Suboptimal Medical Treatment Research Articles

Impact of coronary artery disease phenotype on treatment in chronic coronary syndromes: the EURECA registry

Abstract Background The EURECA registry aimed to assess the use of stress ECG and cardiac imaging in the diagnostic process of patients with chronic coronary syndrome (CCS). To which extent the coronary artery disease (CAD) phenotype, defined by the diagnostic process, may influence the management of these patients in clinical practice is not known. Purpose In the present analysis we aimed to evaluate the impact of the CAD phenotype on downstream therapeutic choices in the EURECA population. Methods Among the 5156 patients enrolled in the EURECA registry between May 2019 and March 2020, early treatment choices (within 6 months from enrolment) could be defined in 4874 patients (mean age 63.5 years, 59.7% males). They were categorized as: 1. no treatment change; 2. optimized medical treatment (OMT, i.e. new therapy or increase of previous therapy); 3. revascularization. The CAD phenotypes were defined in 3771 patients as: 1. no CAD; 2. non-obstructive CAD; 3. obstructive CAD without documented ischemia (including patients with no stress test performed); 4. obstructive CAD with documented ischemia. Results In 3049/4874 patients (63%) treatment was unchanged, in 1204 (24%) medical treatment was optimized and in 621 patients (13%) revascularization was performed. At the end of the diagnostic process, the disease phenotype was no CAD in 1409/3771 patients (37%), non-obstructive CAD in 1463 (39%), obstructive CAD without documented ischemia in 374 (10%) and obstructive CAD with documented ischemia in 525 patients (14%). In patients with non-obstructive CAD, medical treatment was optimized more frequently than in those with no CAD (34% vs 19%, P<0.001) but in 65% of these patients treatment was unchanged. In patients with obstructive CAD revascularization frequency was similar in patients without or with documented ischemia (60% vs 61%, P=NS) as well as OMT alone (21% and 18%, P=NS) (Figure 1). Revascularization or OMT alone were associated with enrolment in cardiology departments, older age, male gender, typical symptoms, higher frequency of risk factors, history of previous CAD and positive results of any non-invasive test (Figure 2). At multivariate analysis independent predictors of more intense treatment were enrolment in cardiology department (OR 1.55, 95% CI 1.30-1.83), typical angina (OR 1.96, 95% CI 1.69-2.27), hypertension (OR 1.29, 95% CI 1.11-1.49) and positivity of any non-invasive test. Conclusions In patients with CCS the diagnosis of non-obstructive CAD is associated with a suboptimal medical treatment. On the other hand, the diagnosis of anatomical obstructive CAD drives revascularization procedures, independently of documenting inducible ischemia. The intensity of treatment management depends on the overall estimation of patient risk based more on clinical variables and positivity of any diagnostic test than on specific disease phenotypes.Treatment according to CAD phenotypePredictors of revascularization or OMT

Presentation, Management and Early Mortality of Patients with Acute Coronary Syndrome in a Large Sample Study of a Middle East Country.

Due to lack of contemporary data on the presentation, management, and mortality of acute coronary syndrome (ACS) admissions in Iran, in this prospective registry study, we aimed to evaluate the presentation, management, and mortality as the outcome of patients with ACS in Isfahan, Iran, 2001-2016 to address treatment and healthcare depletions. Data of 62,276 patients admitted with the diagnosis of ACS from 2001 to 2016 prospectively were obtained by Surveillance Unit of Isfahan Cardiovascular Research Center, Isfahan, Iran, in 13 hospitals of Isfahan province. We evaluated data on presentation, management, and in-hospital and 28-day mortality. Nearly half of the patients ranged in age from 51 to 70 years (32050, 51.5%), which did not differ among ACS types (ST-segment myocardial infarction (STEMI): 53.9%; non-STEMI: 53.4%; unstable angina: 51.9%). In-hospital, anti-platelets use was high (84.9%). Thrombolytic were used in 48.1% of STEMI, 3.8% of non-STEMI, and 1.1% of unstable angina. Discharge medication rates were suboptimal. In-hospital and 28-day mortality were highest for STEMI (6.5 and 12.6%, respectively). These data represent the large ACS registry in Iran. Data revealed the various presentations of ACS and demonstrated opportunities for improving ACS management by focusing on increasing use of recommended drugs especially after discharge due to suboptimal medical treatment in these patients. The high mortality rate needs to be taken into consideration in ACS patients.

Impact of Inpatient Initiation of Sodium-Glucose Cotransporter-2 Inhibitors on Prescription Rates in Patients With Heart Failure With Reduced Ejection Fraction

Despite large, randomized controlled trials and guideline recommendations, patients with heart failure with reduced ejection fraction (HFrEF) continue to receive suboptimal guideline-directed medical treatment (GDMT). This study aimed to evaluate the potential effect of inpatient initiation of sodium-glucose cotransport-2 (SGLT2) inhibitors on postdischarge prescribing rates and the downstream impact on clinical outcomes. The INitiation of SGlt2i in Hospital for HFrEF (INSIGHT-HF) study was a retrospective analysis of hospitalized patients older than 18 years with a left ventricular ejection fraction (LVEF) ≤40% conducted from July 2020 and July 2021. Our primary outcome was SGLT2i prescription rates at 30days. Among 2,663 eligible patients with documented HFrEF, 177 (6.6%) had SGLT2i initiated during their index hospitalization. The rate of SGLT2i prescriptions at 30days was significantly higher in those with inpatient initiation of SGLT2i compared with those who did not start while inpatient (96% vs 14.7%, p <0.0001). The heart failure readmission rate in the first 30days was significantly lower in those with inpatient initiation of SGLT2i compared with those who did not start during hospitalization. (9.3% vs 22.7%, p=0.04). Cardiovascular mortality was numerically, but not significantly, different between groups (4% vs 10.7%, p=0.21). Inpatient initiation of an SGLT2i was associated with a significantly higher postdischarge rate of SGLT2i prescriptions and significantly lower heart failure readmission rates at 30days. In conclusion, these findings highlight the importance of initiating SGLT2i during inpatient hospitalization to improve the quality of care in patients with HFrEF.

Effect of frailty on treatment, hospitalisation and death in patients with chronic heart failure

BackgroundFrailty is common in patients with chronic heart failure (CHF) and is associated with poor outcomes. The natural history of frail patients with CHF is unknown.MethodsFrailty was assessed using the clinical frailty scale (CFS) in 467 consecutive patients with CHF (67% male, median age 76 years, median NT-proBNP 1156 ng/L) attending a routine follow-up visit. Those with CFS > 4 were classified as frail. We investigated the relation between frailty and treatments, hospitalisation and death in patients with CHF.Results206 patients (44%) were frail. Of 291 patients with HF with reduced ejection fraction (HeFREF), those who were frail (N = 117; 40%) were less likely to receive optimal treatment, with many not receiving a renin–angiotensin–aldosterone system inhibitor (frail: 25% vs. non-frail: 4%), a beta-blocker (16% vs. 8%) or a mineralocorticoid receptor antagonist (50% vs 41%). By 1 year, there were 56 deaths and 322 hospitalisations, of which 25 (45%) and 198 (61%), respectively, were due to non-cardiovascular (non-CV) causes. Most deaths (N = 46, 82%) and hospitalisations (N = 215, 67%) occurred in frail patients. Amongst frail patients, 43% of deaths and 64% of hospitalisations were for non-CV causes; 58% of cardiovascular (CV) deaths were due to advancing HF. Among non-frail patients, 50% of deaths and 57% of hospitalisations were for non-CV causes; all CV deaths were due to advancing HF.ConclusionFrailty in patients with HeFREF is associated with sub-optimal medical treatment. Frail patients are more likely to die or be admitted to hospital, but whether frail or not, many events are non-CV.Graphical abstract

Determinants of adherence to antihypertensive treatment among patients attending a primary care clinic with limited medical armamentarium in Delhi, India: A qualitative study.

To determine perspectives on reasons for non-adherence to antihypertensive therapy and its socioeconomic determinants among patients attending a primary care center in a low-income area in Delhi, India. We conducted in-depth interviews with a total of 30 patients having hypertension at a primary care facility located in a low-income urban area in Delhi. All the participants were aware that hypertension was a serious illness, and medication intake was necessary throughout life to prevent uncontrolled hypertension. All participants in varying quantities practiced salt restriction, but the consumption of fresh fruit and vegetables was low primarily due to economic reasons. The participants were unable to differentiate the concept of exercise from physical activity. Medication adherence was suboptimal, and significant reasons for non-adherence were forgetfulness, carelessness and running out of drug stocks. Blood pressure control was also suboptimal in a majority of the participants, but combination therapy was restricted due to limited medical armamentarium at the clinic. Laboratory investigations for monitoring target end-organ damage were either delayed or not conducted in most participants. Hypertensive patients undergoing treatment at primary care facilities often report suboptimal medical adherence and treatment outcomes, with socioeconomic causes being a major driver of non-adherence.

SAT-311 Role of SREBP in Regulation of Corticotroph Tumor ACTH Secretion and Cell Proliferation

Cushing Disease (CD) is a life-threatening condition with suboptimal medical treatment. To identify drugs that not only inhibit ACTH secretion to attain eucortisolemia but also inhibit tumor growth, we conducted a high throughput screen employing a novel “gain of signal” ACTH AlphaLISA assay. From a kinase inhibitor library containing 430 compounds, we identified the dual PI3K/HDAC inhibitor, CUDC-907, as a potent inhibitor of both in vitro and in vivo corticotroph tumor ACTH secretion and growth. By stepwise comparison of CUDC-907 with mono-functional PI3K and HDAC inhibitors, we demonstrated that CUDC-907 exerts its inhibitory effect on ACTH secretion primarily through its inhibition of HDAC activity at the POMC transcriptional level; while PI3K-mediated inhibition of corticotroph cell viability further contributes to reduced ACTH secretion. We also used RNA-seq to characterize the global transcriptiome changes associated with CUDC-907 treatment. Hierarchical clustering showed that 1432 differentially expressed genes (DEGs, p≤0.05 and fold-change≥1.5) were altered by CUDC-907 treatment in comparison to the vehicle-treated control cells. Gene ontology (GO) analysis of 456 downregulated and 976 upregulated DEGs revealed that the most enriched biological processes were cholesterol biosynthesis (GO:0006695, p=1.977e-17) and the type I interferon signaling pathway (GO: 0060337, p=4.928e-7) respectively. Further analysis demonstrated downregulation of the membrane-bound transcription factor sterol regulatory element binding proteins (SREBPs). Downregulation of SREBP-2 by CUDC-907 as well as the several other target enzymes in the cholesterol biosynthesis and uptake pathway including IDI2, NSDHL, MVD, and HMGCR, was confirmed by real-time PCR. To further characterize a role for SREBP-2 in regulation of corticotroph tumor ACTH secretion and proliferation, we employed siRNA targeting endogenous SREBP-2 (SREBP-2 mRNA, Control vs. siRNA 1±0.03 vs. 0.6±0.08, p<0.05), and demonstrated that knockdown of SREBP-2 not only inhibited POMC mRNA expression (POMC mRNA, 1±0.03 vs. 0.7±0.01, p<0.01), and ACTH secretion (ACTH (ng/mL) 29±0.4 vs. 23±0.3, p<0.005), but also suppressed cell proliferation (Relative Proliferation Rate, 1±0.01 vs. 0.7±0.01, p<0.005). This was further confirmed by overexpression of cleaved mature SREBP-2, which led to increased POMC expression and cell proliferation. We demonstrate for the first time the role of the SREBP-mediated cholesterol biosynthesis pathway in regulation of corticotroph tumor POMC regulation and growth. Our studies identify SREBP and cholesterol biosynthesis as a therapeutic target in CD.

The Effect of Adenomyosis in Myometrial Invasion and Overall Survival in Endometrial Cancer.

The aim of this study was to evaluate whether adenomyosis had an effect on myometrial tumor invasion, stage of the disease, and survival in endometrial cancer. Endometrial cancer patients encountered between 2007 and 2016 were identified from pathology records. Patients who underwent suboptimal surgical or medical treatment or with insufficient clinical or surgical data were excluded. Patients diagnosed as having concurrent adenomyosis constituted the study group. Control group patients were randomly selected in a paired design according to the tumor grades in the study group, and for each tumor grade, 4 times as many as patients were included. Tumor stage, histologic type and grade, myometrial invasion, lymphovascular space invasion, presence and location of the adenomyosis in myometrial wall, distance from endometrial line, tumor in adenomyosis, adjuvant treatment, and relapse were primary outcomes.Age, body mass index, medical comorbidities, and type of operation were also recorded. Univariate and multivariate Cox proportional hazards regression models were performed for overall survival. Of those 1242 endometrial cancer patients, 80 with concurrent adenomyosis were identified and compared with 320 patients without adenomyosis following a paired selection based on tumor grade. Higher rates of myometrial invasion, lymphovascular space invasion, tumor diameter, and adjuvant treatments were found in the nonadenomyosis group compared with adenomyosis group (P ≤ 0.001). In patients with adenomyosis, rates of early-stage disease and overall survival were significantly higher compared with the control group (P = 0.001 and 0.01, respectively). Our results showed that adenomyosis is significantly associated with lower stage in endometrial cancer that may suggest a possible limiting effect on endometrial cancer spread. In addition, despite similar rates in disease-free survival and endometrial cancer-related death, overall survival rate was significantly higher in the presence of adenomyosis and might be considered as a good prognostic factor for endometrial cancer.

Settling for second best: when should doctors agree to parental demands for suboptimal medical treatment?

BackgroundDoctors sometimes encounter parents who object to prescribed treatment for their children, and request suboptimal substitutes be administered instead (suboptimal being defined as less effective and/or more expensive). Previous studies...

Managing spine surgery referrals: The consultation of neurosurgery and its nuances

IntroductionSpinal disorders, particularly low back pain, are among the most common reasons for general practitioner (GP) consultation and can sometimes be a source of professional friction. Despite their frequency and published guidelines, many patients are still mistakenly referred by their GP to specialists for spinal surgery consultation which can create colleague relationship problems, suboptimal or unnessary delayed care, as well as the financial implications for patients. PurposeTo assess the management of GP lumbar spine referrals made to 4 neurosurgeons from 3 neurosurgical teams specialized in spinal surgery. MethodsAll patient's medical records relating to 672 primary consultants over a period of two months (January and February 2015) at three institutions were retrospectively reviewed. Medical referral letters, clinical evidence and imaging data were analyzed and the patients were classified according the accuracy of surgical assessment. The final decisions of the surgeons were also considered. ResultsOf the 672 patients analyzed, 198 (29.5%) were considered unsuitable for surgical assessment: no spinal pathology=10.6%, no surgical conditions=35.4%, suboptimal medical treatment=31.3%, suboptimal radiology=18.2% and asymptomatic patients=4.5%. ConclusionUnnecessary referrals to our consultation centers highlight the gap between the reason for the consultation and the indications for spinal surgery. Compliance with the guidelines, the creation of effective multidisciplinary teams, as well as the “hands on” involvement of surgeons in primary and continuing education of physicians are the best basis for a reduction in inappropriate referrals and effective patient care management.

Hearing Loss and Misunderstandings

Hearing health professionals have a key role in making old age less hazardous for patients who are ill and seeking medical help. Older people are more likely to have chronic diseases, physical or psychological decline, and regular contact with a range of health professionals in hospitals and medical facilities. They may also have hearing loss—a disability associated with older patients—that may contribute to suboptimal medical treatment. Unfortunately, older people also are at increased risk of medication errors, some so serious as to require casualty department evaluation or inpatient admission. Premature readmission of elderly patients is common and costly. One in five Medicare beneficiaries is readmitted within 30 days, costing more than $26 billion per year (JAMA Intern Med. 2014;174[7]:1095 http://bit.ly/2uD3L55). A 2014 study reported cognitive status to be an overriding factor that correlates with health literacy, physical health, and depression in older adults; however, participants with hearing impairment were excluded from this study (Health Serv Res. 2014;49[4]:1249 http://bit.ly/2uCNixy). Researchers working with the Vanderbilt Inpatient Cohort Study found that about half of the elderly patients in their study experienced discharge medication errors (BMC Health Serv Res. 2014;14:10 http://bit.ly/2uCORvq;Mayo Clin Proc. 2014;89[8]:1042 http://bit.ly/2uCEdVT). Hearing-impaired patients were also excluded from this study. To date, there remains a lack of well-developed research on hearing-impaired patients’ understanding of medical consultations, investigations, and treatments of health conditions unrelated to their hearing loss (Ann Fam Med. 2008;6[5]:441 http://bit.ly/2uD8XWz). Professionals may be unwise to assume that patients have an accurate understanding of their care. Patients (including practicing physicians) are reluctant to question their treating clinician. While written materials may adequately supplement a clinical interview, the quality of these materials has been questioned. Furthermore, one-third of older adults in England reported problems in reading and understanding written health information (BMJ. 2012;344:e1602http://bit.ly/2vNpqG5). As medical educators, we wondered if it was possible to train our students differently to reduce medication errors when managing elderly patients. To answer this, we had to disentangle hearing impairment from other possible factors like cognitive decline. We embarked on a study involving a large number of young, intelligent, assertive, and hearing-impaired adults. This may be the first qualitative investigation of words commonly misheard by hearing-impaired patients at clinical consultations in a primary care or hospital setting (J Patient Saf. 2017 http://bit.ly/2uCJ5u4). We also looked at contextual factors that contributed to miscommunication and medical errors. Fifty-nine percent of the respondents said they have misheard a physician/nurse in a hospital; 60 percent identified these in relation to consultation content; 33 percent misheard words; 21 percent misinterpreted statements like diagnosis and medication details; 22 percent indicated physician/nurse-patient communication failures; and 19 percent noted failures to initiate/maintain eye contact and wearing surgical masks while speaking, preventing patients from lip reading. Concerning common words that were misheard or misinterpreted, 23 percent identified phonological similarity such as similar sounding words and numbers, while seven percent noted discrimination of unvoiced consonants. Similar findings emerged in community clinics. Our findings underscore the need to identify hearing-impaired patients and augment communication with visual aids and other strategies like lip reading.Figure: Patrick Henn, MB, BCh, BAOFigure: Simon Smith, BSc, MScFigure: Colm O. Tuathaigh, PhD

Successful treatment of thyroid storm presenting as recurrent cardiac arrest and subsequent multiorgan failure by continuous renal replacement therapy.

SummaryThyroid storm is a rare and potentially life-threatening medical emergency. We experienced a case of thyroid storm associated with sepsis caused by pneumonia, which had a catastrophic course including recurrent cardiac arrest and subsequent multiple organ failure (MOF). A 22-year-old female patient with a 10-year history of Graves’ disease was transferred to our emergency department (ED). She had a cardiac arrest at her home and a second cardiac arrest at the ED. Her heart recovered after 20 min of cardiac resuscitation. She was diagnosed with thyroid storm associated with hyperthyroidism complicated by pneumonia and sepsis. Although full conventional medical treatment was given, she had progressive MOF and hemodynamic instability consisting of hyperthermia, tachycardia and hypotension. Because of hepatic and renal failure with refractory hypotension, we reduced the patient’s dose of beta-blocker and antithyroid drug, and she was started on continuous veno-venous renal replacement therapy (CRRT) with intravenous albumin and plasma supplementation. Subsequently, her body temperature and pulse rate began to stabilize within 1 h, and her blood pressure reached 120/60 mmHg after 6 h. We discontinued antithyroid drug 3 days after admission because of aggravated hyperbilirubinemia. The patient exhibited progressive improvement in thyroid function even after cessation of antithyroid drug, and she successfully recovered from thyroid storm and MOF. This is the first case of thyroid storm successfully treated by CRRT in a patient considered unfit for antithyroid drug treatment.Learning points:The presenting manifestations of thyroid storm vary and can include cardiac arrest with multiorgan failure in rare cases.In some patients with thyroid storm, especially those with severe complications, conventional medical treatment may be ineffective or inappropriate.During thyroid storm, the initiation of CRRT can immediately lower body temperature and subsequently stabilize vital signs.Early initiation of CRRT can be life-saving in patients with thyroid storm complicated by MOF, even when used in combination with suboptimal medical treatment.

Hearing Impairment and the Amelioration of Avoidable Medical Error: A Cross-Sectional Survey.

Hearing loss contributes to suboptimal medical treatment. We investigated the nature and magnitude of potential health-care harm of hearing loss alone on a patient's understanding of medical consultations, investigations, and treatments of health conditions unrelated to their hearing loss. A cross-sectional, questionnaire-based design of a convenience sample of students with hearing loss, registered with the institutional disability support service in 8 Irish and 15 UK third-level institutions. Content analysis of open-ended item responses identified and coded emergent themes. Closed-ended questionnaire items recorded demographic and clinically relevant characteristics. Ninety-five responses were received and analyzed. Fifty-six (58.9%) indicated "yes" to mishearing a physician/nurse in a hospital. Approximately 60.7% identified this in relation to consultation content; 33.9% mishearing; and 21.4% misinterpreting what was said, including diagnosis, guidelines and advice, and matters relating to medications. Approximately 22.3% indicated physician/nurse-patient communication failures; 19.6% identified failure to initiate/maintain eye contact, turning away from the patient, speaking while wearing surgical masks, excluding the possibility of lip reading. Approximately 7.1% identified speaking in too low a volume or too fast. Concerning common words misheard or misinterpreted, 23.2% identified phonological similarity such as similar sounding words and numbers, 7.4% discrimination of unvoiced consonants. Similar findings emerged in GP clinics. Most hearing-impaired students experienced difficulty in understanding health-care professionals in a hospital and general practice setting. This underscores the importance for health-care providers to identify hearing-impaired patients and to augment communication using visual aids, a quite environment and optimizing lip reading communication.

Cost-equivalence and Pluralism in Publicly-funded Health-care Systems

Clinical guidelines summarise available evidence on medical treatment, and provide recommendations about the most effective and cost-effective options for patients with a given condition. However, sometimes patients do not desire the best available treatment. Should doctors in a publicly-funded healthcare system ever provide sub-optimal medical treatment? On one view, it would be wrong to do so, since this would violate the ethical principle of beneficence, and predictably lead to harm for patients. It would also, potentially, be a misuse of finite health resources. In this paper, we argue in favour of permitting sub-optimal choices on the basis of value pluralism, uncertainty, patient autonomy and responsibility. There are diverse views about how to evaluate treatment options, and patients’ right to self-determination and taking responsibility for their own lives should be respected. We introduce the concept of cost-equivalence (CE), as a way of defining the boundaries of permissible pluralism in publicly-funded healthcare systems. As well as providing the most effective, available treatment for a given condition, publicly-funded healthcare systems should provide reasonable suboptimal medical treatments that are equivalent in cost to (or cheaper than) the optimal treatment. We identify four forms of cost-equivalence, and assess the implications of CE for decision-making. We evaluate and reject counterarguments to CE. Finally, we assess the relevance of CE for other treatment decisions including requests for potentially superior treatment.

A systems BIOlogy Study to TAilored Treatment in Chronic Heart Failure: rationale, design, and baseline characteristics of BIOSTAT-CHF.

Despite major improvements in pharmacological and device treatments, heart failure remains a syndrome with high morbidity and mortality, poor quality of life, and high health-care costs. Given the extensive heterogeneity among patients with heart failure, substantial differences in the response to therapy can be expected. We hypothesize that individualized therapy is an essential next step to improve outcomes in patients with heart failure. The BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF) included 2516 patients with worsening signs and/or symptoms of heart failure from 11 European countries, who were considered to be on suboptimal medical treatment. Another 1738 patients from Scotland were included in a validation cohort. Overall, both patient cohorts were well matched. The majority of patients were hospitalized for acute heart failure, and the remainder presented with worsening signs and/or symptoms of heart failure at outpatient clinics. Approximately half of the patients were in New York Heart Association class III, and 7% vs 34% of patients of the index vs validation cohort had heart failure with preserved ejection fraction. According to study design, all patients used diuretics, but owing to the inclusion criteria of both cohorts, patients were not on optimal, evidence-based medical therapy. In the follow-up phase, uptitration to guideline-recommended doses was encouraged. By using a novel systems biology approach, incorporating demographics, biomarkers, genome-wide analysis, and proteomics, a model that predicts response to therapy will be developed, which should be instrumental in developing alternative therapies for patients with suboptimal response to currently recommended therapies and thus further improve care for patients with heart failure.

Clinical presentation, management, in-hospital and 90-day outcomes of heart failure patients in Trivandrum, Kerala, India: the Trivandrum Heart Failure Registry.

To evaluate the presentation, management, and outcomes of patients hospitalized for heart failure (HF) in Trivandrum, India. The Trivandrum Heart Failure Registry (THFR) enrolled consecutive admissions from 13 urban and five rural hospitals in Trivandrum with a primary diagnosis of HF from January to December 2013. Clinical characteristics at presentation, treatment, in-hospital outcomes, and 90-day mortality data were collected. 'Guideline-based' medical treatment was defined as the combination of beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aldosterone receptor blockers in patients with left ventricular systolic dysfunction (LVSD). We enrolled 1205 cases (834 men, 69%) into the registry. Mean (standard deviation) age was 61.2 (13.7) years. The most common HF aetiology was ischaemic heart disease (IHD) (72%). Heart failure with preserved ejection fraction (≥45%) constituted 26% of the population. The median hospital stay was 6 days (interquartile range = 4-9 days) with an in-hospital mortality rate of 8.5% (95% confidence interval 6.9-10.0). The 90-day all-cause mortality rate was 2.43 deaths per 1000 person-days (95% confidence interval 2.11-2.78). Guideline-based medical treatment was given to 19% and 25% of patients with LVSD during hospital admission and at discharge, respectively. Older age, lower education, poor ejection fraction, higher serum creatinine, New York Heart Association functional class IV, and suboptimal medical treatment were associated with higher risk of 90-day mortality. Patients hospitalized with HF in the THFR were younger, more likely to be men, had a higher prevalence of IHD, reported longer length of hospital stay, and higher mortality compared with published data from other registries. We also identified key areas for improving hospital-based HF medical care in Trivandrum.

Soft Systems Methodology in Action: The Example of a Private Hospital

The paper dealt with the issues of communication between physicians and patients, health care needs of patients and appointment and documentation systems leading to sub-optimal medical treatment, disorganised files and congestion and improperly stored medical treatment records of patients Two Strands Model of Soft Systems Methodology (SSM) revealed and handled at a private hospital in Turkey. SSM helped make changes as recommendations to the hospital. However, the SSM-based enquiry also disclosed some difficulties in the processes of cooperation between the practitioner and the client, arranging democratic group discussions, drawing rich pictures, designating, listing and selecting organisational concerns, designing human activity systems, comparing conceptual models with the problem situation and offering and adopting changes. Thus, the paper proposed possible solutions to these methodological problems through synthesising relevant key conceptions of specific soft and other change methodologies into a framework that attempted to bring robust developmental specifications and order for using SSM.

The influence of optimal medical treatment on the ‘obesity paradox’, body mass index and long-term mortality in patients treated with percutaneous coronary intervention: a prospective cohort study

ObjectiveTo assess whether the obesity paradox persists in the long term and to study the effect of optimal medical treatment on this phenomenon.DesignA retrospective cohort study.SettingA tertiary care centre in...

Uninsured South Florida vascular surgery patients are less likely to receive optimal medical management than their insured counterparts

Vascular disease is the most prevalent condition in patients aged >60 years, leading to increasing complications associated with their comorbid conditions. Poor medical compliance could be one reason why the rate of complications may be higher in this patient population, particularly the uninsured. This study was conducted to better assess rates of medication compliance in vascular surgical patients. Consecutive patients seen in vascular clinics at a busy tertiary academic center were prospectively studied. Physicians and physician assistants used a standardized questionnaire to collect patient data and evaluated patients for coexisting medical conditions and medication use. Optimal medical therapy was defined according to the 2006 American Heart Association (AHA)/American College of Cardiology (ACC) "Guidelines for Secondary Prevention for Atherosclerotic Vascular Disease." Data were analyzed using multivariate regression. During the 4-month study period, 180 consecutive patients (47% men) were seen in vascular surgery clinics. Most patients (79%) were nonsmokers and only 21% admitted to smoking. Comorbid conditions surveyed included hypertension in 141, diabetes mellitus in 56, coronary artery disease in 24, hypercholesterolemia in 89, and chronic renal failure in 13; of these, 61% were insured and 39% had no insurance. Overall, only 31% of all patients were receiving adequate medical therapy for their comorbid conditions, and about 66% were receiving suboptimal medical treatment for their vascular disease. Uninsured patients were less likely (19%) than insured patients (39%) to receive optimal medical therapy (P = .012). Lack of insurance was a predictor of suboptimal medical therapy for hypertension (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.20-8.16; P = .016), hypercholesterolemia (OR, 5.1; 95% CI, 1.87-13.88; P = .001), peripheral arterial disease (OR, 13.32; 95% CI, 2.84-62.54, P < .001), and any disease overall (OR, 2.43; 95% CI, 1.21-4.88, P = .012). Overall, men and women were equally likely (68%) to receive suboptimal medical therapy; however, women were significantly more likely to be undertreated for coronary artery disease (OR, 0.022; 95% CI, 0.0017-0.293; P < .001). Compliance with optimal medical therapy for secondary risk factor management amongst our vascular surgery patients is low. Uninsured patients are less likely to receive optimal medical therapy than their insured counterparts. This survey provides sobering statistics regarding medical compliance in our population. This issue deserves further study and may indirectly affect outcomes in minority groups that are disproportionately represented in our uninsured patients.

Insights From a Cardiac Resynchronization Optimization Clinic as Part of a Heart Failure Disease Management Program

Our aim was to determine the feasibility and value of a protocol-driven approach to patients with cardiac resynchronization therapy (CRT) who did not exhibit a positive response long after implant. Up to one-third of patients with advanced heart failure do not exhibit a positive response to CRT. A total of 75 consecutive ambulatory patients with persistent advanced heart failure symptoms and/or adverse reverse remodeling and CRT implanted >6 months underwent a comprehensive protocol-driven evaluation to determine the potential reasons for a suboptimal response. Recommendations were made to maximize the potential of CRT, and adverse events were documented. All patients (mean left ventricular [LV] ejection fraction 23 +/- 9%, LV end-diastolic volume 275 +/- 127 ml) underwent evaluation. Eighty-eight percent of patients had significantly better echocardiographic indexes of LV filling and LV ejection with optimal setting of their CRT compared with a temporary VVI back-up setting. Most patients had identifiable reasons for suboptimal response, including inadequate device settings (47%), suboptimal medical treatment (32%), arrhythmias (32%), inappropriate lead position (21%), or lack of baseline dyssynchrony (9%). Multidisciplinary recommendations led to changes in device settings and/or other therapy modifications in 74% of patients and were associated with fewer adverse events (13% vs. 50%, odds ratio: 0.2 [95% confidence interval: 0.07 to 0.56], p = 0.002) compared with those in which no recommendation could be made. Routine protocol-driven approach to evaluate ambulatory CRT patients who did not exhibit a positive response is feasible, and changes in device settings and/or other therapies after multidisciplinary evaluation may be associated with fewer adverse events.

Medical Care of Employees Long-Term Sick Listed Due to Mental Health Problems: A Cohort Study to Describe and Compare the Care of the Occupational Physician and the General Practitioner

To describe medical management by the general practitioner (GP) and occupational physician (OP) of workers sick listed due to mental health problems, and to determine agreement in diagnosis, main cause of sickness absence and obstacles in return to work. A cohort of 555 employees being sick listed for 12 to 20 weeks due to mental health problems was recruited and followed for 1 year. These employees were interviewed about their mental health and contacts with GP, OP, other specialists and employer. In addition, the GP and/or the OP of 72 employees were interviewed about the medical diagnosis and management. Most employees sick listed for 12-20 weeks visited their GP and OP. According to the employees most interventions applied by the GP were medical interventions, such as referral of employees and prescription of medical drugs. Working conditions were seldom discussed by the GP and work-related interventions were never applied. Most interventions applied by the OP were work-related interventions and/or contact with the employer. The OP more often talked about working conditions and conflicts. According to the employees, the communication between GP and OP only took place in 8% of the cases. Agreement in the diagnosis, main cause of sickness absence, and obstacles in return to work reported by the GPs and OPs of the same employee was poor. In addition, similarity in reported diagnosis by GP and/or OP and the employees' scores on valid questionnaires on (mental) health was limited. The lack of communication and agreement by Dutch GPs and OPs in medical diagnosis and management of employees long-term sick listed due to mental health problems are indicators of sub-optimal medical treatment and return-to-work strategies.