By Chesda Eng, MD, PGY-1
Faculty Peer Reviewed
Valentine’s Day has come and gone, but Cupid’s influence lingers. Couples were out and about this week in New York City enjoying a preview of spring weather. We too will be dealing with matters of the heart in our weekly installment of Primecuts.
First from the Archives of Internal Medicine comes an examination of resources used in the last 6 months of life among Medicare patients with congestive heart failure (CHF). Close to 30% of Medicare spending occurs in the last year of life.[1] Resources used in the last 180 days of life were reviewed in a retrospective cohort study of 229 543 Medicare patients who died between January 1, 2000, and December 31, 2007. Unroe and colleagues found that close to 80% of patients were hospitalized in the last 6 months of life.[2] From 2000 to 2007 there was an increase in the average number of intensive-care-unit days from 3.5 to 4.6, but also an increased use of hospice care from 19% to 40% of patients. The increased cost per Medicare patient was $28,766 to $38,216 over this period. After adjusting for age, sex, race, geographic differences, and co-morbidities, this turns out to be an 11% cost increase. Renal disease, chronic obstructive pulmonary disease, and black race were all independent predictors of higher costs.
It is said that the quickest way to a man’s heart is through his stomach, but what if that man has an increased risk for a gastrointestinal (GI) bleed? In the same issue of the Archives, Earnshaw and colleagues addressed the question of aspirin use with or without a proton pump inhibitor for the primary prevention of coronary heart disease among men with different levels of risk for GI bleeding.[3] They compared costs and outcomes of low-dose aspirin and omeprazole 20 mg, low-dose aspirin alone, or no treatment for coronary heart disease prevention. They found that aspirin appeared to be cost-saving when compared with no treatment across a wide range of coronary heart disease and GI bleeding risks for men 45-65 years old. Adding omeprazole to aspirin was not cost-effective in most cases because the risk of bleeding was not significant enough to warrant prophylaxis. The cutoff point for cost-effectiveness for adding a PPI is at a GI bleeding risk of 5 episodes per 1000 patients per year.
Next up in cardiac-related news is from this week’s JAMA, where Joyn and colleagues took a look at 30-day readmission rates after hospitalization for acute myocardial infarction (MI), CHF, and pneumonia (not the heart, but in close proximity). Using data from more than 3.1 million Medicare beneficiaries between 2006 and 2008, the investigators sought to determine if black patients have a higher odds ratio of readmission compared with white patients, and if this disparity was related to where the care was received.[4] They found that black patients did indeed have a higher readmission rate than white patients regardless of where they received care (24.8% vs. 22.6%, OR 1.13). All patients discharged from a hospital serving a high proportion of minority patients had about 23% higher odds of readmission versus patients discharged from a hospital with a lower proportion of minorities. Blacks discharged from minority-serving hospitals had the highest rate of readmission and, conversely, whites at non-minority-serving hospitals had the lowest 30-day readmission rates. When comparing white patients discharged from a non-minority-serving hospital following an MI, black patients discharged from the same setting had 20% higher odds of readmission, but 35% higher odds if they were discharged from a minority-serving hospital. The authors concluded that the association of readmission rates with site of care appears to be greater than the association with race. In an editorial in the same issue of JAMA, Hernandez and Curtis wrote that addressing these disparities requires further investigation into where the system fails and why it fails in different ways for black and white patients.[5]
Looking ahead to preventing readmissions (for CHF at least), this week’s Lancet takes a look at wireless pulmonary artery pressure monitoring.[6] Abraham and his colleagues from the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) Trial Study Group sought to assess whether the use of a wireless pulmonary artery pressure monitor could help clinicians better manage CHF, and if this would reduce the rate of CHF-related admissions. This single-blinded, multi-center trial took patients with NYHA class III heart failure, irrespective of ejection fraction, and randomly assigned them to either management with a wireless implantable hemodynamic monitoring system (n=270) or usual care (n=280) for 6 months. In the treatment group, daily pulmonary artery pressures were used to guide changes in drug regimen. There were 83 heart-failure-related hospitalizations in the treatment group compared to 120 in the control group. During a mean follow-up period of 15 months, the treatment group had a 39% reduction in heart-failure-related hospitalizations versus the control group. On first glance these results are promising; time will tell if wireless pulmonary artery pressure monitors will become as commonplace as pacemakers.
We round up this week’s edition of Primecuts with news not of the heart, but of the prostate. Reported in the Annals of Oncology, Yassa and colleagues sought to determine whether early-onset alopecia is associated with increased risk of prostate cancer later in life.[7] The investigators looked at 668 subjects, 388 with a history of prostate cancer. The subjects were asked to score their balding patterns at ages 20, 30, and 40. They found that patients with prostate cancer were twice as likely as controls to have had androgenic alopecia at 20 years old (OR 2.01). Perhaps we will be asking our patients about their balding patterns before offering a prostate-specific antigen (PSA) test in the future.
This ends this week’s Primecuts. Stay warm with your loved ones (and hats if you are balding).
Dr. Eng is a 1st year resident at NYU Langone Medical Center
Peer reviewed by Dr. Michael Tanner, MD, section editor, Clinical Correlations
References:
1. Riley GF, Lubitz, JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010;45(2):565–576. doi: 10.1111/j.1475-6773.2010.01082.
2. Unroe KT, Greiner MA, Hernandez AF, et al. Resource use in the last 6 months of life among medicare beneficiaries with heart failure, 2000-2007. Arch Intern Med. 2011;171(3):196-203. http://archinte.ama-assn.org.ezproxy.med.nyu.edu/cgi/content/full/171/3/194
3. Earnshaw SR, Scheiman J, Fendrick M, McDade C, Pignone M. Cost-utility of aspirin and proton pump inhibitors for primary prevention. Arch Intern Med. 2011;171(3):218-225. http://archinte.ama-assn.org.ezproxy.med.nyu.edu/cgi/content/full/171/3/218
4. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681. http://jama.ama-assn.org/content/305/7/675.long
5. Hernandez AF, Curtis LH. Minding the gap between efforts to reduce readmissions and disparities. JAMA. 2011;305(7):715-716. http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=21325191
6. Abraham WT, Adamson PB, Bourge RC, et al, for the CHAMPION Trial Study Group. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet. 2011;377(9766):658-666. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60101-3/fulltext
7. Yassa M, Saliou M, De Reyke Y, et al. Male pattern baldness and the risk of prostate cancer. Ann Oncol. 2011 Feb 15. [Epub ahead of print] http://annonc.oxfordjournals.org/content/early/2011/01/25/annonc.mdq695.long