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 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 CONTENT
JAMA NEWS RELEASES
(Embargoed for Release: 3:00 p.m. CT, Tuesday, December 11, 2007)
JAMA NEWS RELEASES
GERIATRIC CARE INTERVENTION APPEARS TO PROVIDE SOME BENEFITS FOR LOW-INCOME SENIORS
USE OF DIABETES MEDICATION BY OLDER ADULTS ASSOCIATED WITH INCREASED RISK OF SERIOUS HEART PROBLEMS, DEATH
SEDATIVE APPEARS TO HAVE BETTER OUTCOMES THAN COMMONLY-USED MEDICATION FOR ICU PATIENTS ON RESPIRATOR
SMOKING ASSOCIATED WITH INCREASED RISK OF DIABETES
JAMA REPORT (VIDEO SCRIPT)
VIDEO: Windows Media | Quicktime
IN-HOME HEALTHCARE PROGRAM FOR LOW-INCOME SENIORS REDUCED HOSPITAL ADMISSIONS BY MORE THAN FORTY PERCENT
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED.
TV Note: This week's JAMA Report video is on the effectiveness of a home-based geriatrics care program for low-income seniors. The report will be fed Tuesday, December 11, from 9:00 - 9:30 a.m. ET and 2:00 - 2:30 p.m. ET, on Galaxy 26 (formerly Intelsat America 6) C-Band, Transponder 14, downlink frequency: 3880 vertical, audio 6.2/6.8. For more information, call 312/464-JAMA.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 11, 2007
Media Advisory: To contact Steven R. Counsell, M.D., call Cindy Fox Aisen at 317-274-7722. To contact editorial author David B. Reuben, M.D., call Enrique Rivero at 310-794-2273.
GERIATRIC CARE INTERVENTION APPEARS TO PROVIDE SOME BENEFITS FOR LOW-INCOME SENIORS
CHICAGO—A home-based geriatric care program for low-income seniors resulted in higher-quality medical care, improvement in quality of life and fewer emergency department visits, but did not appear to prevent decline in physical functioning, according to a study in the December 12 issue of JAMA.
Low-income seniors frequently have chronic medical conditions and limited access to health care. Older adults in general, and especially the poor, often do not receive the recommended standard of care for preventive services and management of chronic diseases. “These patient groups have been understudied in previous trials and represent a complex and high-cost population that might especially benefit from improved coordination and integration of their health care,” the authors write.
The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care was developed specifically to improve the quality of care for low-income seniors. Features of the GRACE intervention include in-home assessment and care management provided by a nurse practitioner and social worker team; extensive use of specific care protocols for evaluation and management of common geriatric conditions; utilization of an integrated electronic medical record and a Web-based care management tracking tool; and integration with affiliated pharmacy, mental health, home health, community-based and inpatient geriatric care services.
Steven R. Counsell, M.D., of the Indiana University School of Medicine, Indianapolis, and colleagues conducted a study to test the effectiveness of the GRACE intervention on health outcomes for 951 low-income adults 65 years or older. The participants’ primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers. Patients received two years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions.
Analysis of the results indicated significant improvements for intervention patients compared with usual care at 24 months in several measurements, including general health, vitality, social functioning and mental health. No group differences were found for physical function outcomes or death. The two-year emergency department visit rate was lower in the intervention group, but hospital admission rates were not significantly different between groups.
In a pre-defined group at high risk of hospitalization (consisting of 112 intervention and 114 usual-care patients), emergency department visit and hospital admission rates were lower for intervention patients in the second year.
“Future studies should compare potential cost savings from less acute care utilization with program costs to determine feasibility. Under current fee-for-service Medicare, most of the services provided by the GRACE intervention are not reimbursed. Medicare managed care, however, presents a financial vehicle under which the GRACE intervention could currently be supported,” the researchers write.
“We hope the GRACE model will prove to be a practical health system innovation that will contribute to improved geriatric care and outcomes while reducing high-cost acute care utilization in low-income seniors.”
(JAMA. 2007;298(22):2623-2633. Available pre-embargo to the media 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.
EDITORIAL: BETTER CARE FOR OLDER PEOPLE WITH CHRONIC DISEASES — AN EMERGING VISION
In an accompanying editorial, David B. Reuben, M.D., of the University of California, Los Angeles, writes that research has indicated what is important to deliver optimal health care for older persons with chronic diseases.
“First, care must be personalized to meet each patient’s goals, values, and resources. … Second, care should be provided in accordance with best practices. … Third, physicians cannot do the job alone. Team care, which has been a hallmark of geriatrics, is essential for providing high-quality care for patients of all ages who have chronic diseases.”
Dr. Reuben adds that other important points include coordinating care among those caring for patients; care must consider the resources and environment of the person; and older persons must be included as active partners in their care except when they are too frail, mentally or physically.
“These principles fit well within the chronic care model, a construct that espouses better health care linked to community-based services. If the chronic care model is followed, patients become more informed and activated and practice teams are more prepared to be proactive, which should result in improved clinical and functional outcomes. Implementing this type of care requires staff, support systems, and a payment mechanism.”
(JAMA. 2007;298(22):2673-2674. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 11, 2007
Media Advisory: To contact Lorraine L. Lipscombe, M.D., M.Sc., call Kristine Galka at 416-480-4780.
USE OF DIABETES MEDICATION BY OLDER ADULTS ASSOCIATED WITH INCREASED RISK OF SERIOUS HEART PROBLEMS, DEATH
CHICAGO—Older patients treated with the diabetes medications known as thiazolidinediones (which include rosiglitazone) had a significantly increased risk of heart attack, congestive heart failure and death, compared with the use of other hypoglycemic drugs, according to a study in the December 12 issue of JAMA. The authors suggest that these results provide further evidence that this class of medication may cause more harm than good.
The thiazolidinediones (TZDs) rosiglitazone and pioglitazone are oral hypoglycemic agents used to treat type 2 diabetes and have been shown to improve glycemic control. “While improved glycemic control has been linked to better clinical outcomes in diabetes and TZDs have been suggested as having potential cardiovascular benefits, recent concerns have arisen regarding adverse cardiac effects of these drugs,” the authors write.
Some research has indicated that both rosiglitazone and pioglitazone may increase the risk of congestive heart failure (CHF), and that rosiglitazone may be associated with an increased risk of acute myocardial infarction (AMI; heart attack) and death. “These findings prompted a recent hearing by a U.S. Food and Drug Administration advisory panel regarding the safety of rosiglitazone; however the panel voted against removing rosiglitazone from the market because of insufficient data.”
Lorraine L. Lipscombe, M.D., M.Sc., of the Institute for Clinical Evaluative Sciences, Toronto, and colleagues evaluated the risks of CHF, heart attack, and all-cause death associated with the use of TZDs, compared with other oral hypoglycemic agents among patients age 66 years or older with diabetes. This older patient population has often been under-represented in trials of TZDs, even though they have a high prevalence of diabetes, and may be at greater risk of medication-related harms. The researchers analyzed data from health care databases in Ontario that included 159,026 individuals with diabetes who were treated with oral hypoglycemic agents and were followed for a median (midpoint) of 3.8 years, through March 2006. During this time, 7.9 percent of patients had a hospital visit for congestive heart failure (n = 12,491), 7.9 percent had a hospital visit for a heart attack (n = 12,578), and 19 percent died (n = 30,265).
Compared to oral hypoglycemic agent combination therapy users, current users of TZD monotherapy had a 60 percent increased risk of congestive heart failure; had a 40 percent increased risk of heart attack; and had a 29 percent increased risk of death. These increased risks associated with TZD use appeared limited to rosiglitazone.
“Our findings argue against current labeling of TZDs that warns against use only in persons at high risk of CHF, as we did not identify any subgroup of older diabetes patients who may be protected from adverse effects of TZDs,” the authors write. “These findings provide evidence from a real-world setting and support data from clinical trials that the harms of TZDs may outweigh their benefits, even in patients without obvious baseline cardiovascular disease.”
“Further studies are needed to better quantify the risk-benefit tradeoffs associated with TZD therapy and to explore whether the hazards associated with these agents are specific to rosiglitazone. In the interim, treatment decisions must remain individualized, with clinicians weighing the potential benefits and harms of TZD treatment, especially among high-risk elderly populations.”
(JAMA. 2007;298(22):2634-2643. Available pre-embargo to the media 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 the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 11, 2007
Media Advisory: To contact Pratik P. Pandharipande, M.D., M.S.C.I., call Craig Boerner at 615-322-4747.
SEDATIVE APPEARS TO HAVE BETTER OUTCOMES THAN COMMONLY-USED MEDICATION FOR ICU PATIENTS ON RESPIRATOR
CHICAGO—Intensive care unit patients on respirators who were sedated with the drug dexmedetomidine had more days alive without delirium or coma and better sedation compared to patients treated with the recommended drug lorazepam, according to a study in the December 12 issue of JAMA.
Benzodiazepine drugs, such as lorazepam, are routinely administered to mechanically ventilated (respirators) patients to reduce pain and anxiety and to allow patients to tolerate invasive procedures in the intensive care unit (ICU). But these medications may also increase mechanical ventilation time, ICU length of stay and the risk of developing acute brain dysfunction, i.e., delirium and coma, according to background information in the article. The medication dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction.
Pratik P. Pandharipande, M.D., M.S.C.I., of Vanderbilt University Schools of Medicine and Nursing, Nashville, Tenn., and colleagues conducted a study to determine if dexmedetomidine, when compared with benzodiazepine drugs, reduces the duration of delirium and coma while effectively sedating mechanically ventilated ICU patients. The randomized controlled trial included 106 adult ICU patients who were mechanically ventilated between August 2004 and April 2006. Patients were sedated with dexmedetomidine or lorazepam for as many as 120 hours.
The researchers found that dexmedetomidine patients had more days alive without delirium or coma (median [midpoint], 7 vs. 3). About 30 percent fewer patients experienced coma in the dexmedetomidine group than in the lorazepam group (63 percent vs. 92 percent). Nonsignificant differences were noted between the dexmedetomidine and lorazepam groups in death at 28-days (17 percent vs. 27 percent) and ventilator-free days (22 days vs. 18 days alive and free of mechanical ventilation).
A higher but nonsignificant percentage of patients in the dexmedetomidine group were able to complete post-ICU neuropsychological testing. Patients administered dexmedetomidine spent more time near the targeted level of sedation compared with patients sedated with lorazepam (median percentage of days, 80 percent vs. 67 percent). The 12-month time to death in the dexmedetomidine vs. the lorazepam group was 363 vs. 188 days, respectively.
“In this double-blind, randomized controlled trial, dexmedetomidine was more effective than lorazepam for achieving sustained sedation of mechanically ventilated medical and surgical ICU patients. Dexmedetomidine-treated ICU patients had 4 more days alive and without delirium or coma, significantly higher accuracy at meeting the stated sedation goals, and no added cost of care, as measured using data obtained at the largest enrolling site,” the authors conclude.
(JAMA. 2007;298(22):2644-2653. Available pre-embargo to the media 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 the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 11, 2007
Media Advisory: To contact Carole Willi, M.D., email: carole.willi{at}hospvd.ch. To contact co-author William A. Ghali, M.D., M.P.H., call Karen Thomas at 403-220-2431. To contact editorial co-author Eric L. Ding, Sc.D., call Todd Datz at 617-432-3952.
SMOKING ASSOCIATED WITH INCREASED RISK OF DIABETES
CHICAGO—A review of previous studies indicates that people who currently smoke have an increased risk of developing type 2 diabetes, compared with non-smokers, according to an article in the December 12 issue of JAMA.
A number of studies have examined the association between smoking and incidence of glucose abnormalities, and have suggested that smoking could be independently associated with glucose intolerance, impaired fasting glucose and type 2 diabetes, which could make smoking a modifiable risk factor for type 2 diabetes. However, it appears the quality and clinical features of these studies have not been fully assessed regarding this possible association.
Carole Willi, M.D., of the University of Lausanne, Switzerland, and colleagues conducted a systematic review and meta-analysis of studies describing the association between active smoking and the incidence of diabetes or other glucose metabolism irregularities. A search of databases yielded 25 studies, which were published between 1992 and 2006. The number of participants per study ranged from 630 to 709,827, for a total of 1.2 million participants. A total of 45,844 new cases of diabetes were reported during a study follow-up period ranging from 5 to 30 years.
Analysis of the data indicated that active smokers have a 44 percent increased risk of developing type 2 diabetes compared with non-smokers. Further analyses suggested a dose-response relationship between smoking and diabetes, with the association stronger for heavy smokers (20 or more cigarettes/day; 61 percent increased risk) compared with lighter smokers (29 percent increased risk). The association also was weaker for former smokers (23 percent increased risk) than it was for active smokers.
“...we conclude that the relevant question should no longer be whether this association exists, but rather whether this established association is causal,” the authors write.
They add that observational primary studies cannot prove causality, but that the studies in this review do meet several recommended criteria for causation. “First, there is an appropriate temporal relationship: the cigarette smoking preceded diabetes incidence in all studies. Second, the findings are consistent with a dose-response relationship, with stronger associations for heavy smokers relative to lighter smokers and for active smokers relative to former smokers. ...Third, there is theoretical biological plausibility for causality, in that smoking may lead to insulin resistance or inadequate compensatory insulin secretion responses according to several but not all studies.”
“Conversely, there are also possible non-causal explanations for this association. Smoking is often associated with other unhealthy behaviors that favor weight gain and/or diabetes, such as lack of physical activity, poor fruit and vegetable intake, and high alcohol intake,” the researchers write.
“Considering the consistent finding of increased diabetes incidence associated with active cigarette smoking across a large number of studies, we believe that there is no need for further cohort studies to test this hypothesis. However, there is a need for studies that include detailed measurement and adjustment for potential confounding factors such as socioeconomic status, education, and exercise with a goal of establishing whether the association with smoking is causal. We recommend that future studies focus on plausible causal mechanisms or mediating factors such as obesity, lack of physical activity, dietary habits, and stress levels.”
(JAMA. 2007;298(22):2654-2664. Available pre-embargo to the media 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.
EDITORIAL: SMOKING AND TYPE 2 DIABETES — UNDERRECOGNIZED RISKS AND DISEASE BURDEN
In an accompanying editorial, Eric L. Ding, Sc.D., and Frank B. Hu, M.D., Ph.D., of the Harvard School of Public Health, Boston, write that several steps need to be taken regarding smoking and diabetes.
“...recommendations for type 2 diabetes prevention should incorporate smoking avoidance accompanied by lifestyle modification. Although a frequent concern of smoking cessation is subsequent weight gain, moderately increasing exercise can largely minimize the approximately [4.4 lbs.] weight gain associated with stopping smoking, indicating that the public health issues of smoking, exercise, and obesity are inextricably intertwined. Major population prevention of type 2 diabetes is achievable via avoidance of smoking and modification of lifestyle factors through a combination of healthy weight control, regular physical activity, moderate alcohol intake, and proper diet.”
(JAMA. 2007;298(22):2675-2676. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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JAMA REPORTS
VIDEO: Windows Media | Quicktime
IN-HOME HEALTHCARE PROGRAM FOR LOW-INCOME SENIORS REDUCED HOSPITAL ADMISSIONS BY MORE THAN FORTY PERCENT
INTRO:
The medical “house call” may be considered a charming relic of the past. But a new study says a variation on the traditional house call may be an effective way to provide low-income seniors with quality healthcare, and reduce their rates of emergency room visits and hospital stays. Mavis Prall explains in this week’s JAMA Report.
VIDEO:
NAT SOT UP FULL FOR :04
Myrle Ann and nurse practitioner greet and hug
AUDIO:
“It’s nice to see you.”
“Nice to see you, too.”
VIDEO:
B-ROLL
Continue hug/greeting
Nurse listening to Myrle Ann’s heart
AUDIO:
THIS IS HOW MYRLE (merle) ANN MILLER GREETS THE NURSE PRACTITIONER WHO’S MADE REGULAR VISITS TO HER HERE IN HER BUILDING FOR THE LAST TWO YEARS.
VIDEO:
SOT/FULL
@ :11
Super: Myrle Ann Miller
79 years old
Runs :09
AUDIO:
“That was much better than trying to go to the emergency room or trying to go to the clinic, and it makes it kinda hard for older people to do that.”
VIDEO:
B-ROLL
Nurse checking Myrle Ann’s ear
AUDIO:
PARTICULARLY LOW-INCOME OLDER PEOPLE. THAT’S WHERE A SPECIAL PROGRAM COMES IN.
VIDEO:
SOT/FULL
@ :26
Super: Steven Counsell, M.D.
Indiana University School of Medicine
Runs :06
AUDIO:
“We called this program the GRACE program, or Geriatric Resources for Assessment and Care of Elders.”
VIDEO:
B-ROLL
Pan of Dr. Counsell and colleagues around conference table
Social worker coming to Willie’s door, they embrace and enter apartment
AUDIO:
DR. STEVEN COUNSELL AND COLLEAGUES AT INDIANA UNIVERSITY FORMED THE GRACE PROGRAM, WHICH INCLUDES SOCIAL WORKERS AND NURSE PRACTITIONERS SPECIALLY TRAINED IN GERIATRICS… MEANING HEALTH ISSUES SPECIFIC TO OLD AGE. THEY VISITED THE PATIENTS, ABOUT FIVE-HUNDRED OF THEM, IN THEIR HOMES...
VIDEO:
SOT/FULL
Steven Counsell, M.D.
Indiana University School of Medicine
Runs :10
AUDIO:
“...especially focusing on things like vision and hearing, a medication review, screening for depression, looking at mobility and also doing a home safety check.”
VIDEO:
B-ROLL
Social worker with Willie
Sequence of their interaction
Back to Dr. Counsell and colleagues around tables… Different young physician wearing white coat when narration says “doctors”
GFX/JAMA COVER
AUDIO:
THE TEAM CONTINUED TO VISIT AND SPEAK TO PATIENTS ON THE PHONE, HAVING ABOUT EIGHTEEN CONTACTS WITH EACH PATIENT PER YEAR OF THE TWO-YEAR STUDY. THE SOCIAL WORKERS AND NURSE PRACTITIONERS REGULARLY CONSULTED WITH EACH OTHER AND WITH DOCTORS ABOUT THE PATIENTS’ NEEDS. THE RESULTS ARE PUBLISHED IN JAMA, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
VIDEO:
SOT/FULL
Steven Counsell, M.D.
Indiana University School of Medicine
Runs :10
AUDIO:
“We showed that the GRACE program can reduce emergency department visits by over 20% and decrease hospitalization rates in the sickest group of patients by over 40%.”
VIDEO:
B-ROLL
Nurse practitioner testing Myrle Ann’s leg strength
AUDIO:
AND THERE WERE MORE BENEFITS FOR GRACE PATIENTS AS COMPARED TO PATIENTS RECEIVING USUAL CARE.
VIDEO:
SOT/FULL
Steven Counsell, M.D.
Indiana University School of Medicine
Runs :13
AUDIO:
“Measures of general health, vitality, social functioning, and mental health were on average improved in the GRACE patients, whereas they worsened somewhat in the usual care patients.”
VIDEO:
B-ROLL
Willie and social worker walking into apartment… Willie limping in with cane
AUDIO:
HE HOPES TO EXPAND THE PROGRAM TO MORE LOW-INCOME SENIORS, SUCH AS WILLIE MOORE, WHO HAS NO TRANSPORTATION. SO BEFORE THE GRACE PROGRAM…
VIDEO:
SOT/FULL
@ 1:50
Super: Willie Moore
82-years old
Runs :10
AUDIO:
“I wasn’t getting any care, and that’s what excited me and that’s why I was so open to receiving it because I wasn’t getting any care at all.”
VIDEO:
B-ROLL
More Willie interacting with social worker
AUDIO:
THIS IS MAVIS PRALL WITH THE JAMA REPORT.
TAG:
The study determined fitness through a treadmill test, and found that twenty percent of the people in the study who were the least fit had a death rate that was four times higher than the most fit twenty percent. For more information, visit www.jama.com.
