Self-Reported and Actual Beta-Blocker Prescribing for Heart Failure Patients: Physician Predictors

Beta-blockers reduce mortality among patients with systolic heart failure (HF), yet primary care provider prescription rates remain low.To examine the association between primary care physician characteristics and both self-reported and actual prescription of beta-blockers among patients with systolic HF.Cross-sectional survey with supplementary retrospective chart review.Primary care providers at three New York City Veterans Affairs medical centers.Main outcomes were: 1) self-reported prescribing of beta-blockers, and 2) actual prescribing of beta-blockers among HF patients. Physician HF practice patterns and confidence levels, as well as socio-demographic and clinical characteristics, were also assessed.Sixty-nine of 101 physicians (68%) completed the survey examining self-reported prescribing of beta-blockers. Physicians who served as inpatient ward attendings self-reported significantly higher rates of beta-blocker prescribing among their HF patients when compared with physicians who did not attend (78% vs. 58%; p = 0.002), as did physicians who were very confident in managing HF patients when compared with physicians who were not (82% vs. 68%; p = 0.009). Fifty-one of these 69 surveyed physicians (74%) were successfully matched to 287 HF patients for whom beta-blocker prescribing data was available. Physicians with greater self-reported rates of prescribing beta-blockers were significantly more likely to actually prescribe beta-blockers (p = 0.02); however, no other physician characteristics were significantly associated with actual prescribing of beta-blockers among HF patients.Physician teaching responsibilities and confidence levels were associated with self-reported beta-blocker prescribing among their HF patients. Educational efforts focused on improving confidence levels in HF care and increasing exposure to teaching may improve beta-blocker presciption in HF patients managed in primary care

Early versus delayed initiation of antiretroviral therapy for Indian HIV-Infected individuals with tuberculosis on antituberculosis treatment

BACKGROUND: For antiretroviral therapy (ART) naive human immunodeficiency virus (HIV) infected adults suffering from tuberculosis (TB), there is uncertainty about the optimal time to initiate highly active antiretroviral therapy (HAART) after starting antituberculosis treatment (ATT), in order to minimize mortality, HIV disease progression, and adverse events. METHODS: In a randomized, open label trial at All India Institute of Medical Sciences, New Delhi, India, eligible HIV positive individuals with a diagnosis of TB were randomly assigned to receive HAART after 2-4 or 8-12 weeks of starting ATT, and were followed for 12 months after HAART initiation. Participants received directly observed therapy short course (DOTS) for TB, and an antiretroviral regimen comprising stavudine or zidovudine, lamivudine, and efavirenz. Primary end points were death from any cause, and progression of HIV disease marked by failure of ART. FINDINGS: A total of 150 patients with HIV and TB were initiated on HAART: 88 received it after 2-4 weeks (early ART) and 62 after 8-12 weeks (delayed ART) of starting ATT. There was no significant difference in mortality between the groups after the introduction of HAART. However, incidence of ART failure was 31% in delayed versus 16% in early ART arm (p = 0.045). Kaplan Meier disease progression free survival at 12 months was 79% for early versus 64% for the delayed ART arm (p = 0.05). Rates of adverse events were similar. INTERPRETATION: Early initiation of HAART for patients with HIV and TB significantly decreases incidence of HIV disease progression and has good tolerability. TRIAL REGISTRATION: CTRI/2011/12/00226

Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions

Introduction: Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Some patients admitted from the ED may not require inpatient care if outpatient care could be optimized. However, access to primary care especially immediately after ED discharge is challenging. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center. Methods: We conducted a retrospective review of patients referred from the ED to primary care (Weill Cornell Internal Medicine Associates – WCIMA) through a rapid-access-to-primary-care program developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals were classified as either an avoided admission or not, and classifications were performed by both emergency physician (EP) and internal medicine physician reviewers. We also collected outcome data on rapid visit completion, ED revisits, hospitalizations and primary care engagement. Results: EPs classified 26 (16%) of referrals for rapid primary care follow-up as avoided admissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapid appointment. There were no differences in rates of ED revisits or subsequent hospitalizations between those who attended the rapid follow-up and those who did not attend. Patients who attended the rapid appointment were significantly more likely to attend at least one subsequent appointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8 (18%), P=0.001]. Conclusion: A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care

Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions

Introduction: Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Some patients admitted from the ED may not require inpatient care if outpatient care could be optimized. However, access to primary care especially immediately after ED discharge is challenging. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center. Methods: We conducted a retrospective review of patients referred from the ED to primary care (Weill Cornell Internal Medicine Associates – WCIMA) through a rapid-access-to-primary-care program developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals were classified as either an avoided admission or not, and classifications were performed by both emergency physician (EP) and internal medicine physician reviewers. We also collected outcome data on rapid visit completion, ED revisits, hospitalizations and primary care engagement. Results: EPs classified 26 (16%) of referrals for rapid primary care follow-up as avoided admissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapid appointment. There were no differences in rates of ED revisits or subsequent hospitalizations between those who attended the rapid follow-up and those who did not attend. Patients who attended the rapid appointment were significantly more likely to attend at least one subsequent appointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8 (18%), P=0.001]. Conclusion: A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care

Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions

Introduction: Hospital admissions from the emergency department (ED) now account forapproximately 50% of all admissions. Some patients admitted from the ED may not requireinpatient care if outpatient care could be optimized. However, access to primary care especiallyimmediately after ED discharge is challenging. Studies have not addressed the extent to whichhospital admissions from the ED may be averted with access to rapid (next business day)primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol onavoidance of hospitalizations in a large, urban medical center.Methods: We conducted a retrospective review of patients referred from the ED to primary care(Weill Cornell Internal Medicine Associates – WCIMA) through a rapid-access-to-primary-careprogram developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals wereclassified as either an avoided admission or not, and classifications were performed by bothemergency physician (EP) and internal medicine physician reviewers. We also collected outcomedata on rapid visit completion, ED revisits, hospitalizations and primary care engagement.Results: EPs classified 26 (16%) of referrals for rapid primary care fol low-up as avoidedadmissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapidappointment. There were no differences in rates of ED revisits or subsequent hospitalizationsbetween those who attended the rapid follow-up and those who did not attend. Patients whoattended the rapid appointment were significantly more likely to attend at least one subsequentappointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8(18%), P=0.001].Conclusion: A rapid-ED-to-primary-care-access program may allow EPs to avoid admittingpatients to the hospital without risking ED revisits or subsequent hospitalizations. This protocolhas the potential to save costs over time. A program such as this can also provide a safe andreliable ED discharge option that is also an effective mechanism for engaging patients in primarycare. [West J Emerg Med. 2017;18(5)870-877.]

BRIEF REPORT: β-Blocker Use Among Veterans with Systolic Heart Failure

Numerical results for kinetic and thermal energy dissipation rates in bubbly Rayleigh-Bénard convection are reported. Bubbles have a twofold effect on the flow: on the one hand, they absorb or release heat to the surrounding liquid phase, thus tending to decrease the temperature differences responsible for the convective motion; but on the other hand, the absorbed heat causes the bubbles to grow, thus increasing their buoyancy and enhancing turbulence (or, more properly, pseudoturbulence) by generating velocity fluctuations. This enhancement depends on the ratio of the sensible heat to the latent heat of the phase change, given by the Jakob number, which determines the dynamics of the bubble growth

Early versus delayed initiation of antiretroviral therapy for Indian HIV-Infected individuals with tuberculosis on antituberculosis treatment

AbstractBackgroundFor antiretroviral therapy (ART) naive human immunodeficiency virus (HIV) infected adults suffering from tuberculosis (TB), there is uncertainty about the optimal time to initiate highly active antiretroviral therapy (HAART) after starting antituberculosis treatment (ATT), in order to minimize mortality, HIV disease progression, and adverse events.MethodsIn a randomized, open label trial at All India Institute of Medical Sciences, New Delhi, India, eligible HIV positive individuals with a diagnosis of TB were randomly assigned to receive HAART after 2-4 or 8-12 weeks of starting ATT, and were followed for 12 months after HAART initiation. Participants received directly observed therapy short course (DOTS) for TB, and an antiretroviral regimen comprising stavudine or zidovudine, lamivudine, and efavirenz. Primary end points were death from any cause, and progression of HIV disease marked by failure of ART.FindingsA total of 150 patients with HIV and TB were initiated on HAART: 88 received it after 2-4 weeks (early ART) and 62 after 8-12 weeks (delayed ART) of starting ATT. There was no significant difference in mortality between the groups after the introduction of HAART. However, incidence of ART failure was 31% in delayed versus 16% in early ART arm (p = 0.045). Kaplan Meier disease progression free survival at 12 months was 79% for early versus 64% for the delayed ART arm (p = 0.05). Rates of adverse events were similar.InterpretationEarly initiation of HAART for patients with HIV and TB significantly decreases incidence of HIV disease progression and has good tolerability.Trial registrationCTRI/2011/12/00226