JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases.
THIS WEEK'S CONTENTS
ARCHIVES OF INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, July 23, 2007)
POOR HEALTH LITERACY ASSOCIATED WITH INCREASED MORTALITY IN THE ELDERLY
STUDIES ASSESS BLOOD CLOT PREVALENCE OUTSIDE HOSPITAL, PREVENTION IN HOSPITAL
STUDY EXAMINES FACULTY'S BELIEFS ON THE EFFECTS OF DECREASED RESIDENT DUTY-HOURS
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, July 23, 2007
Media Advisory: To contact David W. Baker, M.D, M.P.H., call Marla Paul at 312-503-8928.
POOR HEALTH LITERACY ASSOCIATED WITH INCREASED MORTALITY IN THE ELDERLY
CHICAGO—Older adults who cannot read and understand basic health information appear to have increased mortality rates over a five-year period than those with adequate health literacy, according to a report in the July 23 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Education, as measured by the number of years of school completed, has been linked to longer life, according to background information in the article. This may be because more education tends to result in better job opportunities, a higher annual income and access to housing, food and health insurance. "Another possible mechanism by which education could exert a direct effect on health is reading fluency," the authors write. "The number of years of school completed is strongly associated with reading fluency. As a result, individuals with more education tend to have a better capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions: i.e., they have higher levels of health literacy."
David W. Baker, M.D., M.P.H., of Northwestern University Feinberg School of Medicine, Chicago, and colleagues interviewed 3,260 Medicare patients age 65 and older in four metropolitan areas in 1997, asking questions about demographics and health. Participants also completed a test of health literacy that involved two reading passages and four mathematical items. Scores range from zero to 100, with zero to 55 designating inadequate health literacy, 56 to 66 indicating marginal health literacy and 67 to 100 signifying adequate health literacy. The National Death Index was then used to identify participants who died through 2003.
Among the participants, 2,094 (64.2 percent) had adequate health literacy, 366 (11.2 percent) had marginal health literacy and 800 (24.5 percent) had inadequate health literacy. A total of 815 (25 percent) died during the average 67.8 months of follow-up, including 39.4 percent of those with inadequate health literacy, 28.7 percent of those with marginal health literacy and 18.9 percent of those with adequate health literacy. The results suggesting an increased risk of mortality associated with inadequate health literacy remained statistically significant after the researchers factored in demographics, socioeconomic status, and health behaviors at the beginning of the study. In contrast, years of school completed were only weakly associated with death during the study period.
Health literacy was most strongly associated with death from cardiovascular disease-380 (11.7 percent) of participants died of this cause during the study, including 19.3 percent of those with inadequate health literacy and 16.7 percent of those with marginal health literacy, compared with only 7.9 percent of those with adequate health literacy.
"Inadequate health literacy is associated with less knowledge of chronic disease and worse self-management skills for patients with hypertension, diabetes mellitus, asthma and heart failure," the authors write. "Use of cancer screening and vaccinations are also lower among people with inadequate health literacy. Thus, the association between health literacy and adverse health outcomes probably occurs as the result of a wide variety of pathways that have a cumulative effect."
Recent studies have suggested that it is possible to improve the health of patients with diabetes and heart failure despite their low health literacy using targeted interventions. However, a broader solution is needed, the authors note. "Most people will have many acute and chronic medical conditions during their life and face many situations in which they must make health and health care choices and decisions," they conclude. "As a result of these myriad demands placed on patients today, widespread improvements in health and health care communication will likely be necessary to reduce the association between health literacy and mortality."
(Arch Intern Med. 2007;167(14):1503-1509. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: This study was supported by a grant from the National Institute on Aging and a Career Development Award from the Centers for Disease Control and Prevention. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, July 23, 2007
Media Advisory: To contact Frederick A. Spencer, M.D., call Veronica McGuire at 905-525-9140, ext. 22169. To contact corresponding author Henry Krum, M.B.B.S., Ph.D., F.R.A.C.P., e-mail: henry.krum{at}med.monash.edu.au. To contact editorialist Samuel Z. Goldhaber, M.D., call Kevin Myron at 617-534-1605.
STUDIES ASSESS BLOOD CLOT PREVALENCE OUTSIDE HOSPITAL, PREVENTION IN HOSPITAL
CHICAGO—More cases of venous thromboembolism are diagnosed in the three months following hospitalization than during hospitalization, but less than half of inpatients receive medications to prevent blood clots from occurring, according to a report in the July 23 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. A meta-analysis of previous studies published in the same issue finds that both unfractionated and low-molecular-weight heparin are effective in preventing blood clots in the legs and lungs of hospitalized patients.
Venous thromboembolism, which includes deep vein thrombosis (blood clot in the deep veins, such as of the legs and pelvis) and pulmonary embolism (clot that occurs in the lungs), is a major cause of complications and death in hospitalized patients, according to background information in the articles. As many as 10 percent of hospital deaths can be attributed to pulmonary embolism. However, previous studies suggest most cases of venous thromboembolism occur out of the hospital.
Frederick A. Spencer, M.D., of McMaster University Medical Center, Hamilton, Ontario, Canada, and colleagues analyzed the medical records of residents from the Worcester, Mass., metropolitan area who were diagnosed with venous thromboembolism during 1999, 2001 and 2003.
"A total of 1,897 subjects had a confirmed episode of venous thromboembolism," the authors write. "In all, 73.7 percent of patients developed venous thromboembolism in the outpatient setting; a substantial proportion of these had undergone surgery (23.1 percent) or hospitalization (36.8 percent) in the preceding three months." Among those patients, 67 percent experienced the condition within one month of their hospitalization. Other major risk factors included active cancer (29 percent) or a previous blood clot (19.9 percent).
Of the 516 patients with venous thromboembolism who had recently been hospitalized, three of five (59.7 percent) received any kind of therapy to prevent the condition while in the hospital. A total of 42.8 percent received anti-clotting medications and an addition 16.9 percent received only non-pharmaceutical prevention methods. "Because most of the cases of venous thromboembolism occurred within 29 days of hospital discharge (and 41 percent occurred within 14 days), it is not unreasonable to assume that some of these cases may have been prevented simply by increased use of appropriate in-hospital deep vein thrombosis prophylaxis (e.g., compression stockings, pneumatic compression devices and, in high-risk patients, anticoagulants)," the authors write.
"Approximately half of the outpatients who experienced venous thromboembolism following hospitalization had a length of stay that was four days or less," they continue. This suggests that patients in the hospital for a short time also should be given preventive therapy. In addition, because the length of hospital stays is decreasing overall, patients may spend more time immobilized at home and therefore may benefit from anti-clotting therapy even after discharge.
In a related paper, Lironne Wein of Monash University and Alfred Hospital, Melbourne, Australia, and colleagues conducted a meta-analysis of previously published randomized controlled trials, all of which compared medications used to prevent venous thromboembolism with each other or with a control group of patients who did not receive prophylactic (preventive) therapy. Thirty-six studies published before June 2006 were included. Fourteen of them compared the drug unfractionated heparin with a control, 11 compared low-molecular-weight heparin to a control, 10 compared the two types of heparin to each other and one compared a drug known as fondaparinux sodium with placebo.
Compared with control groups, unfractionated heparin was associated with a 67 percent lower risk of deep vein thrombosis and a 36 percent lower risk of pulmonary embolism, while low-molecular-weight heparin was associated with a 44 percent lower risk of deep vein thrombosis and 63 percent lower risk of pulmonary embolism. When the drugs were compared with each other, low-molecular-weight heparin was associated with a 32 percent lower risk of deep vein thrombosis and a 53 percent lower rate of hematoma [localized bleeding into or beneath the skin] at the injection site. However, prophylactic therapy was not associated with reduced mortality rates. Fondaparinux sodium was also effective in the prevention of venous thromboembolism.
"This meta-analysis has shown that unfractionated heparin and low-molecular-weight heparin are both associated with a reduced risk of venous thromboembolism in medical patients, with low-molecular-weight heparin being more effective in preventing deep vein thrombosis than unfractionated heparin when considering trials that directly compared the two agents," the authors write. "The unfractionated heparin dosage of 5,000 units three times daily was more effective than the unfractionated heparin dosage of 5,000 units twice daily in reducing the risk of deep vein thrombosis."
"We believe that routine prophylactic anticoagulation has an important place in the medical setting," they conclude. "Although such therapy may not necessarily decrease mortality among hospitalized medical patients, it will reduce the occurrence of deep vein thrombosis and pulmonary embolism and therefore the burden of illness currently caused by these events."
(Arch Intern Med. 2007;167(14):1471-1475 and 1476-1486. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: VENOUS THROMBOEMBOLISM A COMMON BUT PREVENTABLE THREAT
Venous thromboembolism is a common public health threat, but can be prevented if at-risk patients are targeted for preventive therapy and barriers between inpatient and outpatient care are removed, writes Samuel Z. Goldhaber, M.D., of Brigham and Women's Hospital, Boston, in an accompanying editorial.
"I predict that preventing outpatient venous thromboembolism will be the 'hot button' issue in 2008," Dr. Goldhaber writes. "We must start collecting relevant data at the time of hospital discharge so that we can provide these vulnerable patients with proper and comprehensive venous thromboembolism prophylaxis. Recognizing the public health threat of outpatient venous thromboembolism and breaking down artificial barriers between outpatient and inpatient venous thromboembolism prophylaxis are vital first steps."
(Arch Intern Med. 2007;167(14):1451-1452. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, July 23, 2007
Media Advisory: To contact Darcy A. Reed, M.D., M.P.H., call Lee Aase at 507-284-5005. To contact editorialist Barbara Schuster, M.D., call Judi Engle at 937-775-2951.
STUDY EXAMINES FACULTY'S BELIEFS ON THE EFFECTS OF DECREASED RESIDENT DUTY-HOURS
CHICAGO—Internal medicine faculty heavily involved in residency programs believe that resident duty-hour limitations negatively affect aspects of residents' patient care, education and professionalism, but improve residents' well-being, according to a report in the July 23 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Residency duty-hour restrictions were put into place in 2003 to reduce the risk of negative events resulting from sleep deprivation and to improve residents' well-being. "Before implementation of duty-hour regulations, some cautioned that reductions in duty hours may have unanticipated negative effects on patient care, resident education and professionalism," according to background information in the article. Some also feared that reducing residents' duty hours would increase clinical faculty workload.
Darcy A. Reed, M.D., M.P.H., of the Mayo Clinic College of Medicine, Rochester, Minn., and colleagues surveyed 154 key clinical faculty from 39 internal medicine residency programs affiliated with U.S. medical schools in 2005 to obtain their views on the effect of residents' duty-hour limitations. Key clinical faculty consists of faculty members who dedicate at least 15 hours per week to the residency program and provide clinical teaching and supervision of residents.
Of the 154 faculty members targeted, 111 (72 percent) responded. Three-fourths of them had five or more years teaching residents and one-third had more than 15 years of experience.
Key clinical faculty reported they believe resident duty-hour restrictions:
- Worsen the continuity of patient care provided by residents (87 percent), residents' communication with patients and families (66 percent) and overall quality of patient care (60 percent)
- Decrease opportunities for didactic [instructive] (69 percent) and bedside (73 percent) teaching, decrease opportunities for residents to perform clinical procedures (57 percent), decrease conference attendance (51 percent) and worsen residents' autonomy (57 percent)
- Worsen residents' professionalism (51 percent), accountability to patients (73 percent) and ability to place patient needs above self-interests (57 percent)
- Improve residents' well being and level of fatigue (85 percent) and personal-professional life balance (81 percent)
- Decrease resident burnout (approximately 50 percent)
- Increase time spent by faculty attending on inpatient teaching services directly providing patient care without residents (47 percent)
- Impair faculty ability to accurately evaluate residents (49 percent) and develop mentoring relationships with residents (40 percent)
- Decrease faculty's overall satisfaction with teaching residents (56 percent)
"One-third of the key clinical faculty reported a decrease in overall satisfaction with their careers as a result of duty-hour limitations for residents," the authors write.
"These faculty, who have the most contact with residents, believe that duty-hour limitations have adversely affected important aspects of residents' patient care, education and professionalism, as well as the workload and satisfaction of faculty teachers," they conclude. "Residency programs should continue to look for ways to optimize experiences for residents and faculty within the confines of the duty-hour limitations."
(Arch Intern Med. 2007;167(14):1487-1492. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This study was supported by a grant from The Johns Hopkins University School of Medicine. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: TEACHING FACULTY FACED WITH MORE RESPONSIBILITIES
"Clearly, internal medicine programs have been dealing with limited duty hours for more than 15 years, yet the gravity of complaints about change in resident behavior and change in faculty member workload are only now coming to active discussion," writes Barbara Schuster, M.D., of Wright State University, Dayton, Ohio, in an accompanying editorial.
"This change has had less to do with duty-hour restrictions and more to do with patient safety and hospital quality measures," Dr. Schuster writes. "The faculty is increasingly held fully responsible for patient length of stay on the service, cost of care per discharge and accuracy of resident dictation."
"The increased demand for clinical service personally delivered by faculty members presently interferes with teaching responsibilities. The duty-hour restrictions have improved the well-being of the residents but may be worsening the well-being of faculty members," she concludes.
(Arch Intern Med. 2007;167(14):1453-1455. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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