ShortCuts-This Week in The Journals

June 18, 2007

A study reported in this week’s issue of JAMA attempts to correlate preoperative hematocrit levels with postoperative outcomes in elderly veterans undergoing noncardiac surgery. Both 30-day postoperative mortality and cardiac event rates increased in patients with hematocrits either higher or lower than the normal range (39 to 53.9%). A 1.6% increase in mortality was associated with every percentage point positively or negatively deviating from the normal range. Although compelling, this study does not establish a causal relationship between hematocrit and postoperative complications, and the appropriate treatment of preoperative anemia or polycythemia remains unknown.

A study published in the May 29th issue of Circulation found an increased risk of bleeding in elderly patients starting warfarin for atrial fibrillation. The cohort study followed patients older than 65 years of age for 1 year. The cumulative incidence of major hemorrhage for patients 80 years of age was 13.1 per 100 person-years and 4.7 for those <80 years of age (P=0.009). Rates of hemorrhage were highest within the first 90 days of treatment. Overall, this study shows that rates of hemorrhage previously derived from younger cohort studies underestimate the true rate of complications seen in clinical practice.

The NY Times released a consensus statement by the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists, and the American Cancer Society identifying a set of symptoms that are associated with early stage ovarian cancer. The symptoms include bloating, pelvic or abdominal pain, feeling full quickly or difficulty eating, and frequent or urgent urination. The statement urges that women see a gynecologist if they experience any of these symptoms almost every day for longer than 2 or 3 weeks.

The NY Times also reported on a survey revealing that more expensive medicine does not necessarily guarantee higher quality care. In a government survey of Pennsylvania’s hospitals that perform cardiac bypass surgery, the hospitals receiving the highest payments for their services by private insurers do not necessarily provide better quality care, and some of the higher paid hospitals actually had the highest mortality levels.

In other quality news, a hopeful study from the RAND corporation published in this week’s NEJM assessed the quality of care provided in three separate cohorts of adult patients. The quality of care, as assessed as the percentage of quality indicators satisfied among those for which the patient was eligible, actually increased as the number of medical conditions increased in all three cohorts examined. In the future era of public reporting and pay for performance, this study optimistically shows that those providers who opt to care for more complex patients may not be unfairly penalized.

-Cara Litvin MD, Associate Editor Clinical Correlations

Addendum

Cara’s of course being modest…Clearly the most important article of the week was her perspective piece in this week’s New England Journal of Medicine entitled In the Dark-The Case for Electronic Health Records. It’s a terrific read. We’re very proud of our associate editor…NS

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