CHICAGO—Previously uninsured adults substantially increase their use of covered basic preventive health services after gaining Medicare coverage, according to the authors of a study in the August 13 issue of The Journal of the American Medical Association, and they suggest the same might be true if near-elderly uninsured adults could purchase Medicare coverage.

"Uninsured adults in the United States have worse access to needed health care services, receive less appropriate care, and have worse health outcomes than insured adults," the authors provide as background information in the article. "The risks of experiencing major health problems and incurring substantial medical expenses increase dramatically for adults aged 55 to 64 years, so the consequences of lacking insurance may be more severe." The authors write that the uninsured near-elderly may have difficulty purchasing health insurance because of high premiums, restrictions due pre-existing medical conditions, and high out-of-pocket expenses for prescription drugs. "These obstacles to coverage for uninsured near-elderly adults have motivated proposals to enable them to purchase Medicare coverage prior to age 65 years, with subsidies for those with low incomes."

J. Michael McWilliams, M.D., from Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues analyzed data collected from 2,203 adults who participated in the national Health and Retirement Study sponsored by the National Institute on Aging to determine differences in basic clinical services received by adults in 1994, 1996 and 2000, before and after becoming eligible for Medicare at age 65 years. The participants were classified as continuously uninsured (n = 167), intermittently uninsured (n = 216), or continuously insured (n = 1,820). The authors compared the use of basic clinical services including cholesterol testing, mammography, prostate examination, and treatment of arthritis and hypertension among adults who reported these conditions.

"The difference in cholesterol testing between continuously insured and continuously uninsured adults was significantly reduced after Medicare eligibility (35.4 percent vs. 17.7 percent), and the reduction was substantially greater among those with hypertension or diabetes than among other adults (29.2 percent vs. 7.7 percent)," the authors report. "Differences in use were similarly reduced after Medicare eligibility for mammography in women (30.3 percent vs. 15 percent) and prostate examination in men (45.2 percent vs. 20 percent)." The authors found that although the participants increased their use of Medicare covered health services, they did not increase their use of medications for arthritis or hypertension.

"This longitudinal study demonstrated that substantial differences in cholesterol testing, mammography, and prostate examination between continuously uninsured and insured near-elderly adults before age 65 years were reduced by half or more after these adults became eligible for Medicare coverage," the authors write.

CHICAGO—An herbal extract used for treating high cholesterol, guggulipid, did not improve cholesterol levels over the short term, and may in fact have raised levels of LDL, according to a study in the August 13 issue of The Journal of the American Medical Association (JAMA).

Guggul is an extract from the resin of the mukul myrrh tree, according to background information in the article. Herbal extracts from guggul have been widely used in Asia as cholesterol-lowering agents, and their popularity is increasing in the United States. Recently, guggulsterones, the purported bioactive compounds of guggul, have been shown to be potent antagonists of 2 nuclear hormone receptors involved in cholesterol metabolism, establishing a plausible mechanism of action for the hypolipidemic (high cholesterol) effects of these extracts. However, there are currently no published safety or efficacy data on the use of guggul extracts in Western populations.

Guggulipid is marketed in the United States to maintain normal levels of serum cholesterol, and as part of multiherbal supplements for "heart health," weight loss, and arthritis. Annual retail sales of guggulipid in the United States increased by 72 percent in 2002 and accounted for approximately $1.3 million in sales last year.

Philippe O. Szapary, M.D., of the University of Pennsylvania School of Medicine, Philadelphia, and colleagues conducted a randomized, placebo-controlled clinical trial to evaluate whether a commonly used dose or a high dose of guggulipid could safely reduce levels of low-density lipoprotein cholesterol (LDL-C) in healthy adults with hyperlipidemia eating a typical Western diet.

The study was a double-blind, randomized, placebo-controlled trial conducted from March 2000 to August 2001 with 103 healthy adult volunteers with high cholesterols from the Philadelphia metropolitan area. The participants took either three daily doses of standard-dose guggulipid (1000 mg), high-dose guggulipid (2000 mg), or matching placebo, for eight weeks.

The researchers found that both standard-dose guggulipid (n=33) and high-dose guggulipid (n=34) raised levels of LDL-C by 4 percent and 5 percent, respectively, at 8 weeks, for a net positive change of 9 percent to 10 percent, compared with participants randomized to placebo (n=36), in whom levels of LDL-C decreased by 5 percent. "There were no significant changes in levels of total cholesterol, high-density lipoprotein cholesterol (HDL-C), triglycerides, or very-low-density lipoprotein cholesterol (VLDL-C) in response to treatment with guggulipid, according to the authors. "While guggulipid was generally well tolerated, 6 participants treated with guggulipid developed a hypersensitivity rash compared with none in the placebo group."

CHICAGO—About 13 percent of patients discharged from a hospital following coronary artery bypass graft (CABG) surgery are readmitted within 30 days for reasons related to the surgery, according to a study in the August 13 issue of The Journal of the American Medical Association (JAMA).

According to background information in the article, CABG surgery may be the most frequently studied of all surgical procedures, probably in part because of its expense, the frequency with which it is performed, and that it relates to the most common cause of death in the United States, coronary heart disease. Risk factors for death after CABG surgery have been studied extensively, however which factors are associated with early readmissions are less clear.

Edward L. Hannan, Ph.D., of the State University of New York, Albany, and colleagues examined the frequency and causes of hospital readmissions within 30 days following CABG surgery in the state of New York from January 1, 1999, through December 31, 1999.

The researchers found that of 16,325 total patients, 2,111 (12.9 percent) were readmitted within 30 days for reasons related to CABG surgery. The most common causes of readmission were postsurgical infection (n=598 [28 percent]) and heart failure (n=331 [16 percent]). Eleven risk factors were independently associated with higher readmission rates: older age, female sex, African American race, greater body surface area, previous myocardial infarction within 1 week, femoral/popliteal (artery) disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, hepatic failure, and renal failure.

After controlling for these preoperative patient-level risk factors, two physician characteristics (annual CABG volume less than100 or hospital risk-adjusted death rate in the highest decile) and 2 postoperative factors (discharge to nursing home or rehabilitation/acute care facility or length of stay during index CABG admission of 5 days or greater) were also related to higher readmission rates.

NEW STUDY FIRST TO LOOK AT HOSPITAL READMISSION RATE FOR COMMON HEART PROCEDURE