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June 22, 2009JAMA 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, June 22, 2009)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 22, 2009
Some Patients Are Not Notified of Abnormal Test Results
CHICAGO—Primary care clinicians and their staff appear to fail to inform some patients, or to fail to document informing patients, about abnormal results on outpatient medical tests, according to a report in the June 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. "Ordering and following up on outpatient laboratory and imaging tests consumes large amounts of physician time and is important in the diagnostic process," the authors write as background information in the article. "Diagnostic errors are the most frequent cause of malpractice claims in the United States; testing-related mistakes can lead to serious diagnostic errors. There are many steps in the testing process, which extends from ordering a test to providing appropriate follow-up; an error in any one of these steps can have lethal consequences." Lawrence P. Casalino, M.D., Ph.D., of Weill Cornell Medical College, New York, and colleagues reviewed the medical records of 5,434 randomly selected patients age 50 to 69 years in 23 primary care practices (19 community-based and four affiliated with academic medical centers). The researchers identified individuals with a clinically significantly abnormal result on one of 11 blood tests or three screening tests commonly performed on an outpatient basis. These patients' records were then assessed for an indication that he or she had been informed about the abnormal result. In cases for which there was no evidence such communication occurred, physicians were sent a form alerting them to the apparent oversight and giving them the opportunity to correct the record if the patient had been informed or to inform the patient at that time. In addition, physicians responded to a six-question survey about the processes for managing test results at their practices and their satisfaction with these processes. Reviewers calculated a score ranging from zero to five for each practice, with five indicating that they closely followed five processes derived from the medical literature—routing results to the responsible physician, having the physician sign off on the results, informing the patient of all results (normal and abnormal, at least in general terms) and asking patients to call after a certain time period if they had not been notified of the results. The reviewers identified 1,889 abnormal test results and 135 apparent failures to inform the patient or to document informing the patient—a rate of 7.1 percent, or about one of every 14 tests. The average process score was 3.8; most practices did not use all five of the basic processes suggested in the literature and most did not have explicit rules for notifying patients of results. "Failure rates varied widely among practices, from 0 percent to 26 percent; practices that used better processes to manage results had lower failure rates and had physicians who were more satisfied with the processes used," the authors write. Practices that used a combination of paper and electronic records—a so-called partial electronic medical record—had the highest failure rates, whereas there was no significant difference between practices that used complete electronic medical records or paper records.
"Some elements of medical care (e.g., diagnosis) are an art as well as a science, depend heavily on the cognitive skills and effort of individual physicians, involve much uncertainty and will probably always have relatively high error rates," the authors conclude. "However, notifying patients of test results does not appear to be such a process; with appropriate within-practice systems, low rates of failure to inform should be possible."
Editor's Note: Funding for this project was provided by the California HealthCare Foundation. 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. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 22, 2009
Less Frequent Social Activity May Be Associated With Motor Function Decline in Older Adults
CHICAGO—Among older adults, less frequent participation in social activity is associated with a more rapid rate of motor function decline, according to a report in the June 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. "Decline in motor function is a familiar consequence of aging, with older persons displaying a wide spectrum of loss of motor abilities ranging from mild decreased muscle strength and bulk and reduced speed and dexterity to overt motor impairment with concomitant disability," the authors write as background information in the article. Motor function decline in older individuals is associated with negative health outcomes including, disability, dementia and death. Although decline in motor function is becoming a major public health concern, "little is known about risk factors for motor function decline that could translate into potential public health or clinical interventions." Aron S. Buchman, M.D., and colleagues at Rush University Medical Center, Chicago, examined whether frequency of social activity in late-life was related to motor function decline in 906 older adults participating in the Rush Memory and Aging Project from 1997 to 2008, with an average follow-up of 4.9 years. Researchers evaluated participants' motor function by measuring their grip and pinch strength and their ability to stand on one leg and then on their toes, to walk in line in a heel-to-toe manner, place pegs on a board in 30 seconds and tap index fingers for 10 seconds bilaterally. Participants completed a health survey to assess their physical activities and used a five-point rating scale to measure frequency of social activity participation, with one indicating participation in a particular activity once a year or less; two, several times a year; three, several times a month; four, several times a week and five, every day or almost every day. Demographic information, education, weight, height and disabilities were also recorded. "A lower frequency of participation in social activity was associated with a more rapid rate of motor function decline," with each one-point decrease in a participant's social activity score associated with an approximate 33 percent more rapid rate of decline, the authors note. Additionally, a one-point decrease on the social activity scale was the same as being approximately five years older at baseline. This amount of change is associated with more than a 40 percent increased risk of death and a 65 percent increased risk of developing disability. "The association of social activity with the rate of global motor decline did not vary along demographic lines and was unchanged after controlling for potential confounders including late-life physical and cognitive activity, disability, global cognition depressive symptoms, body composition and chronic medical conditions," they write.
"These data raise the possibility that social engagement can slow motor function decline and possibly delay adverse health outcomes from such decline. Further work is needed to ensure that this is a causal relationship," the authors conclude. "Additional knowledge of the biological, in particular the neurobiological, mechanisms of motor function decline is needed. Such information would allow for much more refined hypotheses regarding the mechanisms underlying the association that will be important for the design and execution of potential interventions."
Editor's Note: This work was supported by National Institute on Aging grants, the Illinois Department of Public Health and the Robert C. Borwell Endowment Fund. 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. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 22, 2009
Total Knee Replacement Appears Cost-Effective in Older Adults
CHICAGO—Total knee replacement (arthroplasty) appears to be a cost-effective procedure for older adults with advanced osteoarthritis, according to a report in the June 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. The procedure appears to be cost-effective across all patient risk groups, and appeared more costly and less effective in low-volume centers than in high-volume centers. Approximately 12 percent of adults older than 60 have symptoms of knee osteoarthritis, and their direct medical costs are estimated to range from $1,000 to $4,100 per person per year, according to background information in the article. "Total knee arthroplasty is a frequently performed and effective procedure that relieves pain and improves functional status in patients with end-stage knee osteoarthritis," the authors write. "Almost 500,000 total knee arthroplasties were performed in the United States in 2005 at a cost exceeding $11 billion. Projections indicate dramatic growth in the use of total knee arthroplasty over the next two decades." Elena Losina, Ph.D., of Brigham and Women's Hospital and the Boston University School of Public Health, and colleagues developed a computer simulation model and populated it with Medicare claims data and cost and outcomes data from national and multinational sources. They then projected lifetime costs and quality-adjusted life expectancy—or the number of years remaining of good health—for patients at different levels of risk and receiving total knee arthroplasty at high-volume or low-volume facilities. Overall, having a total knee arthroplasty increased quality-adjusted life expectancy of the Medicare population (average age 74) from 6.822 to 7.957 quality-adjusted life years (years of life in perfect health). Total costs increased from $37,100 among individuals not receiving total knee arthroplasty to $57,900 per person undergoing total knee arthroplasty, resulting in a cost-effectiveness ratio of $18,300 per quality-adjusted life year. Therefore, total knee arthroplasty is a highly cost-effective procedure for the management of end-stage knee osteoarthritis compared with non-surgical treatments and is within the range of accepted cost-effectiveness for other musculoskeletal procedures, the authors note. "This result is robust across a broad range of assumptions regarding both patient risk and hospital volume," they write. "For patients who choose to undergo total knee arthroplasty, hospital volume plays an important role: regardless of patient risk level, higher-volume centers consistently deliver better outcomes. But the additional survival benefits associated with high-volume centers provide limited cost-effectiveness benefits for high-risk patients deliberating between medium- and high-volume centers." Even procedures performed in low-volume centers were more cost-effective than not having total knee arthroplasty, regardless of the patient's risk of complications.
"Clinicians, patients and policy makers should consider the relative cost-effectiveness of total knee arthroplasty in making decisions about who should undergo total knee arthroplasty, where and when," the authors conclude.
Editor's Note: This research was supported in part by National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases grants, and an Arthritis Foundation Innovative Research Grant. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Results Highlight Dilemmas in Health Care System
"Although total knee arthroplasty is a safe and effective treatment for advanced knee osteoarthritis, lingering questions remain regarding variations in patient outcomes due to differences among patients undergoing the procedure and among the hospitals where it is performed," write Stephen Lyman, Ph.D., of Weill Medical College of Cornell University, and colleagues in an accompanying editorial. "In this issue of the Archives, Losina et al examine these questions from the perspective of cost-effectiveness, with a focus on Medicare enrollees who were 65 years or older," they write. "The overall findings were favorable to total knee arthroplasty, which had an incremental cost-effectiveness ratio of $18,300 per quality-adjusted life year gained compared with medical treatment alone. This figure falls below the cost-effectiveness thresholds often mentioned as appropriate, such as the £20,000 to £30,000 (approximately $29,000 to $44,000) per quality-adjusted life year threshold used by the British National Health Service's National Institute for Health and Clinical Excellence."
"Analyses such as the one conducted by Losina et al, carefully conducted and wholly transparent, highlight several of the dilemmas policy makers face in evaluating widely used medical technologies," they conclude. "At least in the United States, even well-performed cost-effectiveness analyses do not influence either payers or physicians directly. Payers do not use the results to make coverage determinations nor do physicians use them to make treatment decisions. How we move from this current state to a system in which cost-effectiveness of procedures affects medical practice is unclear."
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. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 22, 2009
Older Men With Breathing Problems During Sleep More Likely to Have Irregular Heartbeats
CHICAGO—Increasingly severe sleep-related breathing disorders in older men appear to be associated with a greater risk of abnormal heart rhythms (arrhythmias), according to a report in the June 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. In addition, different types of breathing problems appear more closely associated with different categories of arrhythmia. Sleep-disordered breathing is a common condition, according to background information in the article. It causes a number of physiologic events that could be stressful to the cardiovascular system, including inadequate blood oxygen levels at night and activation of the sympathetic nervous system (associated with the body's fight-or-flight response). Reena Mehra, M.D., M.S., of Case Western Reserve University School of Medicine, Cleveland, and colleagues studied 2,911 men who underwent sleep testing by polysomnography between 2003 and 2005. The number of times they experienced apnea (brief pauses in breathing) or hypopnea (shallow breathing) during sleep was recorded, as were any periods of time in which the oxygen level of blood in their arteries dipped below 90 percent (hypoxia). Having more episodes of paused or shallow breathing was associated with increased odds of two types of arrhythmias—one involving the heart's upper chambers (atria) and one involving the heart's lower chambers (ventricles). Obstructive sleep apnea—the most common type, involving a partial or complete blockage of the airways—was associated with irregular heartbeats caused by a problem with the lower chambers or ventricles. Lower blood oxygen levels also appeared to be associated with this type of arrhythmia. However, central sleep apnea, involving a malfunction in brain signals controlling breathing muscles, was more strongly associated with arrhythmias in the atria or upper chambers. More severe cases of sleep-disordered breathing were associated with higher odds of arrhythmia; in addition, "there also seems to be a threshold effect such that moderate-to-severe sleep-disordered breathing confers the greatest increased odds of clinically significant arrhythmias independent of self-reported heart failure and cardiovascular disease," the authors write.
"This line of investigation also identified hypoxia as the possible culprit pathophysiologic characteristic of sleep-disordered breathing that may serve as the trigger of ventricular cardiac arrhythmia development in older men. The strong associations between central sleep apnea and atrial fibrillation [arrhythmia originating in the heart's upper chambers] suggest that central sleep apnea may be a sensitive marker of underlying abnormalities in autonomic or cardiac dysfunction associated with atrial fibrillation," they conclude. "Further prospective and intervention studies are needed to better determine causality and the impact of aggressive sleep-disordered breathing interventions on cardiac outcomes."
Editor's Note: Co-author Dr. Varosy has performed research consulting for Atricure, Cierra and BioNova, and has received honoraria from Sanofi-Aventis and Boston Scientific. 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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