Racial Disparities in Cardiac Care: Geography Matters

Racial disparities in health care have been well-documented, although the reasons for many of these disparities remain obscure. An intriguing possibility is that geographic factors—the places where certain groups live or obtain health care—contribute to racial disparities, especially in the use of new medical technologies. This Issue Brief examines racial disparities in the use of life-saving cardiac procedures and mortality after cardiac arrest, and considers how geographic differences in health care affect these disparities

Preventing Sudden Death: Implantable Cardioverter-Defibrillators in Elderly Cardiac Patients

Much of the public was introduced to the implantable cardioverterdefibrillator (ICD) when Vice President Cheney, a survivor of four heart attacks, received the device in 2001. Although ICDs were initially limited to patients with previous cardiac arrests or arrhythmias, more recent studies have demonstrated that ICDs can prevent sudden cardiac death in patients who have not had a cardiac arrest, but are at greater risk for one (for example, those with congestive heart failure and reduced cardiac function). This Issue Brief summarizes studies that analyze health outcomes, costs, and quality of life for patients-at-risk who receive ICDs in real-life settings

Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest

Background— It is unknown whether white and black Medicare beneficiaries have different rates of cardiac procedure utilization or long-term survival after cardiac arrest. Methods and Results— A total of 5948 elderly Medicare beneficiaries (5429 white and 519 black) were identified who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. Demographic, socioeconomic, and clinical information about these patients was obtained from Medicare administrative files, the US census, and the American Hospital Association’s annual institutional survey. A Cox proportional hazard model that included demographic and clinical predictors indicated a hazard ratio for mortality of 1.30 (95% CI 1.09 to 1.55) for blacks aged 66 to 74 years compared with whites of the same age. The addition of cardiac procedures to this model lowered the hazard ratio for blacks to 1.23 (95% CI 1.03 to 1.46). In analyses stratified by race, implantable cardioverter-defibrillators (ICDs) had a mortality hazard ratio of 0.53 (95% CI 0.45 to 0.62) for white patients and 0.50 (95% CI 0.27 to 0.91) for black patients. Logistic regression models that compared procedure rates between races indicated odds ratios for blacks aged 66 to 74 years of 0.58 (95% CI 0.36 to 0.94) to receive an ICD and 0.50 (95% CI 0.34 to 0.75) to receive either revascularization or an ICD. Conclusions— There is racial disparity in long-term mortality among elderly cardiac arrest survivors. Both black and white patients benefited from ICD implantation, but blacks were less likely to undergo this potentially life-saving procedure. Lower rates of cardiac procedures may explain in part the lower survival rates among black patients

Near/Far Matching: A Study Design Approach to Instrumental Variables

Classic instrumental variable techniques involve the use of structural equation modeling or other forms of parameterized modeling. In this paper we use a nonparametric, matching-based instrumental variable methodology that is based on a study design approach. Similar to propensity score matching, though unlike classic instrumental variable approaches, near/far matching is capable of estimating causal effects when the outcome is not continuous. Unlike propensity score matching, though similar to instrumental variable techniques, near/far matching is also capable of estimating causal effects even when unmeasured covariates produce selection bias. We illustrate near/far matching by using Medicare data to compare the effectiveness of carotid arterial stents with cerebral protection versus carotid endarterectomy for the treatment of carotid stenosis

Species delimitation in lemurs: multiple genetic loci reveal low levels of species diversity in the genus Cheirogaleus

<p>Abstract</p> <p>Background</p> <p>Species are viewed as the fundamental unit in most subdisciplines of biology. To conservationists this unit represents the currency for global biodiversity assessments. Even though Madagascar belongs to one of the top eight biodiversity hotspots of the world, the taxonomy of its charismatic lemuriform primates is not stable. Within the last 25 years, the number of described lemur species has more than doubled, with many newly described species identified among the nocturnal and small-bodied cheirogaleids. Here, we characterize the diversity of the dwarf lemurs (genus <it>Cheirogaleus</it>) and assess the status of the seven described species, based on phylogenetic and population genetic analysis of mtDNA (<it>cytb </it>+ <it>cox2</it>) and three nuclear markers (<it>adora3</it>, <it>fiba </it>and <it>vWF</it>).</p> <p>Results</p> <p>This study identified three distinct evolutionary lineages within the genus <it>Cheirogaleus</it>. Population genetic cluster analyses revealed a further layer of population divergence with six distinct genotypic clusters.</p> <p>Conclusion</p> <p>Based on the general metapopulation lineage concept and multiple concordant data sets, we identify three exclusive groups of dwarf lemur populations that correspond to three of the seven named species: <it>C. major</it>, <it>C. medius </it>and <it>C. crossleyi</it>. These three species were found to be genealogically exclusive in both mtDNA and nDNA loci and are morphologically distinguishable. The molecular and morphometric data indicate that <it>C. adipicaudatus </it>and <it>C. ravus </it>are synonymous with <it>C. medius </it>and <it>C. major</it>, respectively. <it>Cheirogaleus sibreei </it>falls into the <it>C. medius </it>mtDNA clade, but in morphological analyses the membership is not clearly resolved. We do not have sufficient data to assess the status of <it>C. minusculus</it>. Although additional patterns of population differentiation are evident, there are no clear subdivisions that would warrant additional specific status. We propose that ecological and more geographic data should be collected to confirm these results.</p

Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia 1

Previous economic studies of Helicobacter pylori eradication in dyspepsia and peptic ulcer disease have not measured quality of life using utilities (preference probabilities), which are needed to compare the cost-effectiveness of such treatment to other health care interventions. The goals of this study were to measure quality of life in patients with dyspepsia or peptic ulcer and apply these measurements to published models of disease management to determine cost-effectiveness in dollars per quality-adjusted life year (QALY) gained. Methods : Utilities for dyspepsia and peptic ulcer disease were measured in adult patients (n = 73) on chronic acid suppression for peptic ulcer or ulcer-like dyspepsia. Median utility values were applied to the results of published cost-effectiveness analyses and a previously validated dyspepsia model. Cost-utility ratios for early H. pylori eradication in uninvestigated dyspepsia and peptic ulcer disease were then computed. Results : The total disutility, or lost quality of life, for an ulcer was 0.11 QALY, of which 0.09 QALY was attributed to dyspeptic symptoms. After these results were incorporated into published studies, cost-utility ratios for ulcer treatment varied from $3,100 to$12,500 per QALY gained, whereas estimates for uninvestigated dyspepsia management ranged from $26,800 to$59,400 per QALY. Sensitivity analyses indicated a range of $1,300 to$27,300 per QALY for management of duodenal ulcer and $15,000 to$129,700 per QALY for dyspepsia. Conclusions: Strategies that emphasize early H. pylori eradication were cost-effective for patients with peptic ulcer and possibly cost-effective for patients with uninvestigated dyspepsia, relative to other medical interventions. Dyspeptic symptoms cause significant disutility that should be incorporated in future cost-effectiveness analyses of treatment strategies.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73031/1/j.1572-0241.2001.03516.x.pd

Adjuvant Chemotherapy Use and Health Care Costs After Introduction of Genomic Testing in Breast Cancer

Genomic testing in patients with early-stage breast cancer is associated with decreased use of chemotherapy and lower costs in younger patients, and slightly increased use of chemotherapy and higher costs in older patients. Genomic testing in actual practice may “rule out” chemotherapy in younger women, and “rule in” chemotherapy in older women

Recruitment for a Hospital-Based Pragmatic Clinical Trial using Volunteer Nurses and Students

BACKGROUND/AIMS: Recruitment of subjects is critical to the success of any clinical trial, but achieving this goal can be a challenging endeavor. Volunteer nurse and student enrollers are potentially an important source of recruiters for hospital-based trials; however, little is known of either the efficacy or cost of these types of enrollers. We assessed volunteer clinical nurses and health science students in their rates of enrolling family members in a hospital-based, pragmatic clinical trial of cardiopulmonary resuscitation education, and their ability to achieve target recruitment goals. We hypothesized that students would have a higher enrollment rate and are more cost-effective compared to nurses. METHODS: Volunteer nurses and student enrollers were recruited from eight institutions. Participating nurses were primarily bedside nurses or nurse educators while students were pre-medical, pre-nursing, and pre-health students at local universities. We recorded the frequency of enrollees recruited into the clinical trial by each enroller. Enrollers\u27 impressions of recruitment were assessed using mixed-methods surveys. Cost was estimated based on enrollment data. Overall enrollment data were analyzed using descriptive statistics and generalized estimating equations. RESULTS: From February 2012 to November 2014, 260 hospital personnel (167 nurses and 93 students) enrolled 1493 cardiac patients\u27 family members, achieving target recruitment goals. Of those recruited, 822 (55%) were by nurses, while 671 (45%) were by students. Overall, students enrolled 5.44 (95% confidence interval (CI): 2.88, 10.27) more subjects per month than nurses (p \u3c 0.01). After consenting to participate in recruitment, students had a 2.85 (95% CI: 1.09, 7.43) increased chance of enrolling at least one family member (p = 0.03). Among those who enrolled at least one subject, nurses enrolled a mean of 0.51(95% CI: 0.42, 0.59) subjects monthly, while students enrolled 1.63 (95% CI: 1.37, 1.90) per month (p \u3c 0.01). Of 198 surveyed hospital personnel (127 nurses, 71 students), 168/198 (85%) felt confident conducting enrollment. The variable cost per enrollee recruited was $25.38 per subject for nurses and$23.30 per subject for students. CONCLUSIONS: Overall, volunteer students enrolled more subjects per month at a lower cost than nurses. This work suggests that recruitment goals for a pragmatic clinical trial can be successfully obtained using both nurses and students

Circulating angiopoietin-2 levels in the course of septic shock: relation with fluid balance, pulmonary dysfunction and mortality

Contains fulltext : 79899.pdf (publisher's version ) (Closed access)PURPOSE: To investigate whether angiopoietin-2, von Willebrand factor (VWF) and angiopoietin-1 relate to surrogate indicators of vascular permeability, pulmonary dysfunction and intensive care unit (ICU) mortality throughout the course of septic shock. METHODS: In 50 consecutive mechanically ventilated septic shock patients, plasma angiopoietin-2, VWF and angiopoietin-1 levels and fluid balance, partial pressure of oxygen/inspiratory oxygen fraction and the oxygenation index as indicators of vascular permeability and pulmonary dysfunction, respectively, were measured until day 28. RESULTS: Angiopoietin-2 positively related to the fluid balance and pulmonary dysfunction, was higher in non-survivors than in survivors and independently predicted non-survival throughout the course of septic shock. VWF inversely related to the fluid balance and pulmonary dysfunction throughout the course of septic shock, was comparable between survivors and non-survivors and predicted non-survival on day 0 only. Angiopoietin-1 positively related to pulmonary dysfunction throughout the course, but did not differ between survivors and non-survivors. CONCLUSIONS: In contrast to VWF, plasma angiopoietin-2 positively relates to fluid balance, pulmonary dysfunction and mortality throughout the course of septic shock, in line with a suggested mediator role of the protein