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April 21, 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
JAMA NEWS RELEASES
(Embargoed for Release: 3 p.m. CT Tuesday, April 21, 2009)
JAMA REPORT (VIDEO SCRIPT)
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: Because JAMA does not publish on the 5th Wednesday of a month, there will be no JAMA or news releases for April 29. TV Note: This week's JAMA Report video is on the trend in continuity of care for older adults. The report will be fed Tuesday, April 21, from 9:00 - 9:30 a.m. ET and 2:00 - 2:30 p.m. ET, on Galaxy 28 (C-Band), Transponder 19, downlink frequency: 4080 vertical, audio 6.2/6.8. For more information, call 312/464-JAMA. 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), Tuesday, April 21, 2009
Type of Physician Certification Associated With Risk of Complications From Implantation of Cardioverter-Defibrillators
CHICAGO—Patients whose implantable cardioverter-defibrillators (ICDs) are implanted by nonelectrophysiologists are at increased risk of complications and are less likely to receive a specific type of ICD when clinically indicated, according to a study in the April 22/29 issue of JAMA. Increases in the population of patients eligible for ICD (a device implanted in the body that converts abnormal heart rhythms back to normal by delivering an electrical shock to the heart) therapy have led to a controversy over which physicians should implant ICDs. Currently, physicians with different training implant ICDs. The training paths range from completion of an electrophysiology fellowship accredited by the American Board of Internal Medicine to industry-sponsored training programs, according to background information in the article. "Differences in training, experience, and technique may result in differences in rates of procedural complications," the authors write. However, it is not known whether outcomes of ICD implantation vary by physician specialty. In addition, appropriate device selection is particularly important for patients who may benefit from an ICD that also is capable of providing cardiac resynchronization therapy (CRT-D), a device that may improve survival and quality of life in patients with certain heart abnormalities. Jeptha P. Curtis, M.D., of Yale University School of Medicine, New Haven, Conn., and colleagues analyzed data from the ICD Registry, a national procedure-based registry of ICD implantations, to assess the association of physician certification with rates of ICD procedural complications and CRT-D implantation. Cases from the ICD Registry were grouped by the certification status of the implanting physician into mutually exclusive categories: electrophysiologists, nonelectrophysiologist cardiologists, thoracic surgeons, and other specialists. Of 111,293 ICD implantations included in the analysis, the researchers found that the majority of implants were performed by electrophysiologists (70.9 percent), with about 29 percent performed by nonelectrophysiologists (nonelectrophysiologist cardiologists, 21.9 percent; thoracic surgeons, 1.7 percent; and other specialists, 5.5 percent). The rates of overall and major complications were 3.5 percent and 1.3 percent, respectively, among electrophysiologists, and 5.8 percent and 2.5 percent, respectively, among thoracic surgeons. "The mechanisms underlying the observed differences in complication rates are not clear, but they may reflect differences in training, experience, and operative technique," the authors write. Among 35,841 patients (32.2 percent) who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist. "Given the substantial benefits associated with CRT-D both in terms of improved survival and quality of life, the decision not to implant a CRT-D device carries significant implications for patient care." The researchers also found that the majority of ICD implantations performed by nonelectrophysiologists took place at or relatively near hospitals in which an electrophysiologist also implanted ICDs.
"If confirmed, these findings may warrant a reappraisal of the need for and methods of training nonelectrophysiologists to implant ICDs," the authors conclude.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Physician Credentials and ICD Implantation — Certified 'Electricians' Best Deal With Electrical Problems
In an accompanying editorial, James Coromilas, M.D., of the Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, New Brunswick, comments on the findings of this study.
"Based on the thorough and insightful analysis by Curtis et al, a compelling argument can be made based on the outcome measure of procedural complications, whenever possible, a board-certified electrophysiologist should be implanting ICDs. Curtis et al found that access to electrophysiologists is not a major factor in the implantation of ICDs by nonelectrophysiologists because two-thirds of the implants by nonelectrophysiologists were performed in hospitals that had electrophysiologists on staff and the distance to a hospital with a board-certified electrophysiologist was only a factor in a small percentage of cases."
Editor's Note: Please see the article for additional information, including 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), Tuesday, April 21, 2009
Continuity of Care For Older Adults From Outpatient to Hospital is Low, and Decreasing
CHICAGO—The proportion of Medicare patients experiencing continuity of care between outpatient and inpatient settings decreased substantially between 1996 and 2006, with decreases occurring in all areas of the country and in all types of hospitals, according to a study in the April 22/29 issue of JAMA. Continuity of care is generally recognized to have 3 dimensions—continuity in information, continuity in management, and continuity in the patient-physician relationship. "Relationship continuity is the ongoing interaction of a patient with one physician, which results in increased knowledge of patient preferences, better communication, and improved trust," the authors write. "Such outpatient continuity has shown to be associated with improved patient satisfaction, increased use of appropriate preventive health services, greater medication adherence, lower hospitalization rates, more appropriate end of life care, and lower cost." Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization. Gulshan Sharma, M.D., M.P.H., of the University of Texas Medical Branch, Galveston, Texas, and colleagues examined outpatient to inpatient continuity of care of older adults between 1996 and 2006, with the study including 3,020,770 hospital admissions during this time period. The researchers used enrollment and claims data for a 5 percent national sample of Medicare beneficiaries older than 66 years of age, with the data including patients' demographic and enrollment information, claims for hospital stays and information on physician services. The researchers found that outpatient to inpatient continuity with any outpatient physician decreased from 50.5 percent in 1996 to 39.8 percent in 2006. Similarly, outpatient to inpatient continuity with a primary care physician (PCP) decreased from 44.3 percent in 1996 to 31.9 percent in 2006. Greater absolute decreases in continuity with any outpatient physician between 1996 and 2006 occurred in patients admitted on weekends (13.9 percent) and those living in large metropolitan areas (11.7 percent) and in New England (16.2 percent). Approximately one-third of the decrease in continuity between 1996 and 2006 was associated with growth in hospitalist activity. Patients with co-existing illnesses and the oldest patients were more likely to have continuity with their outpatient physicians and with their PCP during hospitalization.
"Future research should explore whether the lack of continuity contributes to suboptimal care and whether interventions might ameliorate any detrimental effects of discontinuities in care," the authors conclude.
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), Tuesday, April 21, 2009
Remote or Rural Residence Not Associated With Increased Time to Kidney Transplantation
CHICAGO—Contrary to what may be a common perception, researchers found no evidence that the likelihood of kidney transplantation is lower among remote- or rural-dwelling patients treated for kidney failure in the United States, according to a study in the April 22/29 issue of JAMA. Kidney transplantation is a life-saving medical procedure for which the demand far exceeds the supply of transplantable organs. A recent study suggested that rural location of residence within the United States was associated with lower rates of solid organ transplantation compared with those living in urban areas, a finding that is consistent with other work showing that rural dwellers have reduced access to health services, which raises the possibility that current organ allocation schemes may discriminate against people living farther away from transplant centers, according to background information in the article. Marcello Tonelli, M.D., S.M., of the University of Alberta, Edmonton, and colleagues examined the association between distance from the closest transplant center and time to placement on the kidney transplantation waiting list or time to kidney transplantation. "Because the mandatory pretransplantation medical evaluation is more likely to be available in major medical centers, we hypothesized that people residing further from the nearest transplant center would be less likely to undergo transplantation," the authors write. The study included 699,751 adult patients with kidney failure who had initiated renal replacement in the United States between 1995 and 2007 and were on a prospective mandatory registry list. During median (midpoint) follow-up of 2.0 years, 122,785 (17.5 percent) patients received a kidney transplant. Median distance to the closest transplant center was 15 miles. Participants were classified into distance categories by miles from a transplant center with 0-15 miles serving as the referent category. "In contrast to our a priori hypotheses, we found that the likelihood of receiving a kidney transplant from a deceased or living donor among patients living farther away was similar to or greater than those residing within 15 miles of kidney transplant centers. Similarly, and again in contrast to our hypotheses, the adjusted likelihood of kidney transplantation was slightly lower among rural dwellers." The authors add that the findings were independent of demographic factors, co-existing illnesses and measured socioeconomic characteristics. "Although unexpected, our findings are encouraging because determining eligibility for kidney transplantation is a logistically challenging process that requires sequential diagnostic tests and encounters with health care clinicians. The finding that time to transplantation is similar or even shorter among remote- and rural-dwelling patients with kidney failure suggests that disparities in access for remote- and rural-dwellers with other diseases could be reduced or eliminated," the researchers write.
"These data suggest that efforts to improve equitable access to transplantation should not focus on populations defined solely by residence location."
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.
JAMA REPORTS
VIDEO: Windows Media | Quicktime
PATIENTS A LOT LESS LIKELY TO SEE THEIR PRIMARY CARE PHYSICIANS WHILE IN THE HOSPITAL THAN IN THE PAST
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