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May 5, 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, May 5, 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. TV Note: This week's JAMA Report video is on the effect of an intervention to reduce hospitalizations and emergency room visits among chronically ill homeless adults. The report will be fed Tuesday, May 5, 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, May 5, 2009
Program Helps Reduce Hospital and Emergency Department Use Among Homeless Adults With Chronic Illnesses
CHICAGO—An intervention that provided housing and case management to homeless adults with chronic medical illnesses reduced hospitalizations and emergency department visits, according to a study in the May 6 issue of JAMA. Addressing the health needs of the homeless population is a challenge to physicians, health institutions, and federal, state, and local governments, with an estimated 3.5 million individuals in the U.S. likely to experience homelessness in a given year. Rates of chronic medical illness are high among homeless adults, who are frequent users of costly emergency department and hospital services, largely paid for by public dollars. "The combination of chronic medical illnesses and poor access to primary health care has substantial health and economic consequences," the authors write. Laura S. Sadowski, M.D., M.P.H., of Stroger Hospital of Cook County, Chicago, and colleagues conducted a study to determine whether an intervention that provided housing and case management for homeless adults with chronic medical illness would reduce hospitalizations and visits to the emergency department. Participants (n = 405; 78 percent men, 78 percent African American, with a median [midpoint] duration of homelessness of 30 months) were randomized to the intervention or usual care. The intervention (n = 201) included transitional housing after hospitalization discharge, followed by placement in long-term housing. Case managers facilitated the participant's housing placement and coordinated appropriate medical care, with substance abuse and mental health treatment referrals coordinated as needed. Usual care (n = 204) consisted of participants receiving standard discharge planning from hospital social workers. After 18 months, 73 percent of participants had at least 1 hospitalization or emergency department visit. During this time period there were 583 hospitalizations in the intervention group (1.93 hospitalizations/person per year) and 743 in the usual care group (2.43 hospitalizations/person per year), with a reduction of 0.5 hospitalizations/person per year, and a reduction of 2.7 hospital days/person per year in the intervention group compared with the usual care group. Over 18 months, there were 2.61 emergency department visits/person per year in the intervention group and 3.77 visits/person per year in the usual care group, a reduction of 1.2 emergency department visits/person per year. After adjusting for various factors, compared with the usual care group, the intervention group had a relative reduction of 29 percent in hospitalizations, 29 percent in hospital days and 24 percent in emergency department visits. "Several factors could account for the success of our intervention. First, our case management program was linked to the medical system and provided coordinated services across the full spectrum of settings—hospitals, respite care centers, and stable and unstable community housing. Second, our intervention recognized the heterogeneity within the homeless population and tried to tailor the supportive housing to the participant's needs and characteristics. Third, our intervention represented a city-wide consortium of clinicians, social workers, and housing and other advocacy groups, which facilitated a comprehensive and coordinated effort to obtain case management and housing for every intervention participant."
"These results provide a rationale and a blueprint for programs that address the needs of this vulnerable population," 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: Housing the Chronically Homeless—High Hopes, Complex Realities
In an accompanying editorial, Stefan G. Kertesz, M.D., M.Sc., of the University of Alabama at Birmingham and Saul J. Weiner, M.D., of the University of Illinois at Chicago, write that the findings in this study and a study by Larimer et al, which appeared in the April 1, 2009 issue of JAMA, provide important information on the results of certain programs for the homeless.
"The studies by Larimer et al and Sadowski et al add to the increasing evidence that at least some large U.S. cities cannot afford not to house some who live on their streets. These studies demonstrate that for the most frequent users of costly public services, service use substantially abates when individuals have stable housing. The challenge now is to determine which subgroups of the homeless population could benefit most from Housing First, a valuable new approach—if not a panacea—in the quest to end homelessness."
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, May 5, 2009
Episode of Rapid, Irregular Heart Rhythm Before or After Cardiac Catheterization Associated With Increased Risk of Death Within 3 Months
CHICAGO—Certain heart attack patients who experience a rapid, abnormal heart rhythm before or after a coronary artery intervention or stent placement have a significantly higher risk of death within 90 days of the procedure, according to a study in the May 6 issue of JAMA. The incidence and outcomes of sustained ventricular tachycardia or fibrillation (VT/VF; irregular, rapid abnormal contractions of the ventricles) on patients with ST elevation myocardial infarction (STEMI; a certain pattern on an electrocardiogram following a heart attack) undergoing a coronary angioplasty or stent placement (percutaneous coronary intervention – PCI) have not been well understood, according to background information in the article. Rajendra H. Mehta, M.D., M.S., of the Duke Clinical Research Institute, Durham, N.C., and colleagues evaluated the association of VT/VF and its timing with the risk of death at 30 and 90 days in 5,745 patients with STEMI undergoing PCI at 296 hospitals in 17 countries. The patients were categorized into four groups: no VT/VF; VT/VF any time; early VT/VF, before the end of cardiac catheterization; and late VT/VF, after the end of cardiac catheterization. Of the patients in the trial, VT/VF occurred in 5.7 percent. The majority of VT/VF episodes (90 percent) occurred within 48 hours, and 64 percent occurred before the end of catheterization. The rate of death was significantly higher in patients with any VT/VF compared with those without it (90-day death, 23.2 percent vs. 3.6 percent). Clinical outcomes were particularly worse among patients with late VT/VF, although even those with early VT/VF had a significantly higher event rate compared with those without any VT/VF (90-day mortality for early VT/VF, 17.2 percent; and for late VT/VF, 33.3 percent; vs. 3.6 percent for patients with no VT/VF). After adjusting for various factors, the risk of death at 90 days was more than three times higher for patients with any VT/VF; more than two times higher for early VT/VF; and the risk of death at 90 days was about 5.5 times greater for patients with late VT/VF. Among the factors associated with early VT/VF included lower systolic blood pressure, higher body weight and higher heart rate; factors related to late VT/VF included lower systolic blood pressure, higher heart rate and lack of beta-blockers on admission.
"Our analysis identified patients who may benefit from closer surveillance in the intensive care or telemetry unit after the [PCI] procedure because of the risk for late VT/VF. In contrast, because of very low risk for late VT/VF in patients with complete reperfusion [restoration of blood flow], our findings suggest that close monitoring for late VT/VF may not be necessary and these patients may be candidates for early discharge. Because currently the majority of patients with STEMI worldwide are routinely monitored for longer than 72 hours, our findings have the potential to decrease resource use without compromising patient safety when a risk-based strategy of monitoring or early discharge is followed. However, this finding also needs confirmation in future studies," the authors write.
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, May 5, 2009
Elevated Level of Certain Protein in Urine Linked to Increased Risk for Blood Clots
CHICAGO—Preliminary research suggests that higher than normal levels of the protein albumin in urine is associated with an increased risk for blood clots in the deep veins of the legs or lungs (venous thromboembolism; VTE), according to a study in the May 6 issue of JAMA. The overall incidence of VTE in developed countries is about 0.15 percent per year, varying from less than 0.005 percent in individuals younger than 15 years to as high as 0.5 percent at 80 years of age. Known risk factors for VTE include stasis (a slowing of the normal flow) of the blood and changes in the composition of the blood. However, in as many as 50 percent of VTE cases, none of the known risk factors are present, according to background information in the article. Microalbuminuria (albumin in urine; 30-300 mg per 24-hour urine collection) is associated with changes in the levels of several coagulation proteins. The effect of coagulation disorders is more evident in the development of VTE than of arterial thromboembolism (formation of a blood clot in the arterial system). "Hence, in theory, a link between microalbuminuria and VTE is likely; however, research addressing this issue has yet to be conducted," the authors write. Bakhtawar K. Mahmoodi, B.Sc., of the University Medical Centre Groningen, the Netherlands, and colleagues conducted a study to assess whether microalbuminuria is associated with VTE. The ongoing, community-based study, started in 1997, includes all inhabitants of Groningen, the Netherlands, (age 28 through 75 years [n = 85,421]) who were sent a postal questionnaire and a vial to collect a urine sample for measurement of urinary albumin concentration. Of those who responded (40,856), a group (8,592) including more participants with higher levels of urinary albumin concentration completed screening at an outpatient clinic. Screening data were collected on urinary albumin excretion (UAE) and risk factors for cardiovascular and kidney disease. Of 8,574 evaluable participants (average age, 49 years; 50 percent men), 129 developed at least 1 VTE during an average observation period of 8.6 years, corresponding to an annual incidence of 0.14 percent, ranging from 0.12 percent in participants with UAE of less than 15 mg/24 h to 0.56 percent in participants with UAE of greater than 300 mg/24 h. These annual incidences were 0.40 percent in microalbuminuric vs. 0.12 percent in normoalbuminuric participants (UAE less than 30 mg/24 hour urine collection). During 8 years of follow-up, 3 percent of microalbuminuric participants and 1 percent of normoalbuminuric participants developed VTE. The most commonly encountered first VTE was deep vein thrombosis (57 percent; a blood clot in a deep vein in the thigh or leg), followed by pulmonary embolism (34 percent; a blood clot in a blood vessel in the lungs), and combined deep vein thrombosis and pulmonary embolism (9 percent).
"The fact that microalbuminuria has a high prevalence in the general population (7.2 percent) suggests that on the population level, microalbuminuria may be an important risk factor for VTE. Moreover, in contrast to most of the established VTE risk factors, microalbuminuria could be treated by nonanticoagulant medication. Future studies are needed to evaluate the effect of these drugs on the risk of VTE," the authors write.
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
FEWER HOSPITALIZATIONS FOR HOMELESS PERSONS WITH CHRONIC MEDICAL CONDITIONS WHO RECEIVE ASSISTANCE
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