Differences In Practice Patterns Research Articles

Coronary artery bypass graft surgery—care globalization: The impact of national care on fatal and nonfatal outcome

In an international, prospective, observational study, we contrasted adverse vascular outcomes among four countries and then assessed practice pattern differences that may have contributed to these outcomes. A total of 5065 patients undergoing coronary artery bypass graft surgery were analyzed at 70 international medical centers, and from this pool, 3180 patients from the 4 highest enrolling countries were selected. Fatal and nonfatal postoperative ischemic complications related to the heart, brain, kidney, and gastrointestinal tract were assessed by blinded investigators. In-hospital mortality was 1.5% (9/619) in the United Kingdom, 2.0% (9/444) in Canada, 2.7% (34/1283) in the United States, and 3.8% (32/834) in Germany (P = .03). The rates of the composite outcome (morbidity and mortality) were 12% in the United Kingdom, 16% in Canada, 18% in the United States, and 24% in Germany (P < .001). After adjustment for difference in case-mix (using the European System for Cardiac Operative Risk Evaluation) and practice, country was not an independent predictor for mortality. However, there was an independent effect of country on composite outcome. The practices that were associated with adverse outcomes were the intraoperative use of aprotinin, intraoperative transfusion of fresh-frozen plasma or platelets, lack of use of early postoperative aspirin, and use of postoperative heparin. Significant between-country differences in perioperative outcome exist and appear to be related to hematologic practices, including administration of antifibrinolytics, fresh-frozen plasma, platelets, heparin, and aspirin. Understanding the mechanisms for these observations and selection of practices associated with improved outcomes may result in significant patient benefit.

Dialysis Facility Ownership and Epoetin Dosing in Patients Receiving Hemodialysis

Epoetin therapy for dialysis-related anemia is the single largest Medicare drug expenditure. The type of facility (profit, chain, and affiliation status) at which a patient receives dialysis might affect epoetin dosing patterns and has implications for future epoetin policies. To examine the association between dialysis facility ownership and the dose of epoetin administered. Data from the US Renal Data System were used to identify 159,522 adult Medicare-eligible, end-stage renal disease patients receiving in-center hemodialysis during November and December 2004. Regression models were used to estimate the mean epoetin dose and dose adjustment by profit, chain, and affiliation status. Weekly mean epoetin dose administered in December 2004 and the adjustment in dose between November and December 2004. Compared with patients in nonprofit dialysis facilities (n = 28,199), patients in large for-profit dialysis chain facilities (n = 106,116) were consistently administered the highest doses of epoetin regardless of anemia status. Compared with nonprofit facilities, for-profit facilities administered, on average, an additional 3306 U/wk of epoetin. Among the 6 large chain facilities with a similar patient case-mix, the average dose of epoetin ranged from 17,832 U/wk at chain 5 (nonprofit facilities with a mean hematocrit level of 34.6%) to 24,986 U/wk at chain 2 (for-profit facilities with a mean hematocrit level of 36.5%). Dosing adjustments also differed by type of facility. On average, compared with nonprofit facilities, for-profit facilities increased epoetin doses 3-fold for patients with hematocrit levels of less 33% and also increased the doses among patients with hematocrit levels in the recommended target of 33% to 36%, especially in the largest for-profit chain facilities. The greatest difference in dosing practice patterns between facilities was found among patients with hematocrit levels of less than 33%. Dialysis facility organizational status and ownership are associated with variation in epoetin dosing in the United States. Different epoetin dosing patterns suggest that large for-profit chain facilities used larger dose adjustments and targeted higher hematocrit levels.

Robotically assisted laparoscopic pyeloplasty: a transatlantic comparison of techniques and outcomes

To report a comparison of two techniques of robotically assisted laparoscopic dismembered pyeloplasty (RALDP), and their associated outcomes, for treating pelvi-ureteric junction obstruction (PUJO), evaluating the potential differences in the initial 50 cases of two centres in North America and Europe. Between November 2001 and August 2005, 100 patients had transperitoneal RALDP for PUJO in one centre in the USA (group 1) and one in France (group 2). Group 1 consisted of 50 patients (30 males and 20 females, mean age 31 years, range 16-62) and group 2 of 50 patients (17 males and 32 females, one bilateral PUJO; mean age 39 years, range 17-81). The right side was affected in 30 (60%) patients in group 1 and 32 (64%) in group 2. Differences in preoperative evaluation, surgical technique and follow-up were evaluated. In group 1 all procedures were completed laparoscopically. One conversion was necessary in group 2 due to technical difficulties. The mean operative duration was 122 min (group 1) and 127 min (group 2); the estimated blood loss was negligible (<100 mL) in both groups. Surgical findings included 15 patients with crossing vessels in group 1 and 28 in group 2. There were no peri-operative complications in either group. The mean hospital stay was 1.1 days in group 1 and 5.8 days in group 2, reflecting differences in practice patterns. All patients were asymptomatic at stent removal and in subsequent clinical evaluations in both groups. The combination of results form both series provide information suggesting that the robotically assisted approach is a viable treatment option. The results reflect some differences in techniques, follow-up and practice patterns, but the outcomes were equally effective on both continents. Further follow-up will allow us to determine the long-term efficacy.

Preference-Based Instrumental Variable Methods for the Estimation of Treatment Effects: Assessing Validity and Interpreting Results

Observational studies of drugs and medical procedures based on administrative data are increasingly used to inform regulatory and clinical decisions. However, the validity of such studies is often questioned because available data may not contain measurements of many important prognostic variables that guide treatment decisions. Recently, approaches to this problem have been proposed that use instrumental variables (IV) defined at the level of an individual health care provider or aggregation of providers. Implicitly, these approaches attempt to estimate causal effects by using differences in medical practice patterns as a quasi-experiment. Although preference-based IV methods may usefully complement standard statistical approaches, they make assumptions that are unfamiliar to most biomedical researchers and therefore the validity of such analyses can be hard to evaluate. Here, we propose a simple framework based on a single unobserved dichotomous variable that can be used to explore how violations of IV assumptions and treatment effect heterogeneity may bias the standard IV estimator with respect to the average treatment effect in the population. This framework suggests various ways to anticipate the likely direction of bias using both empirical data and commonly available subject matter knowledge, such as whether medications or medical procedures tend to be overused, underused, or often misused. This approach is described in the context of a study comparing the gastrointestinal bleeding risk attributable to different non-steroidal anti-inflammatory drugs.

Thyroid Scintigraphy in the Assessment of the Solitary Thyroid Nodule: Differences in Practice Patterns between Family Physicians and Specialists

It has been shown that there is considerable variation in the diagnosis and management of the thyroid nodule. The purpose of this study was to investigate the differences in the practice of family physicians and specialists in ordering thyroid scans in the initial workup of patients with thyroid nodules. Retrospective electronic and paper-based chart review. University Health Network, Toronto. All patients who underwent thyroidectomy over a 2-year period. An audit of their preoperative diagnostic tests was performed, and the specialties of the ordering physicians were identified. One hundred ninety-four patients were assessed. Sixty-three patients (32.5%) were investigated exclusively by their family physician, 63 (32.5%) were investigated exclusively by a specialist, and 68 (35%) were investigated by both. Family physicians ordered thyroid scans in 51% of patients, whereas specialists ordered scans in 29% of patients (p<.001). The medical specialists ordered 36 scans (33.6%) in 107 patients, whereas the surgical specialists ordered 2 (8.3%) scans in 24 patients (p<.001). Despite the limited role for thyroid scans in the initial workup of a solitary thyroid nodule, they are still frequently ordered, particularly by family physicians. We recommend publication of Canadian evidence-based guidelines for the management of thyroid nodules, similar to existing American guidelines, which could help reduce the amount of unnecessary testing.

Successful Multidisciplinary Interventions for Arterio-Venous Fistula Creation by the Pacific Northwest Renal Network 16 Vascular access Quality Improvement Program

Background In December 2001, 44.2% of hemodialysis (HD) patients in the Northwest Renal Network (NWRN 16) received dialysis using an arteriovenous fistula (AVF). Substantial differences were noted in percentages of patients with AVF, ranging from 5% to 90% of the facility population, suggesting wide variation in physician practice patterns within the Network. To address the needs of facilities having &lt;40% AVF, NWRN 16 provided education and tools for their vascular access decision-makers to promote AVF creation. Methods In 2002, the Network sponsored 4 regional workshops targeted to nephrologists, vascular surgeons, dialysis nurses, and interventional radiologists. Results 46 facilities (43% of all Network facilities) had &lt;40% AVF in use in December, 2001, dialyzing 2940 patients (Invited Units). Percent AVF in use in all the Invited Facilities increased from 31.3% pre-intervention to 39.8% at 1 year (p&lt;0.001 vs pre) to 56.2% at four years: 79.8% increase in the prevalent AVF rate over a four-year period (95% confidence interval: 77.8% to 81.7%). Conclusion Low prevalent AVF rates in many NWRN 16 facilities may have resulted from differences in physician practice patterns. The success of Network 16 AVF Intervention demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, innovative strategies to increase AVF rates among dialysis patients.

Differences in per capita rates of revascularization and in choice of revascularization procedure for eleven states

BackgroundA few studies have investigated differences in elective procedure rates across small and medium sized referral regions. The purposes of this study are to investigate differences in revascularizations across 11 entire states and to investigate differences in choice of revascularization procedure (percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG) surgery).MethodsAge-sex adjusted rates per 100,000 population who were 20 or older were calculated for PCI, CABG surgery, and total revascularization for each state. Also, the risk-adjusted proportion of revascularized patients who underwent PCI was calculated for each state and differences were compared.ResultsWe found variations in procedures performed per capita of 1.83-fold for PCI, 1.54-fold for CABG surgery, and 1.54-fold for total revascularization. For patients undergoing revascularization of two or more vessels, the age/sex adjusted maximum rate of 224 per 100,000 population over 20 years old in Florida was 53% higher than the minimum rate of 146 in Colorado. Higher catheterization rates per 1,000 Medicare enrollees and higher percent of white patients were significant predictors of higher revascularization rates, and density of specialists was a significant predictor of catheterization rate. The risk-adjusted percentage of revascularized patients with two or more arteries attempted who underwent PCI ranged from 10.4% in Oregon to 29.0% in Iowa.ConclusionThere are reasonably large differences among states in total revascularization rates and in type of revascularization among revascularization. These differences appear to be related to practice pattern differences. Future effort should be devoted to understanding the reason for these differences and the impact on patients' health and survival.

Practice Analysis

Medical practice governance is made more challenging by the fact that many procedures may be performed by various medical or surgical specialties. Thyroid cancer surgery is performed by both physicians with general surgery (GS) and those with otolaryngology/head and neck surgery (HNS) credentials. Analyses describing differences in practice patterns between the 2 services have not been published previously. The records of the Tumor Registry at the Naval Medical Center San Diego were reviewed for patients presenting with thyroid cancer between January 1, 1990, and December 31, 1999. The review included all patients undergoing partial or total thyroidectomy, and the operative techniques and complications were noted. Of the 178 patients who underwent thyroid cancer surgery in this period, charts were available for 136 (n = 87 HNS, n = 49 GS, 1 combined HNS/GS). There was no difference between the 2 services in terms of the percentage of patients undergoing lymph node sampling (P = 1.000), but each had different approaches to sampling techniques. Head and neck surgeons performed more total thyroidectomies (P < .001) and referred patients more frequently for postoperative radioiodine (P = .025); they resected 426 nodes in 32 patients (mean 13.3, median 6.5), of which 120 (28.2%) were positive. General surgeons resected 28 nodes in 11 patients (median 2.0, mean 2.6), of which 12 (42.8%) were positive (P = .009). Other variables were similar for services, including inpatient hospital days, estimated blood loss, number of patients with temporary hypoparathyroidism, and duration of hypocalcemia. In this cohort, otolaryngologists/head and neck surgeons and general surgeons have a significantly different approach with respect to lymph node sampling in the surgical therapy of thyroid cancer. Outcomes appear independent of technique.

Predictors of Discharge to an Inpatient Extended Care Facility After Total Hip or Knee Arthroplasty

Increased emphasis has been placed on hospital length of stay and discharge planning after total joint arthroplasty (TJA). The purpose of this study was to identify baseline patient characteristics that are predictive of discharge to an inpatient extended care facility (ECF) after TJA. Clinical, demographic, and resource utilization data were analyzed for 7818 consecutive patients who underwent primary or revision TJA at 1 of 3 high-volume TJA centers. A stepwise linear regression model was used to identify predictors of discharge to an ECF. Overall, 29% of patients were discharged to an ECF after TJA. Older age, higher American Society of Anesthesiologists class, Medicare insurance, and female sex were all associated with a higher likelihood of discharge to an ECF. Significant differences in practice patterns were found across hospitals with respect to discharge disposition after TJA. Further study is necessary to determine the appropriate criteria for discharge to an ECF after TJA.

Factors associated with initiation with atomoxetine versus stimulants in the treatment of adults with ADHD: retrospective analysis of administrative claims data.

To determine which factors are associated with use of atomoxetine (ATX) relative to stimulant medications (STIMs) for treatment initiation in adults with attention-deficit/hyperactivity disorder (ADHD). A similar exploratory analysis of the use of ATX versus STIMs in children has been published previously. This was an exploratory analysis using a retrospective observational cohort design applied to administrative pharmacy and medical claims from an integrated managed care database. Patients were identified if they had at least 1 administrative claim with a diagnosis for ADHD. Treatment .initiation. was defined as a new prescription for an ADHD medication preceded by 3 months without similar therapy. Two separate analyses were done, one comparing medication starts for ATX with those of any STIM, the other comparing starts of ATX with long-acting stimulants (LA-STIMs). Logistic regression analyses of prior-year administrative claims were used to compare the frequencies of differential predictors of the use of medication. There were 10,359 patients aged >18 years who initiated ATX or a STIM between April and December of 2003 and had at least 1 claim with a diagnosis for ADHD (International Classification of Diseases, Ninth Revision, Clinical Modification codes 314.0x). Approximately one third (28 of 82) of the comparisons related to patient demographics, diagnostic history, and previous treatment history was found to be related to the use of ATX versus STIMs and/or LA-STIMs. Patients were more likely to have received ATX than a STIM if they had prior diagnoses of bipolar disorder (odds ratio [OR] 1.47; 95% confidence interval [CI], 1.16-1.87), alcohol dependence (OR 1.80; 95% CI, 1.26-2.58), anxiety (OR 1.21; 95% CI, 1.05-1.40), previous use of antipsychotic medication (OR 1.55; 95% CI, 1.22-1.96), or previous antidepressant use (OR 1.14; 95% CI, 1.01-1.28). Prior use of behavioral services greater than 12 visits was associated with the use of ATX relative to STIMs (OR 1.46; 95% CI, 1.20-1.77) but not for ATX relative to LA-STIMs. Conversely, ATX was used less often than STIMs for initiation in younger adults aged 18 to 24 years (OR 0.66; 95% CI, 0.58-0.74), female patients (OR 0.89, 95% CI, 0.80-0.99), patients with personality disorders (OR 0.53; 95% CI, 0.34-0.82), and those with prior use of STIMs (OR 0.62; 95% CI, 0.56-0.69). The majority of comparisons (54 of 82) related to demographics, diagnostic history, and previous treatment history did not show statistically significant associations. During the first year of ATX.s market introduction, some differences in the frequency of various clinical factors were found in adults treated with ATX compared with those patients who received STIMs. This association may suggest that STIMs and ATX are used to address different treatment needs in adults with ADHD. Future studies will need to determine the significance of the practice pattern differences inferred here and if they persist after ATX has been on the market longer.

Retroperitoneal sarcoma

No population-based studies of retroperitoneal sarcoma (RPS) have been conducted, and the use and timing of adjuvant radiotherapy for RPS is controversial. The objective of this study was to examine the incidence and treatment of RPS, specifically regarding the use of adjuvant radiotherapy. The Surveillance, Epidemiology, and End Results (SEER) database was used to evaluate the incidence of RPS over a 29-year period (1973-2001). The rate of surgery, the rate and timing of adjuvant radiotherapy, and the influence of demographic factors on treatment were evaluated. A total of 2348 cases of RPS were identified. The mean annual incidence of RPS was 2.7 cases per 10(6) persons and did not change significantly over time (2.6 in 1973 vs. 2.8 in 2001; P = .92). Most patients (1654; 70.4%) underwent surgical resection. Radiotherapy was used in 428 patients (25.9%) who underwent surgery; radiation was given postoperatively in 366 (85.5%), preoperatively in 20 (4.7%), and intraoperatively or unknown in 42 (9.8%). Patients who received any adjuvant radiotherapy were on average 5 years younger than those who underwent surgery alone (P < .0001). Radiotherapy was more commonly used among whites than African Americans (25.8% vs. 16.7%; P = .02) and there was significant variation in the use of adjuvant radiotherapy by geographic location (P = .003). On multivariate analysis, race (P = 0.004), age (P < .0001), and geographic location (P = .006) were independently associated with the use of adjuvant radiotherapy. The incidence of RPS, a rare disease, appears stable. Most patients who undergo surgery do not receive any adjuvant radiotherapy, and very few receive preoperative radiotherapy. Differences in adjuvant radiotherapy use related to demographic and geographic factors suggest that at least some treatment variations reflect differences in individual and institutional practice patterns.

Chronic Laryngitis Associated with Gastroesophageal Reflux: Prospective Assessment of Differences in Practice Patterns Between Gastroenterologists and ENT Physicians

Ear, nose, and throat (ENT) physicians often diagnose gastroesophageal reflux disease (GERD)-related laryngitis on the basis of symptoms and laryngeal signs; and may refer patients to gastroenterologists who contend that many such patients do not have reflux. Because of this dichotomy we designed this study to assess the practice pattern differences among ENT physicians and gastroenterologists in relation to the diagnosis and treatment of patients with GERD-related laryngitis. Separate surveys were specifically designed for ENT physicians and gastroenterologists to assess the following: the percentage of patients diagnosed with GERD-related laryngitis, dose and duration of therapy, treatment response, and other diagnostic options in nonresponders. A total of 2000 surveys were mailed randomly to members of both the American Academy of Otolaryngology Head and Neck Surgery and the American Gastroenterological Association. Of the total 4,000 surveys sent, 782 (39%) ENT physicians and 565 (28%) gastroenterologists responded. Most respondents (both specialties) were private practitioners (82% and 74%, respectively). From the ENT survey, the diagnosis was most commonly suspected based on the following symptoms: globus = throat clearing > cough > hoarseness. The most useful signs were laryngeal erythema and edema reported by 70% of respondents. Seventy-four percent of ENT physicians reported they made the diagnosis more on symptoms than on laryngeal signs, and initiated therapy most often with proton pump inhibitor (PPI) once daily for 2 months. Gastroenterologists were divided on pre-therapy testing, 50% reporting testing with esophagogastro-duodenoscopy followed by pH monitoring (distal > proximal) prior to therapy, while the remaining 50% reported treating empirically with PPI twice daily for 3 months. Seventy percent of gastroenterologists reported treatment response of less than 60%, while 62% of ENT physicians reported response rate of greater than 60% (p < 0.05). (1) Globus and throat clearing were considered the most useful symptoms in diagnosing GERD-related laryngitis, while laryngeal erythema and edema were considered the most useful signs for diagnosis and treatment of this condition by ENT physicians. However, these symptoms and signs may represent the least specific markers for reflux. (2) Many gastroenterologists perform pre-therapy testing which has low sensitivity in GERD-related laryngitis. (3) There is a dichotomy in treatment dose, duration, and perceived patient response to therapy between the two specialists. (4) Our study highlights a need for cross communication and education between these two disciplines in understanding and treating GERD-related laryngitis better.

Practice Patterns of Underrepresented Minority Nurse Practitioners in New York State, 2000

Using data collected from a sample of 1,319 nurse practitioners (NPs) in New York state in 2000, differences in practice patterns by race and ethnicity were identified. NPs from underrepresented minority (URM) groups were more likely than non-URM NPs to work in hospitals, community health centers, and schools but less likely to work in physician offices and NP practices. URM NPs were also more likely to report a specialty certification in women's health. Several different measures of primary care provision were examined, with URM NPs substantially more likely to meet all four measures of primary care practice than non-URM NPs. Finally, URM NPs were more likely than non-URM NPs to practice in federally designated health profession shortage areas.

Making Sense Of Medical Technology

In seeking to explain contradictory reports that increased medical spending is both valuable and wasteful, Jonathan Skinner and colleagues rightly emphasize differences in regional practice patterns in response to constraints. However, it is more accurate to view the situation not as a choice between valuable but inexpensive care and more costly care with worse outcomes-as Skinner and colleagues theorize-but as a choice between responses to regional inefficiencies. Given that we do not know what will best improve the efficiency of medical care in a given area, experiments with financial incentives to both providers and individual patients should receive high priority.

Current Status of the European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons Congenital Heart Surgery Database

After utilizing separate congenital databases in the early 1990s, the Society of Thoracic Surgeons (STS) and the European Association for Cardio-Thoracic Surgery (EACTS) collaborated on several joint database initiatives. In 1998, the joint EACTS-STS International Congenital Heart Surgery Nomenclature and Database Project Committee was created and a common nomenclature and common core minimum database dataset were adopted and published by the STS and the EACTS. In 1999, the joint EACTS-STS Aristotle Committee was created and the Aristotle Score was adopted and published as a method to provide complexity adjustment for congenital heart surgery. Collaborative efforts involving the EACTS and STS are underway to develop mechanisms to verify data completeness and accuracy. Since 1998, this nomenclature, database, and methodology of complexity adjustment have been used by both the STS and EACTS to analyze outcomes of over 40,000 patients. A huge amount of data have been generated which allow comparison of practice patterns and outcomes analysis between Europe and North America. The aggregate data from the first 5 years of data collection not only make for interesting comparison but also allow examination of regional difference in practice patterns. For example, in the EACTS, out of 4,273 neonates, 885 (20.7%) underwent arterial switch procedures and 297 (6.95%) underwent Norwood stage 1 procedures. In the STS, out of 3,988 neonates, 472 (11.8%) underwent arterial switch procedures and 575 (14.4%) underwent Norwood stage 1 procedures. This analysis of the EACTS-STS multi-institutional outcomes database confirms that in both Europe and North America, case complexity and mortality is highest among neonates, then infants, and then children. Regional differences in practice patterns are demonstrated, with the overall goal being the continued upgrade in the quality of surgery for congenital heart disease worldwide.

A Multistate Comparison of Patient Characteristics, Outcomes, and Treatment Practices in Acute Myocardial Infarction

The primary purpose of this study was to examine variations in patient characteristics, outcomes, and treatment practices in acute myocardial infarction (AMI) across 11 states. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Dataset. Patients who had a primary diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification, code 410.x1) from 11 states were extracted from the Healthcare Cost and Utilization Project 1999 dataset. Bivariate comparisons were conducted to examine the characteristics, treatment practices, and outcomes of patients who had AMI. Multivariate regression models were used to examine the association between geographic location (and other factors) and the likelihood of in-hospital mortality, undergoing coronary artery bypass grafting (CABG), or percutaneous coronary interventions (PCIs). Results revealed considerable variations across states in practice patterns and treatment outcomes. New York had the highest average length of stay (8.2 days, p <0.01), rate of patients who had AMI being transferred (20.7%, p <0.01), and in-hospital case fatality rate (10.7%, p <0.01) and the lowest rate of alive discharges being routine (65.6%, p <0.01). PCI was performed 2 times as often as CABG for patients who had AMI (23.9% vs 11.3%, p <0.01), with patients who underwent CABG being transferred more often. Multivariate analyses showed that state of residence, age, female gender, transfer status, and number of co-morbidities were predictors of in-hospital mortality and the likelihood of undergoing CABG or PCI. In conclusion, large differences in practice patterns and treatment outcomes exist across states.

Improving Subspecialty Healthcare: Lessons from Cystic Fibrosis

Improving Subspecialty Healthcare: Lessons from Cystic Fibrosis

Comparison of Management Patterns and Clinical Outcomes in Patients With Atrial Fibrillation in Canada and the United States (from the Analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management [AFFIRM] Database)

Little is known about differences in practice patterns or outcomes in the management of patients who have atrial fibrillation in Canada compared with those in the United States (US). We evaluated the effect that the country of enrollment may have on the management patterns and clinical outcomes in patients who participated in the AFFIRM study. Three thousand four hundred patients came from the US and 660 from Canada. In the US, patients were more likely to have a history of coronary artery disease (39% vs 35%, p = 0.03), hypertension (72% vs 67%, p = 0.01), or congestive heart failure (24% vs 18%, p = 0.0002). More US participants were <65 years of age (25% vs 19%, p = 0.003). Although at randomization the use of warfarin was comparable, during follow-up Canadians were more likely to be treated with warfarin and to be therapeutically anticoagulated. Mortality rate at 5 years was higher in US patients (24% vs 16%, p = 0.001), and the composite end point (death, disabling stroke, major bleeding, cardiac arrest, or anoxic encephalopathy) was also higher in US patients (30% vs 22%, p = 0.0005). Even after adjusting for known differences in baseline characteristics, the risk of death was lower in Canada (hazard ratio 0.70, p = 0.02). In conclusion, in the AFFIRM study, US subjects were more likely to have preexisting cardiovascular diseases despite being younger (<65 years old) than those in Canada. Effective warfarin therapy was more commonly employed in Canada. After correcting for the known differences in baseline characteristics, Canadian patients who had atrial fibrillation had a lower mortality risk.

Impact of age on management and outcome of acute coronary syndrome: Observations from the global registry of acute coronary events (GRACE)

Background Evidence-based cardiac therapies are underutilized in elderly patients. We assessed differences in practice patterns, comorbidities, and in-hospital event rates, by age and type of acute coronary syndrome (ACS). Methods We studied 24165 ACS patients in 102 hospitals in 14 countries stratified by age. Results Approximately two-thirds of patients were men, but this proportion decreased with age. In elderly patients (≥ 65 years), history of angina, transient ischemic attack/stroke, myocardial infarction(MI), congestive heart failure, coronary artery bypass graft (CABG) surgery, hypertension or atrial fibrillation were more common, and delay in seeking medical attention and non-ST-segment elevation MI were significantly higher. Aspirin, β-blockers, thrombolytic therapy, statins and glycoprotein IIb/IIIa inhibitors were prescribed less, while calcium antagonists and angiotensin-converting enzyme inhibitors were prescribed more often to elderly patients. Unfractionated heparin was prescribed more often in young patients, while low-molecular-weight heparins were similarly prescribed across all age groups. Coronary angiography and percutaneous intervention rates significantly decreased with age. The rate of CABG surgery was highest among patients aged 65–74 years (8.1%) and 55–64 years (7.7%), but reduced in the youngest (4.7%) and oldest (2.7%) groups. Major bleeding rates were 2–3% among patients aged < 65 years, and > 6% in those ≥ 85 years. Hospital-mortality rates, adjusted for baseline risk differences, increased with age (odds ratio: 15.7 in patients ≥ 85 years compared with those < 45 years). Conclusions Many elderly ACS patients do not receive evidence-based therapies, highlighting the need for clinical trials targeted specifically at elderly cohorts, and quality-of-care programs that reinforce the use of such therapies among these individuals.

Understanding the Social and Cultural Contexts of Female Sex Workers in Karnataka, India: Implications for Prevention of HIV Infection

The objective of the present study was to compare the sociodemographic characteristics and sex work patterns of women involved in the traditional Devadasi form of sex work with those of women involved in other types of sex work, in the Indian state of Karnataka. Data were gathered through in-person interviews. Sampling was stratified by district and by type of sex work. Of 1588 female sex workers (FSWs) interviewed, 414 (26%) reported that they entered sex work through the Devadasi tradition. Devadasi FSWs were more likely than other FSWs to work in rural areas (47.3% vs. 8.9%, respectively) and to be illiterate (92.8% vs. 76.9%, respectively). Devadasi FSWs had initiated sex work at a much younger age (mean, 15.7 vs. 21.8 years), were more likely to be home based (68.6% vs. 14.9%), had more clients in the past week (average, 9.0 vs. 6.4), and were less likely to migrate for work within the state (4.6% vs. 18.6%) but more likely to have worked outside the state (19.6% vs. 13.1%). Devadasi FSWs were less likely to report client-initiated violence during the past year (13.3% vs. 35.8%) or police harassment (11.6% vs. 44.3%). Differences in sociobehavioral characteristics and practice patterns between Devadasi and other FSWs necessitate different individual and structural interventions for the prevention of sexually transmitted infections, including human immunodeficiency virus infection.