A framework for physician assistant intervention for overweight and obesity.

Overweight and obesity compose a chronic disease process of epidemic proportions that presents on a continuum, likely affecting nearly two out of every three patients treated by physician assistants (PAs). However, meaningful and actionable definitions, including but not limited to anthropometric and clinical descriptors, are needed. The effective treatment of overweight and obesity requires an efficient and timely process of screening, diagnosis, evaluation of complications, staging, and clear algorithmic management. PAs are trained as primary care providers and can diagnose and treat overweight and obese patients regardless of practice setting and across the spectrum of the disease and patient's age.

How likely are PA students to use nonsanctioned material for examinations?

The public perceives nurses, pharmacists, and physicians as some of the most ethical professions, according to Gallup polling data. Physician assistants (PAs) have not been studied. This article describes a nationwide survey of PA students and evaluates the materials allowed for study purposes. The goal was to understand what factors influence a PA student's decision to use nonsanctioned materials during their training.

Establishing sound goals for hypertension management.

There is a clear need to reduce the prevalence of hypertension and, therefore, cardiovascular risk, among Americans. Many are unaware they have elevated BP, less than half who have been diagnosed with hypertension are treated, and only a third of those treated reach recommended goals. While hypertension affects American men and women of many ethnicities, prevalences are notably increased among blacks and Hispanics. Merely adopting positive lifestyle changes that include more exercise, a healthy, low-sodium diet for weight reduction, and smoking cessation can significantly improve both systolic and diastolic BP When pharmacologic treatment is needed, several classes ofantihypertensive agents with differing mechanisms of action are available for use as monotherapy or in various combinations to help patients reach their BP goals. Often three or more antihypertensive drugs are necessary for adequate BP control; however, the antihypertensive regimen must be tailored to the individual patient. It is more meaningful to assess and understand the individual patient with hypertension in order to set realistic BP goals than to expect all patients to reach the same goal with a uniform therapeutic plan.

Association of a continuous quality improvement initiative with practice and outcome variations of contemporary percutaneous coronary interventions.

BACKGROUND: The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention (PCI). METHODS AND RESULTS: Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline (January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention (January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10,287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case (P<0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points (all P<0.05). CONCLUSIONS: Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a "causal" or a "casual" relationship.

Prognostic implication of anemia on in-hospital outcomes after percutaneous coronary intervention.

BACKGROUND: Although prior studies have shown a relationship between anemia and in-hospital mortality after coronary artery bypass grafting and acute myocardial infarction (MI), the prognostic implication of anemia in patients undergoing percutaneous coronary intervention (PCI) is unknown. Therefore, we evaluated the relationship between anemia and outcomes of PCI. METHODS AND RESULTS: Clinical and outcome data on 48,851 consecutive PCIs were prospectively collected. Patients were classified as anemic using the World Health Organization definition (<12.0 g/dL in women and <13.0 g/dL in men). A total of 6471 men (21.7%) and 4659 women (30.4%) were anemic. Anemic men and women were older and had a higher percentage of comorbidities compared with their nonanemic cohorts (P<0.0001 for all comparisons). When compared with nonanemic patients, anemic patients had higher in-hospital mortality (3.0% versus 0.8% in men; 2.4% versus 1.5% in women; P< or =0.0001) and postprocedural MI (2.0% versus 1.6% in men; 2.4% versus 1.6% in women; P< or =0.02) and a higher combined major cardiovascular events end point, including death, MI, and cerebrovascular event (5.0% versus 2.6% in men; 5.1% versus 3.5% in women; P<0.0001). After adjustment for comorbidities, anemia was associated with a higher risk of in-hospital mortality (odds ratio [OR], 2.29; 95% CI, 1.79 to 2.92; P<0.0001) and MI (OR, 1.34; 95% CI, 1.05 to 1.72; P=0.02) and major cardiovascular events (OR, 1.2; 95% CI, 1.05 to 1.34). Significant gender interactions were observed for death in men and for MI in women. CONCLUSIONS: Preprocedural anemia is associated with increased adverse in-hospital outcomes after PCI. Whether optimization of hemoglobin before PCI is of clinical benefit will need to be determined in a randomized clinical trial.

Frequency and prognosis of emergency coronary artery bypass grafting after percutaneous coronary intervention for acute myocardial infarction.

We evaluated the frequency and prognosis of emergency coronary artery bypass grafting (CABG) after percutaneous coronary intervention (PCI) for acute myocardial infarction in a large, multicenter registry of contemporary PCI. In this study, emergency CABG occurred in 2% of cases, and was associated with high in-hospital mortality (20%) and with a high incidence of stroke (8%), renal failure requiring dialysis (8.3%), and bleeding (63.3%).

Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose.

This study was undertaken to determine the incidence, risk factors, and in-hospital outcome of nephropathy requiring dialysis (NRD) after percutaneous coronary intervention (PCI), and to evaluate the role of a weight- and creatinine-adjusted maximum radiographic contrast dose (MRCD) on NRD. Data were obtained from a registry of 16,592 PCIs. The data were divided into development and test sets. Univariate predictors were identified and a multivariate logistic regression model was developed. The MRCD was calculated for each patient as: MRCD = 5 ml x body weight (kilograms)/serum creatinine (milligrams per deciliter). Predictive accuracy was assessed by receiver-operating characteristic curve analysis. In the development set, 41 patients (0.44%) developed NRD with a subsequent in-hospital mortality rate of 39.0%. NRD increased with worsening baseline renal dysfunction. Other risk factors included peripheral vascular disease, diabetes mellitus, congestive heart failure, and cardiogenic shock. There was a direct relation between the number of risk factors and NRD. After adjustment for baseline risk factors, MRCD was the strongest independent predictor of NRD (adjusted odds ratio 6.2, 95% confidence interval 3.0 to 12.8). NRD and in-hospital mortality were both significantly higher in patients who exceeded the MRCD compared with patients who did not (p <0.001). In conclusion, NRD following PCI is a rare complication with a poor prognosis. Baseline clinical characteristics identify patients at greatest risk for NRD. Optimization of procedural variables such as timing of the intervention relative to the diagnostic catheterization, staging coronary procedures, or dosing within the MRCD may help reduce the risk of this complication in high-risk patients. A risk prediction tool for NRD with guidelines for prevention is presented.

The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions.

The past decade has been characterized by increased scrutiny of outcomes of surgical and percutaneous coronary interventions (PCIs). This increased scrutiny has led to the development of regional, state, and national databases for outcome assessment and for public reporting. This report describes the initial development of a regional, collaborative, cardiovascular consortium and the progress made so far by this collaborative group. In 1997, a group of hospitals in the state Michigan agreed to create a regional collaborative consortium for the development of a quality improvement program in interventional cardiology. The project included the creation of a comprehensive database of PCIs to be used for risk assessment, feedback on absolute and risk-adjusted outcomes, and sharing of information. To date, information from nearly 20,000 PCIs have been collected. A risk prediction tool for death in the hospital and additional risk prediction tools for other outcomes have been developed from the data collected, and are currently used by the participating centers for risk assessment and for quality improvement. As the project enters into year 5, the participating centers are deeply engaged in the quality improvement phase, and expansion to a total of 17 hospitals with active PCI programs is in process. In conclusion, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium is an example of a regional collaborative effort to assess and improve quality of care and outcomes that overcome the barriers of traditional market and academic competition.