Background:

The withdrawal of rofecoxib has highlighted concerns regarding the safety of cyclooxygenase-2 (COX-2) inhibitors. In some patients COX-2 inhibitors may be safer than nonselective nonsteroidal anti-inflammatory drugs (NSAIDs); however, the public health benefit of COX-2 inhibitors depends on their use in patients at higher than normal risk from NSAIDs. We examined trends in COX-2 inhibitor use based on risk for adverse events from NSAIDs.

Methods:

We analyzed data from the National Ambulatory Medical Care Survey (1999-2002) and National Hospital Ambulatory Medical Care Survey (1999-2001), nationally representative surveys of community and hospital-based outpatient practices. The main outcome measure was the proportion of patient visits in which COX-2 inhibitors were prescribed, stratified by risk of adverse gastrointestinal (GI) events from NSAIDs.

Results:

Of the visits in which either a COX-2 inhibitor or NSAID was prescribed, the frequency of COX-2 inhibitor use increased from 35% (1999) to 55% (2000) to 61% (2001 and 2002). Among patients with the lowest risk for adverse events from NSAIDs, the proportion receiving a COX-2 inhibitor increased from 12% in 1999 to 35% in 2002. Overall, increases in COX-2 inhibitor use among patients in whom NSAIDs could be used accounted for more than 63% of the growth in COX-2 inhibitor use during the period examined.

Conclusions:

Marked increases in COX-2 inhibitor use have occurred since their release, primarily among patients at low risk for adverse events from NSAIDs. These findings demonstrate the challenge of limiting innovative therapies to the settings in which they are initially targeted and maximally beneficial.

Objectives

The study was designed to determine whether racial disparity in utilization of the implantable cardioverter-defibrillator (ICD) has improved over time, and whether small-area geographic variation in ICD utilization contributed to national levels of racial disparity.

Background

Although racial disparities in cardiac procedures have been well-documented, it is unknown whether there has been improvement over time. Low ICD utilization rates in predominantly black geographic areas may have exacerbated national levels of disparity.

Methods

Discharge abstracts from elderly black and white Medicare beneficiaries hospitalized with ventricular arrhythmias from 1990 to 2000 were analyzed to determine if ICD implantation occurred within 90 days of initial hospitalization. Multivariate logistic regression models were constructed to assess the relationship between ICD implantation, year of admission, and the percentage of black inhabitants in each patient's county of hospitalization while controlling for clinical, hospital, and demographic characteristics.

Results

There was improvement in ICD implantation racial disparity: In the period 1990 to 1992, black patients had an odds ratio of 0.52 (95% confidence interval [CI] 0.42 to 0.64) for receiving an ICD compared with whites. However, by 1999 to 2000, the odds ratio for blacks had risen to 0.69 (95% CI 0.61 to 0.78) (test-for-trend p = 0.01). Approximately 20% of this trend could be explained by reduction in geographic variation in ICD use between areas with larger black and predominantly white populations.

Conclusions

Rates of ICD implants became more equal among whites and blacks during the 1990s, although persistent disparity remained at the decade's end. Geographic equalization in cardiovascular procedure rates may be an essential mechanism in rectifying disparities in health care.

PURPOSE:

The cost-effectiveness of cardiopulmonary resuscitation (CPR) and defibrillation training for laypersons unselected for risk of encountering cases of cardiac arrest is not known. We compared the costs and health benefits of alternative resuscitation training strategies for adults without professional first-responder duties who are at average risk of encountering cases of out-of-hospital cardiac arrest.

METHODS:

We constructed a cost-effectiveness analytic model. Data on cardiac arrest epidemiology and the effectiveness of CPR/defibrillation training were obtained from the medical literature. Instructional costs were determined from a survey of training programs. Downstream cardiac arrest survivor quality-adjusted life expectancy and long-term health care costs were derived from prior studies. We compared three strategies for training unselected laypersons: CPR/defibrillation training alone, training combined with home defibrillator purchase, and no training. The main outcome measures were total instructional costs for trainees combined with health care costs for additional cardiac arrest survivors, and quality-adjusted survival for additional patients resuscitated by trainees.

RESULTS:

CPR/defibrillation training yielded 2.7 quality-adjusted hours of life at a cost of 62 US dollars per trainee (202,400 US dollars per quality-adjusted life-year [QALY] gained). Training laypersons in CPR/defibrillation with subsequent defibrillator purchase cost 2,489,700 US dollars per QALY. In contrast, CPR/defibrillation training cost less than 75,000 US dollars per QALY if trainees lived with persons older than 75 years or with persons who had cardiac disease, or if total training costs were less than 10 US dollars.

CONCLUSION:

Training unselected laypersons in CPR/defibrillation is costly compared with other public health initiatives. Conversely, training laypersons selected by occupation, low training costs, or having high-risk household companions is substantially more efficient.

The implantable cardioverter defibrillator (ICD) is a costly new treatment for patients at high risk of sudden cardiac death. Randomized trials of the ICD showed it to be effective in some groups of patients but not in others. While new trials testing the ICD were ongoing to clarify the evidence, policymakers faced immediate decisions about providing insurance coverage for the device. The high cost of ICDs, the large population of patients potentially eligible to receive them, the potential to reduce preventable deaths, and the unsettled state of the medical evidence provided a challenge to evidence-based medicine and to policymakers.

Objective:

Hypertension affects more than 50 million people in the United States alone. Despite clear evidence regarding the beneficial effects of quality treatment for high blood pressure, many millions of diagnosed and undiagnosed hypertensives are not receiving the optimal standard of care. The difference in patient outcomes achieved with present hypertension treatment methods and those thought to be possible using best practice treatment methods is known as a quality gap, and such gaps are at least partly responsible for the loss of thousands of lives each year. This review was organized to bring a systematic assessment of different quality improvement (QI) strategies and their effects to the process of identifying and managing hypertension.

Search Strategy and Inclusion Criteria:

Investigators searched the MEDLINE® database, the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) registry, article bibliographies, and relevant journals for experimental evaluations of QI interventions aimed at improving hypertension screening and management of non-pregnant adults with primary hypertension. The reviewers included randomized or quasi-randomized controlled trials, controlled before/after studies, and interrupted time series in which at least one reported outcome measure included changes in blood pressure, or provider or patient adherence to a recommended process of care.

Data Collection and Analysis:

Relevant data were abstracted independently by two reviewers. Each QI intervention was classified into one or more of the following components: provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self-management, patient reminders, audit and feedback, organizational change, or financial incentives. Certain categories were further subdivided into major subtypes (e.g., professional meetings for provider education and disease management for organizational change). The researchers also evaluated the impact of clinical information systems as a mediator for interventions of all types. They compared the different QI strategies in terms of the median effects achieved for blood pressure control and for a generalized measure of provider or patient adherence.

Main Results:

Sixty-three articles reporting a total of 82 comparisons met the inclusion criteria. Studies of hypertension identification were found to be too heterogeneous for quantitative analysis. The majority of screening studies were clinic-based (with a few offered at work sites), and the most common strategies involved patient and/or provider reminders. These generally showed positive results; several studies found that patients were more likely to know their blood pressure or attend clinic visits after receiving reminders. Across all studies with a variety of strategies, the median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 4.5 mmHg (interquartile range: 1.5, 11.0) and 2.1 mmHg (interquartile range: -0.2, 5.0), respectively. The median increase in the proportion of patients in the target SBP range and target DBP range was 16.2 percent (interquartile range: 10.3, 32.2), and 6.0 percent (interquartile range: 1.5, 17.5), respectively. Studies that focused on improving provider adherence showed a range of median reduction of 1.3 percent to a median improvement of 3.3 percent across all QI strategies. Overall, patient adherence showed a median improvement of 2.8 percent (interquartile

range: 1.9, 3.0).

Conclusion:

The findings of this review suggest that QI strategies appear, in general, to be associated with the improved identification and control of hypertension.

The UN has launched an initiative to place 3 million people in developing countries on antiretroviral AIDS treatment by end 2005 (the 3 by 5 target). Lessons for HIV/AIDS treatment scale-up emerge from recent experience with multidrug-resistant tuberculosis. Expansion of treatment for multidrug-resistant tuberculosis through the multipartner mechanism known as the Green Light Committee (GLC) has enabled gains in areas relevant to 3 by 5, including policy development, drug procurement, rational use of drugs, and the strengthening of health systems. The successes of the GLC and the obstacles it has encountered provide insights for building sustainable HIV/AIDS treatment programmes.

OBJECTIVE: Care remains suboptimal for a substantial proportion of the more than 17 million patients in the United States with diabetes. This review examines strategies for improving the quality of care for adult type 2 diabetic patients, through changes in provider behavior and modifications to the organization of care. SEARCH STRATEGY AND
INCLUSION CRITERIA: The researchers searched the MEDLINE® database, the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) registry, article bibliographies, and relevant journals for experimental evaluations of quality improvement (QI) interventions involving outpatient care for adults with type 2 diabetes mellitus. The investigators included randomized or quasi-randomized controlled trials, controlled before-after studies, and interrupted time series in which at least one reported outcome involved changes in serum hemoglobin A1c or a measure of provider adherence to a recommended process of care.
DATA COLLECTION AND ANALYSIS: Two reviewers independently abstracted relevant data, including classifying the components of each QI intervention as provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self-management, patient reminders, audit and feedback, organizational change, or financial incentives. Certain categories were further subdivided into major subtypes (e.g., professional meetings for provider education and disease management for organizational change). The investigators also assessed the impact of clinical information systems as a mediator for interventions of all types. They compared different QI strategies in terms of the median effects achieved for glycemic control and for a generalized measure of clinician adherence. In addition, linear regression analyses were performed using methodologic features and QI types as predictors, taking into account baseline groups differences and study size.
MAIN RESULTS: Fifty-eight articles reporting a total of 66 trials met the established inclusion criteria. The most common interventions employed were organizational change in 40 trials, patient education in 28 trials, and provider education in 24 trials. Fifty-two trials involved interventions employing more than one QI strategy, with a median of 2 strategies per trial and a maximum of 5. The included trials reported a median absolute reduction in HbA1c of 0.48% (interquartile range: 0.20%, 1.38%), and a median improvement in clinician adherence of 4.9% (interquartile range: 3.8%, 15.0%). Trials in the lower 2 quartiles of sample size reported substantially larger effect sizes, as did non-randomized trials, strongly suggesting the presence of publication bias, with publication of smaller non-randomized trials occurring more often when reported improvements are large. Multifaceted trials reported a median reduction in HbA1c of 0.60% (interquartile range: 0.30%, 1.40%), compared to a median reduction of 0.0% (interquartile range: -0.08%, 0.16%) for trials of a single intervention (p=0.01). The benefit of employing more than one QI strategy appeared to persist among larger, randomized trials, but the small numbers of studies limits the reliability of this impression. The investigators did not find any specific type of QI strategy to confer unambiguous benefit. Provider education and disease management were the only strategies to approach statistical significance, compared with interventions absent these strategies.
CONCLUSION: The authors' analysis of quality improvement strategies for diabetes care showed no particular type of QI to have an advantage over others, but suggested that employing at least two strategies provides a greater chance of success than single-faceted interventions, in terms of improving glycemic control or provider adherence. These conclusions are limited by probable publication bias favoring smaller trials and non-randomized trials, and the confounding presence of multiple QI strategies in a given intervention, as well as important patient and provider factors, and organizational characteristics.

This study examined factors affecting medical service use among HIV-infected persons with a substance abuse disorder. The sample comprised 190 participants enrolled in a randomized trial of a case management intervention. Participants were interviewed about their backgrounds, housing status, income, alcohol and drug use problems, health status and depressive symptoms at study entry. Electronic medical records were used to assess medical service use. Poisson regression models were tested to determine the effects of need, enabling and predisposing factors on the dependent variables of emergency department visits, inpatient admissions and ambulatory care visits. During a two-year period, 71% were treated in the emergency department, 64% had been hospitalized and the sample averaged 12.9 ambulatory care visits. Homelessness was associated with higher utilization of emergency department and inpatient services; drug use severity was associated with higher inpatient and ambulatory care service use; and alcohol use severity was associated with greater use of emergency medical services. Homelessness and substance abuse exacerbate the health care needs of HIV-infected persons and result in increased use of emergency department and inpatient services. Interventions are needed that target HIV-infected persons with substance abuse disorders, particularly those that increase entry and retention in outpatient health care and thus decrease reliance on acute hospital-based services.