Management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: physician practices in the community hospital setting.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and sixth most common reason that Medicare patients are hospitalized. We performed retrospective chart review on a statewide random sample of 409 Medicare patients discharged from October 1, 2000, through January 31, 2001, with a diagnosis of COPD. The most commonly performed diagnostic tests were chest radiography (96.8%) and oxygenation assessment (94.9%). The most common treatments provided were inhaled short-acting beta-agonist bronchodilators (98.5%) and oxygen (94.4%). Antibiotics (89.0%) and systemic corticosteroids (85.1%) were prescribed less frequently. The median length of stay was 5 days. The readmission rate was 27.4% (CI, 23.1-32.0) at 30 days and 43.0% (CI, 38.2-47.9) at 180 days. The in-hospital mortality rate was 1.7% (CI, 0.7-3.5) and the 180-day mortality rate was 23.7% (CI, 19.7-28.1). The morbidity and mortality associated with acute exacerbations of COPD remain high. There are opportunities to improve quality of care for this condition.

Screening mammography for Oklahoma Medicare beneficiaries: a national priority for quality improvement.

Breast cancer is one of the most common malignancies diagnosed in women in the United States. It is estimated that more than 2,700 new cases of female breast cancer will be diagnosed in Oklahoma this year. Using the Medicare mammography denominator file and Medicare claims data (October 1999 through September 2001), we assessed the utilization of mammography for this population. The overall biennial mammography rate for Oklahoma Medicare patients was 46.9% (95% CI 46.7-47.1) and was 54.7% (95% CI 54.3-55.2) for Medicare patients aged 50-67 years. There were significant racial disparities in utilization of mammography. In addition, there was substantial county-to-county variation in the utilization of mammography in Oklahoma. When compared to other states and territories, Oklahoma mammography rates for this population were in the lowest quartile nationally, ranking 47th in the nation. Increasing the use of mammography services for Medicare patients is a national priority for healthcare quality improvement.

Smoking in the elderly--it's never too late to quit.

Approximately 3.5 million persons aged 65 years and older smoke cigarettes in the United States--10.9% of this age group in Oklahoma smokes. Up to half of all smokers will experience death or disability related to smoking. Cigarette smoking has been clearly linked to the most common causes of death in the elderly and contributes to the morbidity and disability associated with many chronic illnesses that are common in this age group. The health benefits of smoking cessation in the elderly have been clearly demonstrated. Although there are barriers to smoking cessation that are specific to the older age group, interventions to promote quitting that are successful in younger smokers have been found to be effective in elderly smokers. The extended longevity and quality of life in this country for persons who achieve old age highlights the need for aggressive practices related to smoking cessation in the elderly.

Care of acute myocardial infarction in Oklahoma: an update from the Cooperative Cardiovascular Project.

Acute myocardial infarction remains a common cause of morbidity and mortality in Oklahoma. Nearly 6,000 Oklahoma Medicare beneficiaries are admitted to the hospital with an acute myocardial infarction each year. The death rate from coronary heart disease in Oklahoma is one of the highest in the nation. Utilizing structured medical record review, we have evaluated care given to 6,104 Medicare beneficiaries with acute myocardial infarction in 1994, 1996, and 1998. Since 1994, there have been significant improvements in the use of aspirin and beta-blockers at discharge, and avoidance of calcium channel blockers in those patients with poor left ventricular function. Documentation of smoking cessation counseling decreased significantly from 1994 to 1998. Other measures of quality of care did not change significantly. Despite better performance on many of the measures of quality, we should not be too complacent about the results, as there continues to be considerable room for improvement in care.

The Cooperative Cardiovascular Project in Oklahoma.

BACKGROUND AND OBJECTIVES: Acute myocardial infarction is the leading cause of death in the United States and a common cause for admission of Oklahoma Medicare beneficiaries. Based on guidelines for the management of acute myocardial infarction published by a joint committee of the American College of Cardiology and the American Heart Association, the Cooperative Cardiovascular Project was developed by the Health Care Financing Administration to measure performance on quality indicators that describe care provided to Medicare beneficiaries. The objective of the project is to use those performance measures to assist hospitals in the development of quality improvement efforts for acute myocardial infarction care. METHODS: Retrospective review was performed on the inpatient medical records of 3,436 patients from 102 hospitals in Oklahoma and a random national sample of 2,441 patients discharged with a principal diagnosis of acute myocardial infarction. RESULTS: The diagnosis of acute myocardial infarction was confirmed in 3,055 (89%) of the cases reviewed. For patients considered to be ideal candidates for an intervention, 62% received reperfusion therapy (thrombolytic or PTCA), 84% received aspirin during the hospitalization, 76% received aspirin at discharge, and 40% received beta-blockers at discharge. There were significant variations in performance between hospital peer groups in the use of reperfusion therapy, aspirin, beta-blockers, and smoking cessation counseling. CONCLUSIONS: Potentially life-saving treatments for Medicare patients hospitalized with an acute myocardial infarction are often underutilized. Improving quality of care for Medicare beneficiaries with acute myocardial infarction has been identified as a national priority.

Accreditation: who's counting?

Active physician involvement and leadership in their accreditation process can produce a cubic win for patients, payors, and providers. For health care quality to improve and everyone win, physicians need to understand the accountability system, the what and why of data collection, and be involved in short- and long-term performance assessments.

Carotid endarterectomy in Oklahoma Medicare beneficiaries: patient characteristics and outcomes.

BACKGROUND AND OBJECTIVES: Ischemic stroke represents the third leading cause of death and the most common cause of permanent disability in the United States. Carotid endarterectomy has been widely utilized as a procedure to reduce the risk of stroke and represents the most commonly performed peripheral arterial surgery. This cooperative project was initiated to assess the appropriateness of carotid endarterectomies performed on Medicare beneficiaries and the postoperative outcomes (mortality and stroke) in these patients. METHODS: Retrospective review was performed on the inpatient medical records of 774 patients who underwent 813 carotid endarterectomy procedures in eight hospitals during calendar years 1993 and 1994. Medicare claims data were also analyzed for all carotid endarterectomies performed in Oklahoma during calendar years 1992 through 1995. RESULTS: A history of transient ischemic attack or stroke in the distribution of the operated carotid artery was documented in 57% of the cases. The majority of patients had preoperative ultrasound imaging of the carotid arteries and a preoperative angiogram was performed before 96% of the procedures. Accepted indications for the surgery were documented for 98% of the procedures. Stroke or death within 30 days of the date of the carotid endarterectomy occurred after 4.9% (0-8.8% by hospital) of the procedures. CONCLUSIONS: This project demonstrated considerable variation between hospitals in the outcomes of patients undergoing carotid endarterectomy and the potential for improved care of patients with regard to discharge planning, education, and use of anticoagulant or antiplatelet medications postoperatively.

Standard clinical protocols are important to your survival.

Standard clinical protocols will allow busy physicians to meet the increasing demands made on them to evaluate and perform, if appropriate, in a given manner for a particular problem. When tracked, standard clinical protocols allow the demonstration that the right thing was done every time at the right time and place.

The effect of endotoxin on preirradiated mice.

Adult male mice were given a whole body irradiation with non-lethal doses of 2.5 or 5 Gy. Unirradiated animals served as controls. The animals (including controls) received a single injection of endotoxin (LPS from Salmonella abortus equi) with doses of 100, 200 or 400 micrograms one day up to one year after irradiation. Twelve, 24 or 48 hours after lipopolysaccharide (LPS) application the animals were killed and dissected. Animals which died spontaneously were also examined. Liver, lung, kidney, small intestine, and stomach were histologically investigated. The histological findings showed, that differences exist between irradiated and unirradiated mice and that the cause of death is also different for animals dying spontaneously. The investigations have shown that after irradiation phases of different degrees of sensitivity with regard to the endotoxin response exist. This behaviour can be observed by different lethality rates or in the light of the histological results. Moreover, the histological findings have shown, that distinct regenerative changes occur first of all in the liver, in the mucosa of small intestine, and the gastric mucosa, in which the number of differentiated cells compared with the mitotic active cells is reduced. It can be ascertained, that a whole body irradiation with 2.5 to 5 Gy enhances an additional injury by endotoxin weeks to months later. Contrary to this a preirradiation a few days before endotoxin application leads to a "protection" against the efficacy of endotoxin. These findings can be explained by modes of action described in literature, according to which endotoxins induce the formation of highly active mediators especially the tumor necrosis factor.

A simple and rapid method for the detection of RNA in formalin-fixed, paraffin-embedded tissues by PCR amplification.

A simple and rapid method for the extraction, reverse transcription and PCR amplification of RNA from formalin-fixed, paraffin-embedded tissue is described. The procedure can be completed within 24 hours. In a first application of this method we detect human albumin mRNA in liver tissue, demonstrating the feasibility to retrospectively analyze gene expression and RNA viruses in fixed tissue.

Prolonged radioprotective activity of WR-2721 linked to dextran.

The radioprotective agent WR-2721 was linked to dextran and poly(glutamic acid) respectively, to obtain a prolonged radioprotective ability. Male mice were administered these water soluble polymer conjugates one to 72 hours prior to a whole body irradiation with X-rays. A prolongation of radioprotective efficiency was achieved with two dextran-(WR-2721)-conjugates. For a period of 24 hours between administration, and irradiation dose reduction factors of 1.14 +/- 0.04 and 1.10 +/- 0.03 respectively were found. After 72 hours, no protective effect was observed. Histopathological investigations of the liver for formation of tumors 200 to 600 days after irradiation seems to indicate that a protective effect is not produced by the dextran-(WR-2721)-conjugates.