Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project.

CONTEXT: Quality indicators for the treatment of acute myocardial infarction include pharmacologic therapy, reperfusion, and smoking cessation advice, but these therapies may not be administered to all patients who could benefit from them. OBJECTIVE: To assess geographic variation in adherence to quality indicators for treatment of acute myocardial infarction. DESIGN: Inception cohort using data from the Health Care Financing Administration Cooperative Cardiovascular Project. SETTING: Acute care hospitals in the United States. PATIENTS: A total of 186800 Medicare beneficiaries hospitalized for treatment of confirmed acute myocardial infarction from February 1994 through July 1995. MAIN OUTCOME MEASURES: Adherence to quality indicators for pharmacologic therapy, reperfusion, and smoking cessation advice for patients judged to be ideal candidates for these therapies. The mean rates of adherence to these quality indicators for the entire United States were determined, and the 20th and 80th percentiles of the age- and sex-adjusted rates for each of 306 hospital referral regions were contrasted (mean rate [20th-80th percentiles]). RESULTS: Aspirin was used frequently both during hospitalization (86.2% [82.6%-90.1%]) and at discharge (77.8% [72.5% -83.9%]). Calcium channel blockers were withheld from most patients with impaired left ventricular function (81.9% [73.6%-90.8%]). Lower rates were seen in the use of angiotensin-converting enzyme inhibitors at discharge (59.3% [49.2%-69.2%]); reperfusion, using thrombolytic therapy or coronary angioplasty (67.2% [59.8%-75.1%]); prescription of beta-blockers at discharge (49.5% [35.8%-61.5%]); and for smoking cessation advice (41.9% [32.8%-51.3%]). CONCLUSIONS: Substantial geographic variation exists in the treatment of patients with acute myocardial infarction, and these gaps between knowledge and practice have important consequences. Therapies with proven benefit for AMI are underused despite strong evidence that their use will result in better patient outcomes.

Cooperative Cardiovascular Project (CCP) quality improvement in Maine, New Hampshire, and Vermont.

The Cooperative Cardiovascular Project (CCP) is a nationwide quality improvement project (quality indicator measurement, feedback, remeasurement) in Medicare acute myocardial infarction (AMI) patients sponsored by the Health Care Financing Administration (HCFA). In Maine, New Hampshire, and Vermont, 3,472 baseline records were abstracted from 76 hospitals from January 1994 to February 1995. After feedback, 2,270 remeasurements were collected from October 1996 to May 1997. At remeasurement, performance improved significantly for "ideal" candidates (defined by the CCP) on five quality indicators--aspirin during hospitalization 88% to 93% (p < .001), thrombolytic timing 60% to 69% (p < .01), discharge aspirin 83% to 90% (p < .001), discharge beta-blockers 69% to 82% (p < .01), and calcium channel blocker avoidance 83% to 93% (p < .05). Reperfusion, angiotensin converting enzyme inhibitors, and smoking cessation advice did not improve significantly. This study demonstrates that evidence-based indicators, nationally designed data collection, and locally based interventions can significantly improve AMI care.

Evaluation of a health promotion demonstration program for the rural elderly.

OBJECTIVE: This article evaluates a demonstration program that extended coverage for disease prevention/health promotion services to Medicare beneficiaries. STUDY SETTING/DATA SOURCES: Community-dwelling Medicare beneficiaries who lived in five rural counties in northwest Pennsylvania were recruited between May and December 1989. The demonstration lasted 18 months and beneficiaries were followed for an additional 18 months. Data for the evaluation came from an initial health risk assessment, Medicare administrative records, follow-up surveys, and redeemed vouchers for the waivered services. The waivered services included health screenings, influenza immunization, nutritional counseling, smoking and alcohol cessation, and depression/dementia evaluations. STUDY DESIGN: Medicare beneficiaries were randomized to one of two experimental groups and a control group. One experimental group received the newly waived services from hospitals that received a capitated fee; the other received services from providers who were paid fee-for-service. Eligibility for most waivered services was based on risk. Chi-square tests of association were used to determine if use of health promotion services and use of medical care services varied across groups. Logistic regressions were used to assess the factors associated with participation. Product-limit survival analysis was used to assess whether mortality rates varied across groups. PRINCIPAL FINDINGS: Participation rates in the new programs varied by program and by experimental group, and ranged from 16.8 percent for smoking cessation programs to 58 percent for influenza immunization. The demonstration led to an increase in influenza immunization rates relative to the control group. There were no differences in the use of medical care services or health outcomes between the experimental and control groups. CONCLUSIONS: Older rural Americans will modestly increase their use of disease prevention/ health promotion services if they are covered by Medicare. Use will be higher among those with more education. Further research is needed to assess long-term benefits of such programs.

Mammography and pap smear use by older rural women.

OBJECTIVE: To compare the characteristics of older women who did and did not have screening mammograms and Pap smears during the first two years both services were a Medicare Part B benefit. METHODS: A prospective study was conducted in five rural Pennsylvania counties of 2205 female community-dwelling Medicare Part B beneficiaries who volunteered to participate in a Medicare prevention demonstration project. The baseline health risk appraisal included information on demographics, insurance status, disease history, symptomatology, and functional and cognitive status. These variables were tested for their association with the use of mammography and Pap smear using Medicare utilization claims data from 1991 to 1992. RESULTS: Of 2175 women still alive after three years, 44.6% had had a mammogram and 14.6% had had a Pap smear in either 1991 or 1992. Multivariate logistic regression revealed that women were more likely to have a mammogram if they were younger, were more educated, had supplemental insurance, did not need assistance with activities of daily living, and did not have diabetes or arthritis. Younger, college educated, and non-widowed women were more likely to have Pap smears than women in other categories. CONCLUSIONS: With cost less of a barrier, more aggressive efforts to persuade older women to have mammograms and Pap smears must be developed.

Coronary heart disease mortality and sudden death among the 35-44-year age group in Allegheny County, Pennsylvania.

Deaths among 35- to 44-year-old black and white men and women residing in Allegheny County, Pennsylvania, were investigated. All coroner-certified nontraumatic deaths and practitioner-certified deaths coded as heart, cerbrovascular, or arterial disease, diabetes mellitus, and sudden or ill-defined causes were studied. Using autopsy, coroner, hospital, physician, and/or informant information about medical history, characteristics, and circumstances of death, physicians validated the deaths as due to coronary heart disease (CHD) or another cause. In 1984 to 1989, 616 deaths were investigated, 384 of which were sudden (within 24 hours of onset). Overall CHD mortality was 35.4/100,000/y for white males, 8.4/100,000/y for white females, 61.3/100,000/y for black males, and 19.5/100,000/y for black females. Although rates varied widely, characteristics, circumstances, and disease history were similar across race-sex groups. CHD mortality was 73% higher in black than white males. Approximately 80% of CHD deaths were sudden.

Coronary heart disease mortality and sudden death: trends and patterns in 35- to 44-year-old white males, 1970-1990.

Trends in coronary heart disease mortality and sudden death were studied in 35- to 44-year-old white male residents of Allegheny County, Pennsylvania. Deaths coded as any cardiac or vascular disease, diabetes, unexplained sudden death, and other rubrics were eligible for investigation, and the cause of death was validated by physicians examining multiple data sources about the deaths. During 1970-1990, 1,424 white male deaths were investigated, with 903 validated as coronary heart disease. In that time span, white male coronary heart disease mortality fell from 93.4 to 36.7 per 100,000 population per year, a 60% decline. Little proportionate change was seen in characteristics of the deaths, which were predominantly sudden and out-of-hospital. Diabetes mellitus history increased proportionately over time, largely because diabetics' mortality rates, unlike those of all other subgroups, did not fall. These observations support the contention that the decline in coronary heart disease mortality relates to risk factor modification more than to improvements in the treatment of coronary heart disease. Differences in death certification practices must be considered when interpreting and comparing vital statistics data.

Participation in health promotion programs by the rural elderly.

The Health Care Financing Administration (HCFA) funded a series of demonstration programs to learn about the implications of extending coverage for disease prevention/health promotion services to Medicare beneficiaries. This article examines the use of such services by a rural population under this demonstration program. Individuals enrolled in the demonstration were eligible for specific risk reduction interventions. They were enrolled in one of two groups: (1) a hospital-based group in which hospitals were paid a capitated fee for providing all services and (2) a physician-based group in which physicians were paid fee-for-service for providing each service. Chi-square tests of association as well as logistic regression models were used to assess whether eligibility for services, and use of services by those eligible, varied by group and by sociodemographic characteristics. Forty-one percent were eligible for a nutrition program, 11% for smoking cessation, 2% for alcohol counseling, and 7% for dementia/depression evaluations. Participation in the programs varied across the programs and within programs by gender, education, and group assignment. Older rural Americans will use some disease prevention/health promotion services if they are covered by Medicare. Use will be higher among those with more education. Rural beneficiaries are more likely to use preventive services if encouraged to do so by their doctors rather than by hospital-based programs.

Selection bias and nonresponse to health promotion in older adults.

Some epidemiologic studies have compared the characteristics of individuals who participate, refuse, and are unreachable in population studies, but results have been inconsistent. The Rural Health Promotion Project attempted to recruit all Medicare Part B noninstitutionalized individuals age 65-79 years in a rural community for a trial of preventive health services. Of 962 potential subjects, 360 (37.4%) participated, 253 (26.3%) refused, 176 (18.3%) were ineligible, and 152 (15.8%) were never reached by phone or mail. Approximately 3 years later, we reinterviewed the participants, refusals, and as many of the unreachables as possible. The 3-year mortality was similar for both refusals and participants (approximately 9%) but was much higher for ineligibles (29.0%) and unreachables (23.7%). Participants were more likely to have disease history, to have behavioral risk factors for disease, and to use health screening services. Refusals were the healthiest and possibly chose not to participate because they did not have risk factors targeted by the program. The unreachables had the highest prevalence of disability and health care inpatient reimbursement and may have been ineligible for the demonstration had they volunteered. We conclude that failure to reach potential participants for health promotion services may be a warning of "high risk."

Impact of Medicare reimbursement on influenza vaccination rates in the elderly.

BACKGROUND: Influenza is responsible for significant morbidity, mortality, and medical costs, but immunization rates in the elderly remain low. METHODS: As part of a demonstration project in rural Pennsylvania, 1,989 community-dwelling Medicare beneficiaries, 65-79 years old, completed a health risk appraisal including questions about flu shots. Participants were randomized to two experimental (hospital or physician) or control groups. Experimental groups were offered free flu shots for the 1990-91 flu season. Follow-up interviews to determine vaccination rates were completed about 1 year later. RESULTS: Baseline immunization rates were almost identical for the hospital-based (41.2%), physician-based (41.3%), and control group not offered free immunizations (40.6%). Follow-up rates for the groups offered immunizations rose significantly to 63.6 and 69.1% for hospital and physician groups, respectively, while the control group also increased significantly to 54.1%. Individuals who were more educated, were older, and had greater chronic diseases history (myocardial infarction, hypertension, and pulmonary disease) were more likely to be immunized. Male and married elderly were more likely to be immunized as a result of the demonstration. CONCLUSIONS: Increasing community education and providing immunizations free through Medicare will increase immunization rates among elderly. The elderly are more likely to receive flu shots provided through physicians' offices than through hospital-based clinics.

Use and outcomes of a cholesterol-lowering intervention for rural elderly subjects.

Few studies have evaluated the efficacy of cholesterol-lowering interventions in a community setting and have included a control or comparison group. As part of a preventive health demonstration project in rural Pennsylvania, Medicare beneficiaries underwent cholesterol screening to identify high-risk individuals with serum cholesterol levels > or = 240 mg/dL. These high-risk individuals were randomized to a cholesterol-lowering intervention through either local hospitals or physicians' offices or to a control group. Baseline and follow-up serum cholesterol levels collected two to three years later were compared according to service location (hospital versus physician's office), intervention attendance, degree of participation, baseline heart disease history, and cholesterol-lowering medication use at follow-up. Serum cholesterol levels decreased between 5.7% and 6.6% in the hospital-based and physician-based groups, as well as in a control group not offered the intervention. Participation rates did not differ between treatment groups, nor did participation affect serum cholesterol levels. Attendance level and heart disease history were not associated with a greater decrease in serum cholesterol levels. Individuals reporting cholesterol-lowering drug use at follow-up had significantly higher baseline serum cholesterol levels and a significantly greater decrease in total serum cholesterol (P < .0001) than those not on medication. Both nonpharmacological (diet) and pharmacological (drug) interventions will reduce serum cholesterol levels and heart attack risk. The study results suggest that, at least for older individuals, the impact of nonpharmacological interventions on the community is minimal. We conclude that only very aggressive treatment will significantly loser serum cholesterol levels in older individuals at risk for heart attack.

Morbidity and mortality in rural community-dwelling elderly with low total serum cholesterol.

BACKGROUND: Low serum cholesterol has been associated with morbidity and mortality in the elderly. This study compared the health, functional status, and two-year mortality rates of community-dwelling rural elderly with serum cholesterol < 150 mg/dl to age- and sex-matched controls with serum cholesterol 200-240 mg/dl. METHODS: Self-reported disease history, disability, health habits, and cognitive function data were collected at a health risk appraisal interview. A single blood sample was also collected and analyzed for total serum cholesterol at a central lab. RESULTS: Of the 3,874 participants, 109 (2.8%) had total cholesterol levels < 150 mg/dl. Seventy-five percent of the low cholesterol group were male compared to 44% in the main study population. The low cholesterol group had significantly greater smoking history, current cigarettes smoked, diabetes history, angina and COPD symptoms, and assistance needed for heavy and light work. Men in the low cholesterol group had significantly lower blood pressure. After two years, 14 (12.8%) of the low cholesterol group had died vs 16 (7.3%) in the control group. There was no relationship to specific causes of death and cholesterol level. CONCLUSION: A very low cholesterol level in older individuals should be evaluated carefully to determine whether it is due to genetic or life-style factors such as diet or, more likely, is a marker of disease.

Comparison of recruitment strategies and associated disease prevalence for health promotion in rural elderly.

BACKGROUND: Although interest in health promotion for the elderly is increasing, the issues of recruitment into such programs and self-selection have not been well explored. While clinical studies require high participation levels and expensive recruitment, community efforts are satisfied with recruiting small numbers of volunteers from poorly defined populations. These small samples may not be representative of the populations at risk. METHODS: As part of the Rural Health Promotion Project, a Medicare demonstration, community-based recruitment methods were evaluated and participant characteristics were compared. A total of 3,884 individuals ages 65-79 were recruited in northwestern Pennsylvania, using four sequential recruitment strategies, varying in aggressiveness. The methods were: (A) mail only, (B) mail with phone recruitment follow-up, (C) mail with phone recruitment and scheduling, and (D) mail with aggressive phone recruitment and scheduling. RESULTS: Recruitment yields were Method A, 13.5%; B, 21.1%; and C, 31.6%. The most aggressive Method (D) yielded 37.0% participation. More aggressive methods (C and D) recruited more educated individuals. No other demographic or health status differences were noted. CONCLUSION: These data show that large numbers of the elderly can be recruited into a health promotion program using aggressive methods and professional interviewers.

Symptoms and microenvironmental measures in nonproblem buildings.

Symptoms commonly defined as the sick building syndrome were studied in a cross-sectional investigation of 147 office workers in five building areas using a linear-analog self-assessment scale questionnaire to define symptoms at a specific point in time. At the same time, the environment in the breathing zone was characterized by measuring thermal parameters (dry-bulb temperature, relative humidity, air speed, and radiant temperature), volatile organic compounds, respirable suspended particulates, noise and light intensity, and carbon dioxide and carbon monoxide levels. Demographic characteristics of the occupants and building characteristics were recorded. Up to 25% of the variance in regression models could be explained for mucous membrane irritation and central nervous system symptoms. These two symptom groups were related to the concentrations of volatile organic compounds, to crowding, to layers of clothing, and to measured levels of lighting intensity. Chest tightness was also related to lighting intensity. Skin complaints were related only to gender. Gender, age, and education failed to demonstrate a consistent relationship with symptom categories. This study suggests that the sick building syndrome may have specific environmental causes, including lighting and volatile organic compounds.

Marked decline of coronary heart disease mortality in 35-44-year-old white men in Allegheny County, Pennsylvania.

Trends in coronary heart disease (CHD) mortality were examined among 35-44-year-old white men during 1970-1986. Death certificates were obtained for 1,216 cases. All were coroner-certified natural deaths and noncoroner-certified deaths due to vascular diseases and diabetes mellitus. Autopsy data, coroner's reports, hospital records, physician's reports, and informants were used to validate diagnoses. The reviewers rejected 73 of 805 CHD certifications, but they validated 54 cases not certified as CHD on the death certificate as CHD. The CHD mortality rate fell from 90.6/100,000/year in 1970-1972 to 40.3/100,000/year in 1985-1986. Approximately two thirds of the decline was related to a decline in sudden deaths including 41.6% due to incident sudden CHD death. The proportion of diabetics among validated CHD deaths rose dramatically from 6.5% in 1970-1972 to 23.0% in 1985-1986. The CHD mortality rate among diabetics apparently did not decline during the 17 years of the study. We conclude that primary prevention has contributed substantially to the CHD decline in the 35-44-year age group. Better diagnoses and treatment, especially of angina pectoris and of patients after a myocardial infarction, may also have been important. Control of CHD in diabetics must take high priority in further prevention strategies.

Acute stroke therapy trials: problems in patient accrual.

Temple University Hospital participated in a multicenter acute stroke trial but enrolled only one patient out of 192 screened over 2 years; other centers had similar difficulty in patient recruitment. We analyzed our screening data to determine which enrollment criteria created difficulties in recruitment and whether the problem was attributable to any single criterion or to combinations of criteria. Six individual criteria were frequent causes for exclusion; however, greater than 80% of the patients were excluded for multiple reasons. Consequently, modifying or eliminating any single criterion did not appreciably increase patient accrual. Only 17 of 210 possible pairs of criteria occurred with statistically significant frequency (p less than 0.05), and these were most likely random associations. Therefore, only by minimizing the number and stringency of enrollment criteria will patient accrual be at a level that allows the study to be completed in a timely manner with a fiscally reasonable number of centers.

Chronic low level physical activity as a determinant of high density lipoprotein cholesterol and subfractions.

Physical activity has been associated with reduced risk of coronary heart disease. A mechanism for the reduced risk may be through increased high density lipoprotein cholesterol (HDL-C) and subfractions, in particular HDL2-C. Research associated with increased physical activity investigating HLD-C have assessed the effects of intense aerobic activity. The current research evaluated the relationship between low intensity, long duration activity to HDL-C and subfractions in 35 active postal carriers. Measurements of physical activity via the Large Scale Integrated monitor and reported miles walked, and lipoproteins were assessed at 3-month intervals over a 1-year period. Reported miles walked/day (5.3) was significantly correlated with HLD2-C (r = 0.50, P = 0.003) and approached significance for HDL-C (r = 0.29, P = 0.06). The Large Scale Integrated measures were correlated with HDL-C (r = 0.44, P = 0.008) and HDL2-C (r = 0.44, P = 0.007). Controlling for either age, alcohol consumption, body mass index, or leisure time activity did not reduce the relationship between reported miles walked or Large Scale Integrated readings and HDL2-C, suggesting that the increased HDL-C was the result of long duration, low intensity physical activity.

Some epidemiologic aspects of psychosomatic medicine.

Both surveys of physicians' practices and community studies reveal that psychomatic disorders are very prevalent in our society. In a random sample of 1,645 adults, aged seventeen to ninety-two, we found that slightly more than 50% reported at least one psychosomatic symptom "regularly" during the preceding year; 17.3% reported two or more. A profile of the symptomatic shows that they tend to be widowed, separated, or divorced; many were unemployed, retired, or disabled. Examination of associations between certain sociocultural factors and the presence of psychosomatic symptomatology disclosed that, as a group, symptomatic respondents had been neither more nor less mobile than others. Most had relatives and friends nearby but few felt they could request help from either. Most attended church but few engaged in community activities. The symptomatic group appeared to lack meaningful social support systems. The discussion focuses on possible relationships between social change, support systems, and prevalence of psychosomatic symptomatology.