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1.
J Card Fail ; 29(4): 434-444, 2023 04.
Article in English | MEDLINE | ID: mdl-36516937

ABSTRACT

INTRODUCTION: Beta-blockers (BB) and renin-angiotensin system inhibitors (RASi) are foundational for the treatment of heart failure with reduced ejection fraction (HFrEF). However, given the increased risk of side effects in older patients, uncertainty remains as to whether, on net, older patients benefit as much as the younger patients studied in trials. METHODS AND RESULTS: Using the Get With The Guidelines-Heart Failure registry linked with Medicare data, overlap propensity weighted Cox proportional hazard models were used to examine the association between BB and RASi use at hospital discharge and 30-day and 1-year outcomes among patients with HFrEF. Among the 48,711 patients (aged ≥65 years) hospitalized with HFrEF, there were significant associations between BB and/or RASi use at discharge and lower rates of 30-day and 1-year mortality, including those over age 85 (30-day hazard ratio 0.56, 95% confidence interval 0.45-0.70; 1-year hazard ratio 0.69, 95% confidence interval 0.61-0.78). In addition, the magnitude of benefit associated with BB and/or RASi use after discharge did not decrease with advancing age. Even among the oldest patients, those over age 85, with hypotension, renal insufficiency or frailty, BB and/or RASi use at discharge was still associated with lower 1-year mortality or readmission. CONCLUSIONS: Among older patients hospitalized with HFrEF, BB and/or RASi use at discharge is associated with lower rates of 30-day and 1-year mortality across all age groups and the magnitude of this benefit does not seem to decrease with advancing age. These data suggest that, absent a clinical contraindication, BB and RASi should be considered in all patients hospitalized with HFrEF before or at hospital discharge, regardless of age.


Subject(s)
Heart Failure , Ventricular Dysfunction, Left , United States , Humans , Aged , Heart Failure/drug therapy , Heart Failure/epidemiology , Renin-Angiotensin System , Stroke Volume , Medicare , Hospitalization , Adrenergic beta-Antagonists/therapeutic use , Ventricular Dysfunction, Left/drug therapy , Angiotensin Receptor Antagonists/therapeutic use , Angiotensin Receptor Antagonists/pharmacology
2.
BMJ Open ; 7(6): e014239, 2017 06 23.
Article in English | MEDLINE | ID: mdl-28645954

ABSTRACT

OBJECTIVES: Psychological biases can distort treatment decision-making. The availability heuristic is one such bias, wherein events that are recent, vivid or easily imagined are readily 'available' to memory and are therefore judged more likely to occur than expected based on epidemiological data. We assessed if the occurrence of a serious colonoscopy complication for a primary care physician's patient influenced colonoscopy rates for the physician's other patients. DESIGN: Longitudinal study with time-varying exposure variables. SETTING/PARTICIPANTS: Individuals living in 51 hospital referral regions across the USA identified based on enrolment in fee-for-service Medicare during 2005-2010. We assigned patients to a primary care physician based on office visits during the prior 2 years. EXPOSURES: For each physician in each month, we calculated the proportion of patients assigned to them who had a colonoscopy. We identified two serious complications of which the primary care provider would very likely be aware: gastrointestinal bleed or perforation leading to hospitalisation or death within 14 days of colonoscopy. MAIN OUTCOME MEASURES: We employed Poisson regression models including physician fixed effects to assess the change in number of colonoscopies in the four quarters following an adverse colonoscopy event. RESULTS: We identified 5 360 191 patients assigned to 30 704 physicians. 4864 physicians (16%) had at least one patient with an adverse event. The estimated change in the quarterly number of colonoscopies among physicians' patients was significantly lower in quarter 2 following an adverse colonoscopy event (change=-2.1% (95% CI -3.4 to -0.8%)), before returning to the rate expected in the absence of an adverse event. CONCLUSIONS: Having a patient experience a serious adverse colonoscopy event was associated with a small and temporary decline in colonoscopy rates among a physician's other patients. This finding provides empirical evidence for the influence of notable adverse events on care, possibly due to the availability heuristic.


Subject(s)
Colonoscopy/adverse effects , Physicians, Primary Care , Practice Patterns, Physicians' , Aged , Aged, 80 and over , Colonoscopy/mortality , Decision Making , Female , Gastrointestinal Hemorrhage/etiology , Humans , Intestinal Perforation/etiology , Longitudinal Studies , Male , Medicare , Regression Analysis , United States
3.
BMJ Open ; 7(6): e015945, 2017 06 23.
Article in English | MEDLINE | ID: mdl-28645974

ABSTRACT

INTRODUCTION: Shared decision making (SDM) is a goal of modern medicine; however, it is not currently embedded in routine care. Barriers include clinicians’ attitudes, lack of knowledge and training and time constraints. Our goal is to support the development and delivery of a robust SDM curriculum in medical education. Our objective is to assess undergraduate medical students’ knowledge of and attitudes towards SDM in four countries. METHODS AND ANALYSIS: The first phase of the study involves a web-based cross-sectional survey of undergraduate medical students from all years in selected schools across the United States (US), Canada and undergraduate and graduate students in the Netherlands. In the United Kingdom (UK), the survey will be circulated to all medical schools through the UK Medical School Council. We will sample students equally in all years of training and assess attitudes towards SDM, knowledge of SDM and participation in related training. Medical students of ages 18 years and older in the four countries will be eligible. The second phase of the study will involve semistructured interviews with a subset of students from phase 1 and a convenience sample of medical school curriculum experts or stakeholders. Data will be analysed using multivariable analysis in phase 1 and thematic content analysis in phase 2. Method, data source and investigator triangulation will be performed. Online survey data will be reported according to the Checklist for Reporting the Results of Internet E-Surveys. We will use the COnsolidated criteria for REporting Qualitative research for all qualitative data. ETHICS AND DISSEMINATION: The study has been approved for dissemination in the US, the Netherlands, Canada and the UK. The study is voluntary with an informed consent process. The results will be published in a peer-reviewed journal and will help inform the inclusion of SDM-specific curriculum in medical education worldwide.


Subject(s)
Curriculum , Decision Making , Health Knowledge, Attitudes, Practice , Students, Medical/psychology , Canada , Cross-Sectional Studies , Education, Medical, Undergraduate , Humans , Internet , Multivariate Analysis , Netherlands , Qualitative Research , Surveys and Questionnaires , United Kingdom , United States
4.
Int J Behav Nutr Phys Act ; 14(1): 84, 2017 06 24.
Article in English | MEDLINE | ID: mdl-28646894

ABSTRACT

BACKGROUND: Research has explored associations between diet, body weight, and the food environment; however, few studies have examined historical trends in food environments. METHODS: In the Framingham Heart Study Offspring (N = 3321) and Omni (N = 447) cohorts, we created food environment metrics in four Massachusetts towns utilizing geocoded residential, workplace, and food establishment addresses from 1971 to 2008. We created multilevel models adjusted for age, sex, education, and census tract poverty to examine trends in home, workplace, and commuting food environments. RESULTS: Proximity to and density of supermarkets, fast-food, full service restaurants, convenience stores, and bakeries increased over time for residential, workplace, and commuting environments; exposure to grocery stores decreased. The greatest increase in access was for supermarkets, with residential distance to the closest supermarket 1406 m closer (95% CI 1303 m, 1508 m) by 2005-2008 than in 1971-1975. Although poorer census tracts had higher access to fast-food restaurants consistently across follow-up, this disparity dissipated over time, due to larger increases in proximity to fast-food in wealthier neighborhoods. CONCLUSIONS: Access to most food establishment types increased over time, with similar trends across home, workplace, and commuter environments.


Subject(s)
Commerce , Diet , Environment , Feeding Behavior , Food Supply , Residence Characteristics , Restaurants , Adult , Diet/trends , Fast Foods , Female , Humans , Male , Massachusetts , Middle Aged , Social Environment , Transportation , Workplace
5.
Breast Cancer Res Treat ; 131(2): 589-97, 2012 Jan.
Article in English | MEDLINE | ID: mdl-21881937

ABSTRACT

Clinical trials suggest that increased risk of osteoporosis and fracture are the only serious side effects of adjuvant aromatase inhibitors (AIs), but little is known regarding toxicities of AIs in non-trial populations. We evaluated whether use of AIs was associated with myocardial infarction, stroke, and fracture in a community-based population. Using data from the HealthCore Integrated Research Database, 44,463 women aged ≥ 50 years with ≥ 2 breast cancer diagnosis codes between 2001 and 2007 were followed through 2008. Of these, 44,026 were matched using propensity score methods to women aged ≥ 50 years with no breast cancer codes. We assessed whether treatment with AIs was associated with myocardial infarction, stroke, and fracture using Cox proportional hazards models with time-varying treatment variables. Among breast cancer patients, 68.7% received no hormonal therapy, 20.6% received AIs (15.8% received only AIs, 4.8% were also treated with tamoxifen), and 10.7% received tamoxifen only. Breast cancer patients on AIs had a higher risk of any fracture (AHR = 1.13, 95% CI = 1.02-1.25) than breast cancer patients not receiving hormonal therapy. Patients on tamoxifen had a lower risk of hip fracture (AHR = 0.51, 95% CI = 0.32-0.81) than breast cancer patients not receiving hormonal therapy. Rates of myocardial infarction and stroke for patients on AIs or tamoxifen did not differ significantly from breast cancer patients not on therapy. The side effect profile of AIs in this community-based population was similar to that seen in clinical trials. These findings provide reassurance that AIs appear to be associated with few serious side effects.


Subject(s)
Breast Neoplasms/complications , Fractures, Bone/epidemiology , Myocardial Infarction/epidemiology , Stroke/epidemiology , Aged , Aged, 80 and over , Antineoplastic Agents, Hormonal/adverse effects , Antineoplastic Agents, Hormonal/therapeutic use , Aromatase Inhibitors/adverse effects , Aromatase Inhibitors/therapeutic use , Breast Neoplasms/drug therapy , Cohort Studies , Female , Fractures, Bone/chemically induced , Humans , Incidence , Middle Aged , Myocardial Infarction/chemically induced , Risk , Stroke/chemically induced , Tamoxifen/adverse effects , Tamoxifen/therapeutic use
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