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Context Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. Objective To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. Design, Setting, and Participants Cohort study of 68 439 patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy and 33 647 treated with percutaneous coronary intervention (PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours (weekdays, 7 AM-5 PM) and off-hours (weekdays 5 PM-7 AM and weekends). Main Outcome Measures Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics. Results Most fibrinolytic therapy (67.9%) and PCI patients (54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours (34.3 minutes) than regular hours (33.2 minutes; difference, 1.0 minute; 95% confidence interval [CI], 0.7-1.4; P<.001). In contrast, door-to-balloon times were substantially longer during off-hours (116.1 minutes) than regular hours (94.8 minutes; difference, 21.3 minutes; 95% CI, 20.5-22.2; P<.001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours (25.7%) than regular hours (47%; P<.001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours (41.5%) than regular hours (27.7%; P<.001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory (off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P<.001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours (odds ratio, 1.07; 95% CI, 1.01-1.14; P = .02). Conclusions Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner. [ABSTRACT FROM AUTHOR]

Comments on the push for regional treatment centers for patients with acute coronary syndromes. Planning for regionalized care begun by the State of Maryland; Presentation of concerns for this approach to patient care and possible unintended consequences; Arguments for the benefits of the ACS centers, which are based on studies with notable limitations; Lack of clear consensus on the specific nature of ACS regionalization; Risks to patients; Concerns about how the direct admission of ACS patients will be handled; Economic implications; Concern that regionalization may be the end of quality care at non-ACS facilities; Conclusion and belief there is not enough data to support the value of these centers at this time.

Context Nonwhite patients experience significantly longer times to fibrinolytic therapy (door-to-drug times) and percutaneous coronary intervention (door-to-balloon times) than white patients, raising concerns of health care disparities, but the reasons for these patterns are poorly understood. Objectives To estimate race/ethnicity differences in door-to-drug and door-to-balloon times for patients receiving primary reperfusion for ST-segment elevation myocardial infarction; to examine how sociodemographic factors, insurance status, clinical characteristics, and hospital features mediate racial/ethnic differences. Design, Setting, and Patients Retrospective, observational study using admission and treatment data from the National Registry of Myocardial Infarction (NRMI) for a US cohort of patients with ST-segment elevation myocardial infarction or left bundle-branch block and receiving reperfusion therapy. Patients (73,032 receiving fibrinolytic therapy; 37,143 receiving primary percutaneous coronary intervention) were admitted from January 1, 1999, through December 31, 2002, to hospitals participating in NRMI 3 and 4. Main Outcome Measure Minutes between hospital arrival and acute reperfusion therapy. Results Door-to-drug times were significantly longer for patients identified as African American/black (41.1 minutes), Hispanic (36.1 minutes), and Asian/Pacific Islander (37.4 minutes), compared with patients identified as white (33.8 minutes) (P<.01 for all). Door-to-balloon times for patients identified as African American/black (122.3 minutes) or Hispanic (114.8 minutes) were significantly longer than for patients identified as white (103.4 minutes) (P<.001 for both). Racial/ethnic differences were still significant but were substantially reduced after accounting for differences in mean times to treatment for the hospitals in which patients were treated; significant racial/ethnic differences persisted after further adjustment for sociodemographic characte... [ABSTRACT FROM AUTHOR]

Context The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure emphasizes the importance of systolic hypertension (SH), defined as systolic blood pressure (SBP) of at least 140 mm Hg and diastolic blood pressure of less than 90 mm Hg, in older persons (≥60 years). Objective To systematically review the literature on clinical management of SH in older persons. Data Sources We performed a MEDLINE search of English-language literature from 1966-2004 to identify reports about SH in older persons, with particular emphasis on data from randomized clinical trials. Study Selection and Data Extraction We selected 1064 studies by using the search terms hypertension combined with the terms systole (or systolic) and aged. Data Synthesis There is strong evidence from clinical trials to support the treatment of SH in older persons with SBP of at least 160 mm Hg. Large-scale trials to assess the value of antihypertensive therapy for older patients with SBP of 140 to 159 mm Hg have not been performed, and recommendations to treat these patients are based on observational studies that show a graded relationship of cardiovascular risk with increasing SBP. The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy to treat SH. Conclusions Treatment of SH in older patients with SBP of at least 160 mm Hg is supported by strong evidence. The evidence available to support treatment of patients to the level of 140 mm Hg or those with baseline SBP of 140 to 159 mm Hg is less strong; thus, these treatment decisions should be more sensitive to patient preferences and tolerance of therapy. [ABSTRACT FROM AUTHOR]

Context Despite the importance of diversity of cancer trial participants with regard to race, ethnicity, age, and sex, there is little recent information about the representation of these groups in clinical trials. Objective To characterize the representation of racial and ethnic minorities, the elderly, and women in cancer trials sponsored by the National Cancer Institute. Design, Setting, and Patients Cross-sectional population-based analysis of all participants in therapeutic nonsurgical National Cancer Institute Clinical Trial Cooperative Group breast, colorectal, lung, and prostate cancer clinical trials in 2000 through 2002. In a separate analysis, the ethnic distribution of patients enrolled in 2000 through 2002 was compared with those enrolled in 1996 through 1998, using logistic regression models to estimate the relative risk ratio of enrollment for racial and ethnic minorities to that of white patients during these time periods. Main Outcome Measure Enrollment fraction, defined as the number of trial enrollees divided by the estimated US cancer cases in each race and age subgroup. Results Cancer research participation varied significantly across racial/ethnic and age groups. Compared with a 1.8% enrollment fraction among white patients, lower enrollment fractions were noted in Hispanic (1.3%; odds ratio [OR] vs whites, 0.72; 95% confidence interval [CI], 0.68-0.77; P<.001) and black (1.3%; OR, 0.71; 95% CI, 0.68-0.74; P<.001) patients. There was a strong relationship between age and enrollment fraction, with trial participants 30 to 64 years of age representing 3.0% of incident cancer patients in that age group, in comparison to 1.3% of 65- to 74-year-old patients and 0.5% of patients 75 years of age and older. This inverse relationship between age and trial enrollment fraction was consistent across racial and ethnic groups. Although the total number of trial participants increased during our study period, the representation of racial and ethnic m... [ABSTRACT FROM AUTHOR]

Context: According to package inserts, metformin is contraindicated in diabetic patients receiving drug treatment for heart failure therapy, and thiazolidinediones are not recommended in diabetic patients with symptoms of advanced heart failure. Little is known about patterns of use of these antihyperglycemic drugs in diabetic patients with heart failure. Objective: To determine the proportions of patients hospitalized with heart failure and concomitant diabetes treated with metformin or thiazolidinediones. Design: Serial cross-sectional measurements using data from retrospective medical record abstraction. Setting: Nongovernmental acute care hospitals in the United States. Patients: Two nationally representative samples of Medicare beneficiaries hospitalized with the primary diagnosis of heart failure and concomitant diabetes between April 1998 and March 1999 and between July 2000 and June 2001. Main Outcome Measures: The prescription of either metformin or a thiazolidinedione at hospital discharge. Results: In the 1998-1999 sample (n = 12 505), 7.1% of patients were discharged with a prescription for metformin, 7.2% with a prescription for a thiazolidinedione, and 13.5% with a prescription for either drug. In the 2000-2001 sample (n = 13 158), metformin use increased to 11.2%, thiazolidinedione use to 16.1%, and use of either drug to 24.4% (P<.001 for all comparisons). Similar increases were seen among patients of all age groups, all races, and both sexes. Conclusions: The use of metformin and thiazolidinediones is common and has increased rapidly in Medicare beneficiaries with diabetes and heart failure in direct contrast with explicit warnings against this practice by the Food and Drug Administration. Further studies to establish the safety and effectiveness of this practice are needed to ensure optimal care of patients with diabetes and heart failure. [ABSTRACT FROM AUTHOR]

Context: Black patients hospitalized with heart failure reportedly receive poorer quality of care and have worse outcomes than white patients. Because previous studies have been based on selected patient populations treated more than a decade ago, it is unclear if racial differences in quality of care and outcomes currently exist in the United States. Objective: To evaluate differences in quality of care and patient outcomes between black and white Medicare beneficiaries hospitalized with heart failure. Design: Retrospective analysis of medical record data systematically collected for the National Heart Failure Project. Setting and Patients: Nationwide US sample of 29 732 fee-for-service Medicare beneficiaries hospitalized with heart failure in 1998 and 1999. Main Outcome Measures: Prescription of angiotensin-converting enzyme (ACE) inhibitors, measurement of left ventricular ejection fraction (LVEF), readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission. Results: Black patients and white patients had similar crude rates of LVEF assessment (67.8% black vs 66.6% white; P = .29). Among patients classified as ideal for ACE inhibitor use, black patients had higher crude rates of ACE inhibitor use than white patients (81.0% vs 73.8% white; P<.001) but had similar rates of ACE inhibitor or angiotensin receptor blocker (ARB) use (85.7% black vs 82.5% white; P = .08). After multivariable adjustment, black patients had comparable rates of LVEF assessment (risk ratio [RR], 0.99; 95% confidence interval [CI], 0.95-1.03). Black patients remained more likely to be prescribed ACE inhibitors (RR, 1.22; 95% CI, 1.14-1.28) than were white patients in an adjusted analysis, but there were no significant racial differences in the prescription of ACE inhibitors or ARBs (black vs white, RR, 1.03; 95% CI, 0.97-1.07). Black patients had higher rates of readmission within 1 year of discharge (68.2% vs 63.0%; P<.001) but had lower crude 30-day (6... [ABSTRACT FROM AUTHOR]

Context: Low-carbohydrate diets have been popularized without detailed evidence of their efficacy or safety. The literature has no clear consensus as to what amount of carbohydrates per day constitutes a low-carbohydrate diet. Objective: To evaluate changes in weight, serum lipids, fasting serum glucose, and fasting serum insulin levels, and blood pressure among adults using low-carbohydrate diets in the outpatient setting. Data Sources: We performed MEDLINE and bibliographic searches for English-language studies published between January 1, 1966, and February 15, 2003, with key words such as low carbohydrate, ketogenic, and diet. Study Selection: We included articles describing adult, outpatient recipients of low-carbohydrate diets of 4 days or more in duration and 500 kcal/d or more, and which reported both carbohydrate content and total calories consumed. Literature searches identified 2609 potentially relevant articles of low-carbohydrate diets. We included 107 articles describing 94 dietary interventions reporting data for 3268 participants; 663 participants received diets of 60 g/d or less of carbohydrates—of whom only 71 received 20 g/d or less of carbohydrates. Study variables (eg, number of participants, design of dietary evaluation), participant variables (eg, age, sex, baseline weight, fasting serum glucose level), diet variables (eg, carbohydrate content, caloric content, duration) were abstracted from each study. Data Extraction: Two authors independently reviewed articles meeting inclusion criteria and abstracted data onto pretested abstraction forms. Data Synthesis: The included studies were highly heterogeneous with respect to design, carbohydrate content (range, 0-901 g/d), total caloric content (range, 525-4629 kcal/d), diet duration (range, 4-365 days), and participant characteristics (eg, baseline weight range, 57-217 kg). No study evaluated diets of 60 g/d or less of carbohydrates in participants with a mean age older than 53.1 years... [ABSTRACT FROM AUTHOR]

The Digitalis Investigation Group (DIG) trial reported that digoxin provided no overall mortality benefit and only a modest reduction in hospitalizations among patients with heart failure and depressed left ventricular systolic function. The clinical outcomes associated with digoxin therapy at different serum concentrations in the DIG trial have not been assessed. Our objective was to assess variations in serum digoxin concentration (SDC) and their association with mortality and hospitalization in patients with heart failure. Post hoc analysis of the randomized, double-blinded, placebo-controlled DIG trial, conducted from August 1991 to December 1995, with the main analysis restricted to men with a left ventricular ejection fraction of 45% or less (n = 3782). Patients randomly assigned to receive digoxin were divided into 3 groups based on SDC at 1 month (0.5-0.8 ng/mL, n = 572; 0.9-1.1 ng/mL, n = 322; and ≥1.2 ng/mL, n = 277) and compared with patients randomly assigned to receive placebo (n = 2611). All-cause mortality at a mean follow-up of 37 months. Results: Higher SDCs were associated with increased crude all-cause mortality rates (0.5-0.8 ng/mL, 29.9%; 0.9-1.1 ng/mL, 38.8%; and ≥1.2 ng/mL, 48.0%; P = .006 for trend). Patients with SDCs of 0.5 to 0.8 ng/mL had a 6.3% (95% confidence interval [CI], 2.1%-10.5%) lower mortality rate compared with patients receiving placebo. Digoxin was not associated with a reduction in mortality among patients with SDCs of 0.9 to 1.1 ng/mL (2.6% increase; 95% CI, - 3.0% to 8.3%), whereas patients with SDCs of 1.2 ng/mL and higher had an 11.8% (95% CI, 5.7%-18.0%) higher absolute mortality rate than patients receiving placebo. The association between SDC and mortality persisted after multivariable adjustment (SDC 0.5-0.8 ng/mL hazard ratio [HR] 0.80, 95% CI, 0.68-0.94; SDC 0.9-1.1 ng/mL HR 0.89, 95% CI, 0.74-1.08; SDC ≥1.2 ng/mL HR 1.16, 95% CI, 0... [ABSTRACT FROM AUTHOR]

Provides letters to the editor on a variety of medical issues. Medical residents' emotional well-being; Role of regional anesthesia and preeclampsia; Guidelines for the treatment of anthrax.

Context: beta-Blocker therapy remains substantially underused in cardiac patients despite its proven mortality benefits. Reluctance to prescribe these agents may derive from concerns about their association with symptoms of depression, fatigue, and sexual dysfunction.Objective: To determine the association of beta-blockers with depressive symptoms, fatigue, and sexual dysfunction by performing a quantitative review of randomized trials that tested beta-blockers in myocardial infarction, heart failure, and hypertension.Data Sources: Randomized trials of beta-blockers used in the treatment of myocardial infarction, heart failure, or hypertension were identified by searching the MEDLINE database for English-language articles (1966-2001). In addition, we searched the reference lists of previously published trials and reviews of beta-blockers for additional studies.Study Selection: Criteria for inclusion of trials in the review were: random allocation of study treatments, placebo control, noncrossover design, enrollment of at least 100 patients, and a minimum of 6 months of follow-up. The initial search produced 475 articles, 42 of which met these criteria. Fifteen of these trials reported on depressive symptoms, fatigue, or sexual dysfunction and were selected for inclusion.Data Extraction: For each trial, 1 author abstracted the frequency of adverse events in the beta-blocker and placebo groups and the numbers of patients randomized to the treatment groups. Two other authors verified the counts of events, and all authors adjudicated any discrepancies. Two different types of information on adverse events were abstracted: patient-reported symptoms and withdrawal of therapy due to a specified symptom. We categorized the tested beta-blockers by generation (early vs late) and lipid solubility (high vs low to moderate).Data Synthesis: The 15 trials involved more than 35,000 subjects. beta-Blocker therapy was not associated with a significant absolute annual increase in risk of reported depressive symptoms (6 per 1000 patients; 95% confidence interval [CI], -7 to 19). beta-Blockers were associated with a small significant annual increase in risk of reported fatigue (18 per 1000 patients; 95% CI, 5-30), equivalent to 1 additional report of fatigue for every 57 patients treated per year with beta-blockers. beta-Blockers were also associated with a small, significant annual increase in risk of reported sexual dysfunction (5 per 1000 patients; 95% CI, 2-8), equivalent to one additional report for every 199 patients treated per year. None of the risks of adverse effects differed significantly by degree of beta-blocker lipid solubility. The risk associated with reported fatigue was significantly higher for early-generation than for late-generation beta-blockers (P =.04).Conclusion: The conventional wisdom that beta-blocker therapy is associated with substantial risks of depressive symptoms, fatigue, and sexual dysfunction is not supported by data from clinical trials. There is no significant increased risk of depressive symptoms and only small increased risks of fatigue and sexual dysfunction. The risks of these adverse effects should be put in the context of the documented benefits of these medications. [ABSTRACT FROM AUTHOR]

Context: β-Blocker therapy remains substantially underused in cardiac patients despite its proven mortality benefits. Reluctance to prescribe these agents may derive from concerns about their association with symptoms of depression, fatigue, and sexual dysfunction. Objective: To determine the association of β-blockers with depressive symptoms, fatigue, and sexual dysfunction by performing a quantitative review of randomized trials that tested β-blockers in myocardial infarction, heart failure, and hypertension. Data Sources: Randomized trials of β-blockers used in the treatment of myocardial infarction, heart failure, or hypertension were identified by searching the MEDLINE database for English-language articles (1966-2001). In addition, we searched the reference lists of previously published trials and reviews of β-blockers for additional studies. Study Selection: Criteria for inclusion of trials in the review were: random allocation of study treatments, placebo control, noncrossover design, enrollment of at least 100 patients, and a minimum of 6 months of follow-up. The initial search produced 475 articles, 42 of which met these criteria. Fifteen of these trials reported on depressive symptoms, fatigue, or sexual dysfunction and were selected for inclusion. Data Extraction: For each trial, 1 author abstracted the frequency of adverse events in the β-blocker and placebo groups and the numbers of patients randomized to the treatment groups. Two other authors verified the counts of events, and all authors adjudicated any discrepancies. Two different types of information on adverse events were abstracted: patient-reported symptoms and withdrawal of therapy due to a specified symptom. We categorized the tested β-blockers by generation (early vs late) and lipid solubility (high vs low to moderate). Data Synthesis: The 15 trials involved more than 35 000 subjects. β-Blocker therapy was not associated with a significant... [ABSTRACT FROM AUTHOR]

Context: Health care "report cards" have attracted significant consumer interest, particularly publicly available Internet health care quality rating systems. However, the ability of these ratings to discriminate between hospitals is not known. Objective: To determine whether hospital ratings for acute myocardial infarction (AMI) mortality from a prominent Internet hospital rating system accurately discriminate between hospitals' performance based on process of care and outcomes. Design, Setting, and Patients: Data from the Cooperative Cardiovascular Project, a retrospective systematic medical record review of 141 914 Medicare fee-for-service beneficiaries 65 years or older hospitalized with AMI at 3363 US acute care hospitals during a 4- to 8-month period between January 1994 and February 1996 were compared with ratings obtained from HealthGrades.com (1-star: worse outcomes than predicted, 5-star: better outcomes than predicted) based on 1994-1997 Medicare data. Main Outcome Measures: Quality indicators of AMI care, including use of acute reperfusion therapy, aspirin, β-blockers, angiotensin-converting enzyme inhibitors; 30-day mortality. Results: Patients treated at higher-rated hospitals were significantly more likely to receive aspirin (admission: 75.4% 5-star vs 66.4% 1-star, P for trend = .001; discharge: 79.7% 5-star vs 68.0% 1-star, P = .001) and β-blockers (admission: 54.8% 5-star vs 35.7% 1-star, P = .001; discharge: 63.3% 5-star vs 52.1% 1-star, P = .001), but not angiotensin-converting enzyme inhibitors (59.6% 5-star vs 57.4% 1-star, P = .40). Acute reperfusion therapy rates were highest for patients treated at 2-star hospitals (60.6%) and lowest for 5-star hospitals (53.6% 5-star, P = .008). Risk-standardized 30-day mortality rates were lower for patients treated at higher-rated than lower-rated hospitals (21.9% 1-star vs 15.9% 5-star, P = .001). However, there was marked heterogeneity within rating groups and substantial overlap o... [ABSTRACT FROM AUTHOR]

Context: Care of patients with heart failure has been revolutionized throughout the past decade. A paradigm shift in the strategy for treating heart failure caused by systolic dysfunction is in progress. Despite the initial perception about beta-blockers' safety, they are now the most extensively studied class of agents in the treatment of heart failure and have emerged as an important intervention to improve the clinical outcomes of heart failure patients.Objective: To provide scientific rationale for the use of beta-blockers for patients with heart failure.Data Sources: All English-language articles of large, randomized controlled clinical trials assessing the mortality benefits of beta-blockers in patients with heart failure were identified to provide the scientific rationale for the use of beta-blockers in heart failure. Basic science studies were reviewed to provide an overview of the potential physiologic role of beta-blockers in heart failure. Finally, clinical guidelines for the treatment of patients with heart failure were assessed to determine current recommendations for the use of these agents.Study Selection and Data Extraction: Randomized controlled clinical trials of beta-blockers that included more than 300 subjects and assessed mortality as a primary end point.Data Synthesis: Of the 4 beta-blockers tested in large randomized controlled clinical trials of patients with heart failure, 3 are available in the United States, bisoprolol, carvedilol, and metoprolol; 2 of these, carvedilol and metoprolol, have Food and Drug Administration indications for the treatment of heart failure. Compared with placebo treatment, beta-blocker use is associated with a consistent 30% reduction in mortality and a 40% reduction in hospitalizations in patients with class II and III heart failure.Conclusions: Tested in more than 10,000 patients, beta-blockers reduce morbidity and mortality in class II through IV heart failure. Along with angiotensin-converting enzyme inhibitors, digoxin, and diuretics, beta-blockers have strengthened the armamentarium to improve clinical outcomes of heart failure patients. The science supporting beta-blockers must be translated into practice safely and rationally if the agents are to achieve their full potential. [ABSTRACT FROM AUTHOR]

beta-Blockers reduce morbidity and mortality in heart failure patients with left ventricular systolic dysfunction and stable fluid status. The successful adoption of beta-blocker guidelines for these patients requires an understanding of the value of this therapy and effective systems to maintain safety and ensure high quality of care. This article distills scientific evidence and consensus guidelines into a series of cases and practical answers about patient selection, discussions with patients, management and monitoring, and systems improvements to optimize quality of care, safety, and benefit for all patients with heart failure. [ABSTRACT FROM AUTHOR]

Context: Care of patients with heart failure has been revolutionized throughout the past decade. A paradigm shift in the strategy for treating heart failure caused by systolic dysfunction is in progress. Despite the initial perception about β-blockers' safety, they are now the most extensively studied class of agents in the treatment of heart failure and have emerged as an important intervention to improve the clinical outcomes of heart failure patients. Objective: To provide scientific rationale for the use of β-blockers for patients with heart failure. Data Sources: All English-language articles of large, randomized controlled clinical trials assessing the mortality benefits of β-blockers in patients with heart failure were identified to provide the scientific rationale for the use of β-blockers in heart failure. Basic science studies were reviewed to provide an overview of the potential physiologic role of β-blockers in heart failure. Finally, clinical guidelines for the treatment of patients with heart failure were assessed to determine current recommendations for the use of these agents. Study Selection and Data Extraction: Randomized controlled clinical trials of β-blockers that included more than 300 subjects and assessed mortality as a primary end point. Data Synthesis: Of the 4 β-blockers tested in large randomized controlled clinical trials of patients with heart failure, 3 are available in the United States, bisoprolol, carvedilol, and metoprolol; 2 of these, carvedilol and metoprolol, have Food and Drug Administration indications for the treatment of heart failure. Compared with placebo treatment, β-blocker use is associated with a consistent 30% reduction in mortality and a 40% reduction in hospitalizations in patients with class II and III heart failure. Conclusions: Tested in more than 10 000 patients, β-blockers reduce morbidity and mortality in class II through IV heart failure. Along w... [ABSTRACT FROM AUTHOR]

β-Blockers reduce morbidity and mortality in heart failure patients with left ventricular systolic dysfunction and stable fluid status. The successful adoption of β-blocker guidelines for these patients requires an understanding of the value of this therapy and effective systems to maintain safety and ensure high quality of care. This article distills scientific evidence and consensus guidelines into a series of cases and practical answers about patient selection, discussions with patients, management and monitoring, and systems improvements to optimize quality of care, safety, and benefit for all patients with heart failure. [ABSTRACT FROM AUTHOR]

Reports on a study to investigate the relationship between patient sex, physician sex, and the use of cardiac procedures, specifically whether sex differences in cardiac catheterization after acute myocardial infarcation (AMI) were greater when patients were treated by male attending physicians compared with female physicians. Methods; Results; Conclusion suggesting that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.

Reports on a study to identify factors which would influence the increased prescription of beta-blockers after acute myocardial infarction and to develop a taxonomy for classifying such efforts. Design; Setting; Participants; Main outcome measures; Results; Conclusion.

Presents a study of whether moderate alcohol consumption can predict heart failure risk among older persons, independent of the association of moderate alcohol consumption with lower risk of myocardial infarction (MI). Design; Setting and participants; Main outcome measure; Results; Conclusion that increasing levels of moderate alcohol consumption are associated with a decreasing risk of heart failure among older persons.

While the benefits of physical activity and exercise among older persons are becoming increasingly clear, the role of exercise stress testing and safety monitoring for older persons who want to start an exercise program is unclear. Current guidelines regarding exercise stress testing likely are not applicable to the majority of persons aged 75 years or older who are interested in restoring or enhancing their physical function through a program of physical activity and exercise. In addition to being expensive and of unproven benefit, the current policy of routine exercise stress testing potentially could deter many older persons from participating in an exercise program. Research is needed to investigate current physician practices, evaluate the risk of adverse cardiac events, determine the role of pharmacological stress testing, and measure and compare absolute and relative exercise intensities. To assist clinicians, we offer a set of recommendations regarding precautions that can be taken to minimize the risk of adverse cardiac events among previously sedentary older persons who do not have symptomatic cardiovascular disease and are interested in starting an exercise program. JAMA. 2000;284:342-349 [ABSTRACT FROM AUTHOR]

Determines whether elevated serum cholesterol level is associated with all-cause mortality, mortality from heart disease, or hospitalization for acute myocardial infarction and unstable angina in persons older than 70 years. Number of subjects in study; Measurement of risk factors; Use of t-test and Chi-square tests in data analysis.

Describes the contemporary national pattern of beta-blocker prescription at hospital discharge among patients aged 65 years or older with an acute myocardial infarction (AMI). Attempt to identify the most important predictors of the prescribed use of beta-blockers and to determine the independent association between beta-blockers at discharge and mortality in clinical practice; Design; Setting; Patients; Main outcome measures; Results; Conclusions.

Presents a study to determine the correlates of thrombolytic therapy use in a population-based sample of elderly patients hospitalized with acute myocardial infarction who were eligible for the therapy on presentation. Design; Setting; Patients; Results; Conclusions.

Context: Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement programs has been difficult to establish.Objective: To improve the quality of care for Medicare patients with acute myocardial infarction.Design: Quality improvement project with baseline measurement, feedback, remeasurement, and comparison samples.Setting: All acute care hospitals in the United States.Patients: Preintervention and postintervention samples included all Medicare patients in Alabama, Connecticut, Iowa, and Wisconsin discharged with principal diagnoses of acute myocardial infarctions during 2 periods, June 1992 through December 1992 and August 1995 through November 1995. Indicator comparisons were made with a random sample of Medicare patients in the rest of the nation discharged with acute myocardial infarctions from August 1995 through November 1995. Mortality comparisons involved all Medicare patients nationwide with inpatient claims for acute myocardial infarctions during 2 periods, June 1992 through May 1993 and August 1995 through July 1996.Intervention: Data feedback by peer review organizations.Main Outcome Measures: Quality indicators derived from clinical practice guidelines, length of stay, and mortality.Results: Performance on all quality indicators improved significantly in the 4 pilot states. Administration of aspirin during hospitalization in patients without contraindications improved from 84% to 90% (P< .001), and prescription of beta-blockers at discharge improved from 47% to 68% (P < .001). Mortality at 30 days decreased from 18.9% to 17.1% (P = .005) and at 1 year from 32.3% to 29.6% (P < .001). These improvements in quality occurred during a period when median length of stay decreased from 8 days to 6 days. Performance on all quality indicators except reperfusion was better in the pilot states than in the rest of the nation in 1995, and the differences were statistically significant for aspirin use at discharge (P < .001), beta-blocker use (P < .001), and smoking cessation counseling (P = .02). Postinfarction mortality was not significantly different between the pilot states and the rest of the nation during the baseline period, although it was slightly but significantly better in the pilot states during the follow-up period (absolute mortality difference at 1 year, 0.9%; P = .004).Conclusions: The quality of care for Medicare patients with acute myocardial infarction has improved in the Cooperative Cardiovascular Project pilot states. Performance on the defined quality indicators appeared to be better in the pilot states than in the rest of the nation in 1995 and was associated with reduced mortality. [ABSTRACT FROM AUTHOR]

The article discusses research on the reporting of results in ClinicalTrials.gov, a public clinical trial registry maintained by the U.S. National Library of Medicine. The 2007 Food and Drug Administration (FDA) Amendments Act mandates results reporting within a year of trial completion for all FDA-regulated medical products. The researchers did a cross-sectional analysis of trials whose results were published between July 1, 2010 and June 30, 2011. Results of the analysis are discussed.

In this Viewpoint, Harlan Krumholz and colleagues discuss the promise that social media data hold for helping researchers better understand social determinants of health, and the challenges that must be overcome to reliably link social network data to clinical and health outcomes. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Use of fibrates in the United States and Canada," by C. A. Jackevicius and colleagues, in a 2011 issue.

A letter to the editor is presented which is concerned with research which looked at the payments that the pharmaceutical industry made to physicians in Vermont.

This Viewpoint proposes strategies to manage code linkage gaps and other sources of error in the transition in the United States from use of the International Classification of Diseases, Ninth Revision (ICD-9) to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). [ABSTRACT FROM AUTHOR]

This Viewpoint discusses how the current attention to the opioid epidemic might be used to reinvigorate tobacco control initiatives. [ABSTRACT FROM AUTHOR]

The author presents his thoughts on medical guidelines pertaining to lipid-lowering therapy and the treatment of patients with high cholesterol levels. He states the goal of treatment should be to get the most benefits from clinical care while also adhering to individual patients' preferences and medical goals. Particular attention is given to the use of statins, evidence-based treatment plans, and partnership in decision making with patients.

The article focuses on the option of shared decision making offered to patients instead of the earlier conventional consent procedures, particularly for hip replacement and knee osteoarthritis. It discusses how the physician reviews the options, also informing the patients about the risks involved in the treatment option. It also talks about the legislative route by Washington State encouraging shared decision making.

An essay is presented on whether Hemoglobin A1c should be the proper outcome for diabetes studies. Topics include the goals and approval of hemoglobin A1c based type 2 diabetes treatment, improving approaches for the treatments for type 1 (DCCT) and type 2 (UKPDS) diabetes, and an overview of the implications from type 2 diabetes treatment guidelines. Also mentioned is Canagliflozin Cardiovascular Assessment Study (CANVAS).

The article discusses the notion of a learning health system. Topics include the role of data acquisition and curation in health systems, impediments to the sharing of health data, and the selection of data-sharing tools and platforms that encourage the sharing of health information throughout a healthcare system.

A response from the authors to their article "Change in Body Mass Index Associated With Lowest Mortality in Denmark," which appeared in a 2016 issue is presented.

The article discusses the need to revitalize reasonable-patient standards for informed consent through shared decision making. Topics include policy initiatives to advance informed consent with the reasonable-patient standard, informed consent and high-value patient-centered care, and the importance of implementing value-based payment models that recognize high-quality informed consent practices.

The article discusses a study which showed that data reanalysis occurred infrequently in medical research. Topics discussed include majority of randomized clinical trial (RCT) reanalysis have overlapping authors from the original report, difference in the definitions or measurements of outcomes and interpretations and conclusions of RCT reanalysis different than those in original article.

The authors offers suggestions to reduce the trauma of hospitalization. Topics discussed include the provision of personalized health care services, reducing stress in a hospital stay, and the elimination of unnecessary tests and procedures. Also mentioned are the decrease in random medication alterations, attention to physical activity, and the provision of a postdischarge safety net.

The author focuses son variations in health care, patient attitudes and high-standards of clinical decision making and states that variations should be based on patient preferences and clinical differences and not other factors including payment method, geography, or system proclivities. It further expresses concern for the lack of decision making science in medical education. The author finally discusses several steps to raising the quality of patient-centered quality of health care delivery.

The authors discuss the necessity of data sharing in ensuring that patients and clinicians are fully able to make informed decisions about biological products, pharmaceutical agents, and medical devices tested through clinical trial research. They talk about how data sharing maximizes the value of collected data. Arguments by some that clinical trial data are proprietary and that the risks and benefits of drugs may be misinterpreted are also addressed.

The author proposes a model for dissemination and independent data analysis of comprehensive clinical trial and post-market surveillance data that emphasizes independence, transparency, fairness and reproducibility. The proposed model includes essential components. The author thinks that a new model would support competition and a transparent atmosphere. The first company to commit to this model is Medtronic Inc. and the author hopes that the model will set an ethical standard for other firms.

The author discusses outcomes research and its imperative in the real-world. He asserts that as an emerging field, outcomes research still needs to establish its definition, scope and goals before it becomes a core component of medical care delivery. He believes that outcomes research can serve as the vehicle that will enable learning from practice that can lead to innovation in health care due to the progress made in technology, information science and systems.

The authors reflect on various issues concerning the concept of percutaneous coronary intervention (PCI). They cite the technical challenges that cause the hesitation to perform ad hoc PCI including older imaging systems and procedural techniques. They discuss an article which highlighted informed consent and ethics of self-referral as challenges to ad hoc PCI. The authors also argue that there are ways to enhance the use of ad hoc PCI.