart disease (CHD), stroke, and cardiovascular disease (CVD) death in a large cohort.
Design, Setting, Subjects. POU was assessed in the prospective cohort study of 29,025 participants of the REasons for Geographic and Racial Differences in Stroke study, enrolled between 2003 and 2007 from the continental United States and followed through December 31, 2010. CHD, stroke, and CVD death were expert adjudicated outcome measures.
Methods. Cox proportional hazards models adjusted for CVD risk factors were used.
Results. Over a median (SD) of 5.2 (1.8) years of follow-up, 1,362 CHD events, 749 strokes, and 1,120 CVD death occurred (105, 55, and 104, respectively, in the 1,851 opioid users). POU was not associated with CHD (adjusted hazard ratio aHR) 1.03 95% CI 0.83–1.26 or stroke (aHR 1.04 95% CI 0.78–1.38), but was associated with CVD death (aHR 1.24 95% CI 1.00–1.53) in the overall sample. In the sex-stratified analyses, POU was associated with increased risk of CHD (aHR 1.38 95% CI 1.05–1.82) and CVD death (aHR 1.66 95% CI 1.27–2.17) among females but not males (aHR 0.70 95% CI 0.50-0.97 for CHD and 0.78 95% CI 0.54–1.11 for CVD death).
Conclusion. Female but not male POU were at higher risk of CHD and CVD death. POU was not associated with stroke in overall or sex-stratified analyses.
BACKGROUND:Blacks have higher coronary heart disease (CHD) mortality compared with whites. However, a previous study suggests that nonfatal CHD risk may be lower for black versus white men.
...METHODS:We compared fatal and nonfatal CHD incidence and CHD case-fatality among blacks and whites in the Atherosclerosis Risk in Communities study (ARIC), the Cardiovascular Health Study (CHS), and the Reasons for Geographic and Racial Differences in Stroke study (REGARDS) by sex. Participants 45 to 64 years of age in ARIC (men=6479, women=8488) and REGARDS (men=5296, women=7822), and ≥65 years of age in CHS (men=1836, women=2790) and REGARDS (men=3381, women=4112), all without a history of CHD, were analyzed. Fatal and nonfatal CHD incidence was assessed from baseline (ARIC=1987–1989, CHS=1989–1990, REGARDS=2003–2007) through up to 11 years of follow-up.
RESULTS:Age-adjusted hazard ratios comparing black versus white men 45 to 64 years of age in ARIC and REGARDS were 2.09 (95% confidence interval, 1.42–3.06) and 2.11 (1.32–3.38), respectively, for fatal CHD, and 0.82 (0.64–1.05) and 0.94 (0.69–1.28), respectively, for nonfatal CHD. After adjustment for social determinants of health and cardiovascular risk factors, hazard ratios in ARIC and REGARDS were 1.19 (95% confidence interval, 0.74–1.92) and 1.09 (0.62–1.93), respectively, for fatal CHD, and 0.64 (0.47–0.86) and 0.67 (0.48–0.95), respectively, for nonfatal CHD. Similar patterns were present among men ≥65 years of age in CHS and REGARDS. Among women 45 to 64 years of age in ARIC and REGARDS, age-adjusted hazard ratios comparing blacks versus whites were 2.61 (95% confidence interval, 1.57–4.34) and 1.79 (1.06–3.03), respectively, for fatal CHD, and 1.47 (1.13–1.91) and 1.29 (0.91–1.83), respectively, for nonfatal CHD. After multivariable adjustment, hazard ratios in ARIC and REGARDS were 0.67 (95% confidence interval, 0.36–1.24) and 1.00 (0.54–1.85), respectively, for fatal CHD, and 0.70 (0.51–0.97) and 0.70 (0.46–1.06), respectively, for nonfatal CHD. Racial differences in CHD incidence were attenuated among older women. CHD case fatality was higher among black versus white men and women, and the difference remained similar after multivariable adjustment.
CONCLUSIONS:After accounting for social determinants of health and risk factors, black men and women have similar risk for fatal CHD compared with white men and women, respectively. However, the risk for nonfatal CHD is consistently lower for black versus white men and women.
Background Prior studies suggest that persistence with and adherence to statin therapy is low. Interventions to improve statin persistence and adherence have been developed over the past decade. ...Methods and Results This was a retrospective cohort study of adults aged ≥21 y with commercial or government health insurance in the MarketScan (Truven Health Analytics) and Medicare databases who initiated statins in 2007-2014 and (1) started treatment after a myocardial infarction (n=201 573), (2) had diabetes mellitus but without coronary heart disease (CHD; n=610 049), or (3) did not have CHD or diabetes mellitus (n=2 244 868). Persistence with (ie, not discontinuing treatment) and high adherence to statin therapy were assessed using pharmacy fills in the year following treatment initiation. In 2007 and 2014, the proportions of patients persistent with statin therapy were 78.1% and 79.1%, respectively, among those initiating treatment following myocardial infarction; 66.5% and 67.3%, respectively, for those with diabetes mellitus but without CHD; and 64.3% and 63.9%, respectively, for those without CHD or diabetes mellitus. Between 2007 and 2014, high adherence to statin therapy increased from 57.9% to 63.8% among patients initiating treatment following myocardial infarction and from 34.9% to 37.6% among those with diabetes mellitus but without CHD (each P
<0.001). Among patients without CHD or diabetes mellitus, high adherence did not improve between 2007 (35.7%) and 2014 (36.8%; P
=0.14). In 2014, statin adherence was lower among younger, black, and Hispanic patients versus white patients and those initiating a high-intensity statin dosage. Statin adherence was higher among men and patients with cardiologist care following treatment initiation. Conclusions Persistence with and adherence to statin therapy remain low, particularly among those without CHD.
Depressive symptoms are associated with increased incident and recurrent cardiovascular events. In 2010, the American Heart Association published the Life's Simple 7, a metric for assessing ...cardiovascular health as measured by 4 health behaviors (smoking, physical activity, body mass index, diet) and 3 biological measures (cholesterol, blood pressure, glucose). The association between depressive symptoms and the Life's Simple 7 has not yet been explored.
Data from 20,093 participants ≥45 years of age who enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003 and 2007 and who had complete data available on Life's Simple 7 components were used for these analyses. The prevalence of ideal, intermediate, and poor health on each Life's Simple 7 component and total Life's Simple 7 scores were compared between participants with and without depressive symptoms. Depressive symptoms were measured using the 4-item Centers for Epidemiologic Studies of Depression scale.
Participants with depressive symptoms were more likely to have poor levels on each of the Life's Simple 7 components other than cholesterol adjusted prevalence ratios (95% CI): smoking 1.41 (1.29-1.55); physical activity 1.38 (1.31-1.46); body mass index 1.09 (1.04-1.15); diet 1.08 (1.06-1.10); blood pressure 1.11 (1.02-1.21); glucose 1.24 (1.09-1.41). There was a graded association between increasing depressive symptoms and lower total Life's Simple 7 score.
Depressive symptoms are associated with worse cardiovascular health on the overall Life's Simple 7 and on individual components representing both health behaviors and biological factors.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The use of statins increased among US adults with high coronary heart disease (CHD) risk after publication of the 2001 cholesterol treatment guidelines.
We analyzed the association between lipids and ...CHD among 9578 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants and 346,595 Kaiser Permanente Southern California (KPSC) members with baseline lipid measurements in 2003 to 2007. We performed the same analyses among 14,590 Atherosclerosis Risk In Communities (ARIC) study participants with lipid measurements in 1987 to 1989. Analyses were restricted to blacks and whites 45 to 64 years of age without CHD who were not taking statins at baseline. Total cholesterol, high-density lipoprotein cholesterol, and triglycerides were measured at baseline. Low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and ratios of total to high-density lipoprotein cholesterol and triglycerides to high-density lipoprotein cholesterol were calculated. The prevalence of diabetes mellitus, history of stroke, and antihypertensive medication use increased at higher low-density lipoprotein cholesterol in ARIC but not in REGARDS or KPSC. Over 8.9 years of follow-up, 225 CHD events occurred in REGARDS, 6547 events in KPSC, and 583 events in ARIC. After multivariable adjustment, less favorable lipid levels were associated with higher hazard ratios for CHD in ARIC. These associations were attenuated in REGARDS and KPSC. For example, the hazard ratio associated with the highest versus lowest quartile of low-density lipoprotein cholesterol (≥ 146 versus ≤ 102 mg/dL) was 1.89 (95% confidence interval, 1.42-2.51) in ARIC, 1.25 (95% confidence interval, 0.81-1.92) in REGARDS, and 1.49 (95% confidence interval, 1.38-1.61) in KPSC.
The association between lipids and CHD in contemporary studies may be attenuated by the preferential use of statins by high-risk individuals.
We sought to assess the quality of race and ethnicity information in observational health databases, including electronic health records (EHRs), and to propose patient self-recording as an ...improvement strategy.
We assessed completeness of race and ethnicity information in large observational health databases in the United States (Healthcare Cost and Utilization Project and Optum Labs), and at a single healthcare system in New York City serving a racially and ethnically diverse population. We compared race and ethnicity data collected via administrative processes with data recorded directly by respondents via paper surveys (National Health and Nutrition Examination Survey and Hospital Consumer Assessment of Healthcare Providers and Systems). Respondent-recorded data were considered the gold standard for the collection of race and ethnicity information.
Among the 160 million patients from the Healthcare Cost and Utilization Project and Optum Labs datasets, race or ethnicity was unknown for 25%. Among the 2.4 million patients in the single New York City healthcare system's EHR, race or ethnicity was unknown for 57%. However, when patients directly recorded their race and ethnicity, 86% provided clinically meaningful information, and 66% of patients reported information that was discrepant with the EHR.
Race and ethnicity data are critical to support precision medicine initiatives and to determine healthcare disparities; however, the quality of this information in observational databases is concerning. Patient self-recording through the use of patient-facing tools can substantially increase the quality of the information while engaging patients in their health.
Patient self-recording may improve the completeness of race and ethnicity information.
Background Outcomes following heart failure (HF) hospitalizations are poor, with 90-day mortality rates of 15% to 20%. Although prior studies found associations between individual social determinants ...of health (SDOH) and post-discharge mortality, less is known about how an individuals' total burden of SDOH affects 90-day mortality. Methods and Results We included participants of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study who were Medicare beneficiaries aged ≥65 years discharged alive after an adjudicated HF hospitalization. Guided by the Healthy People 2020 Framework, we examined 9 SDOH. First, we examined age-adjusted associations between each SDOH and 90-day mortality; those associated with 90-day mortality were used to create an SDOH count. Next, we determined the hazard of 90-day mortality by the SDOH count, adjusting for confounders. Over 10 years, 690 participants were hospitalized for HF at 440 unique hospitals in the United States; there were a total of 79 deaths within 90 days. Overall, 28% of participants had 0 SDOH, 39% had 1, and 32% had ≥2. Compared with those with 0, the age-adjusted hazard ratio for 90-day mortality among those with 1 SDOH was 2.89 (95% CI, 1.46-5.72) and was 3.06 (1.51-6.19) among those with ≥2 SDOH. The adjusted hazard ratio was 2.78 (1.37-5.62) and 2.57 (1.19-5.54) for participants with 1 SDOH and ≥2, respectively. Conclusions While having any of the SDOH studied here markedly increased risk of 90-day mortality after an HF hospitalization, a greater burden of SDOH was not associated with significantly greater risk in our population.
CONTEXT A triple-marker approach for chronic kidney disease (CKD) evaluation has not been well studied. OBJECTIVE To evaluate whether combining creatinine, cystatin C, and urine albumin-to-creatinine ...ratio (ACR) would improve identification of risks associated with CKD compared with creatinine alone. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study involving 26 643 US adults enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study from January 2003 to June 2010. Participants were categorized into 8 groups defined by estimated glomerular filtration rate (GFR) determined by creatinine and by cystatin C of either <60 or ≥60 mL/min/1.73 m2 and ACR of either <30 or ≥30 mg/g. MAIN OUTCOME MEASURES All-cause mortality and incident end-stage renal disease with median follow-up of 4.6 years. RESULTS Participants had a mean age of 65 years, 40% were black, and 54% were women. Of 26 643 participants, 1940 died and 177 developed end-stage renal disease. Among participants without CKD defined by creatinine, 24% did not have CKD by either ACR or cystatin C. Compared with those with CKD defined by creatinine alone, the hazard ratio for death in multivariable-adjusted models was 3.3 (95% confidence interval CI, 2.0-5.6) for participants with CKD defined by creatinine and ACR; 3.2 (95% CI, 2.2-4.7) for those with CKD defined by creatinine and cystatin C, and 5.6 (95% CI, 3.9-8.2) for those with CKD defined by all biomarkers. Among participants without CKD defined by creatinine, 3863 (16%) had CKD detected by ACR or cystatin C. Compared with participants who did not have CKD by any measure, the HRs for mortality were 1.7 (95% CI, 1.4-1.9) for participants with CKD defined by ACR alone, 2.2 (95% CI, 1.9-2.7) for participants with CKD defined by cystatin C alone, and 3.0 (95% CI, 2.4-3.7) for participants with CKD defined by both measures. Risk of incident end-stage renal disease was higher among those with CKD defined by all markers (34.1 per 1000 person-years; 95% CI, 28.7-40.5 vs 0.33 per 1000 person-years; 95% CI, 0.05-2.3) for those with CKD defined by creatinine alone. The second highest end-stage renal disease rate was among persons missed by the creatinine measure but detected by both ACR and cystatin C (rate per 1000 person-years, 6.4; 95% CI, 3.6-11.3). Net reclassification improvement for death was 13.3% (P < .001) and for end-stage renal disease was 6.4% (P < .001) after adding estimated GFR cystatin C in fully adjusted models with estimated GFR creatinine and ACR. CONCLUSION Adding cystatin C to the combination of creatinine and ACR measures improved the predictive accuracy for all-cause mortality and end-stage renal disease.
To optimize methods for identifying patients with diabetes based on computerized records and to obtain best estimates of diabetes prevalence in Department of Veterans Affairs (VA) patients.
The VA ...Diabetes Epidemiology Cohort (DEpiC) is a linked national database of all VA patients since 1998 with data from VA medical visits, Medicare claims, pharmacy and laboratory records, and patient surveys. Using DEpiC, we examined concordance of diabetes indicators, including ICD-9-CM codes (250.xx), prescription drug treatment, HbA(1c) tests, and patient self-report. We determined the optimal criterion for identifying diabetes and used it in estimating diabetes prevalence in the VA.
The best criterion was a prescription for a diabetes medication in the current year and/or 2+ diabetes codes from inpatient and/or outpatient visits (VA and Medicare) over a 24-month period. This definition had high sensitivity (93%) and specificity (98%) against patient self-report, and reasonable rates of HbA(1c) testing (75%). HbA(1c) testing alone added few additional cases, and a single diagnostic code added many patients, but without confirmation (reduced specificity). However, including codes from Medicare was critical. Applying this definition for 1998-2000, we identified an average of 500,000 VA patients with diabetes per year. We also estimated high and increasing diabetes prevalence rates of 16.7% in FY1998, 18.6% in FY1999, and 19.6% in FY2000 and an incidence estimated to be approximately 2% per year.
Development and evaluation of methodology for analyzing computerized patient data can improve the identification of patients with diabetes. The increasing high prevalence of diabetes in VA patients will present challenges for clinicians and health system management.
PDF
