Archives of internal medicine最新文献

Background: Communication between African American patients and white health care providers has been shown to be of poorer quality when compared with race-concordant patient-provider communication. Fear on the part of patients that providers stereotype them negatively might be one cause of this poorer communication. This stereotype threat may be lessened by a values-affirmation intervention.

Methods: In a blinded experiment, we randomized 99 African American patients with hypertension to perform a values-affirmation exercise or a control exercise before a visit with their primary care provider. We compared patient-provider communication for the 2 groups using audio recordings of the visit analyzed with the Roter Interaction Analysis System. We also evaluated visit satisfaction, trust, stress, and mood after the visit by means of a questionnaire.

Results: Patients in the intervention group requested and provided more information about their medical condition (mean [SE] number of utterances, 66.3 [6.8] in the values-affirmation group vs 48.1 [5.9] in the control group [P = .03]). Patient-provider communication in the intervention group was characterized as being more interested, friendly, responsive, interactive, and respectful (P = .02) and less depressed and distressed (P = .03). Patient questionnaires did not detect differences in visit satisfaction, trust, stress, or mood. Mean visit duration did not differ significantly between the groups (19.2 minutes in the control group vs 20.5 minutes in the intervention group [P = .29]).

Conclusions: A values-affirmation exercise improves aspects of patient-provider communication in race-discordant primary care visits. The clinical impact of the intervention must be defined before widespread implementation can be recommended.

Background: We sought to develop and validate a simple clinical prediction rule for death and severe disability after acute ischemic stroke that can be used by general clinicians at the time of hospital admission.

Methods: We analyzed data from a registry of 9847 patients (4943 in the derivation cohort and 4904 in the validation cohort) hospitalized with acute ischemic stroke and included in the Registry of the Canadian Stroke Network (July 1, 2003, to March 31, 2008; 11 regional stroke centers in Ontario, Canada). Outcome measures were 30-day and 1-year mortality and a modified Rankin score of 5 to 6 at discharge.

Results: Overall 30-day mortality was 11.5% (derivation cohort) and 13.5% (validation cohort). In the final multivariate model, we included 9 clinical variables that could be categorized as preadmission comorbidities (5 points for preadmission dependence [1.5], cancer [1.5], congestive heart failure [1.0], and atrial fibrillation [1.0]), level of consciousness (5 points for reduced level of consciousness), age (10 points, 1 point/decade), and neurologic focal deficit (5 points for significant/total weakness of the leg [2], weakness of the arm [2], and aphasia or neglect [1]). Maximum score is 25. In the validation cohort, the PLAN score (derived from preadmission comorbidities, level of consciousness, age, and neurologic deficit) predicted 30-day mortality (C statistic, 0.87), death or severe dependence at discharge (0.88), and 1-year mortality (0.84). The PLAN score also predicted favorable outcome (modified Rankin score, 0-2) at discharge (C statistic, 0.80).

Conclusions: The PLAN clinical prediction rule identifies patients who will have a poor outcome after hospitalization for acute ischemic stroke. The score comprises clinical data available at the time of admission and may be determined by nonspecialist clinicians. Additional studies to independently validate the PLAN rule in different populations and settings are required.

Background: Despite receipt of dual antiplatelet therapy, patients after an acute coronary syndrome (ACS) remain at significant risk for thrombotic events. The role of orally activated Xa antagonist (anti-Xa) and direct thrombin inhibitors is debated in this setting. Our study objective was to evaluate the efficacy and safety of new-generation oral anticoagulant agents compared with placebo in patients receiving antiplatelet therapy after an ACS.

Methods: Electronic databases were searched to identify prospective randomized placebo-controlled clinical trials that evaluated the effects of anti-Xa or direct thrombin inhibitors in patients receiving antiplatelet therapy after an ACS. Efficacy measures included stent thrombosis, overall mortality, and a composite end point of major ischemic events, while thrombolysis in myocardial infarction-defined major bleeding events were used as a safety end point. The net clinical benefit was calculated as the sum of composite ischemic events and major bleeding events.

Results: For the period January 1, 2000, through December 31, 2011, we identified 7 prospective randomized placebo-controlled clinical trials that met the study criteria, involving 31 286 patients. Based on the pooled results, the use of new-generation oral anticoagulant agents in patients receiving antiplatelet therapy after an ACS was associated with a dramatic increase in major bleeding events (odds ratio, 3.03; 95% CI, 2.20-4.16; P < .001). Significant but moderate reductions in the risk for stent thrombosis or composite ischemic events were observed, without a significant effect on overall mortality. For the net clinical benefit, treatment with new-generation oral anticoagulant agents provided no advantage over placebo (odds ratio, 0.98; 95% CI, 0.90-1.06; P = .57).

Conclusion: The use of anti-Xa or direct thrombin inhibitors is associated with a dramatic increase in major bleeding events, which might offset all ischemic benefits in patients receiving antiplatelet therapy after an ACS.

Background: In the last 6 months of life, many older adults will experience a hospitalization, followed by a transfer to a skilled nursing facility (SNF) for additional care. We sought to examine patterns of Medicare posthospitalization SNF use in the last 6 months of life.

Methods: We used data from the Health and Retirement Study, a longitudinal survey of older adults, linked to Medicare claims (January 1994 through December 2007). We determined the number of individuals 65 years or older at death who had used the SNF benefit in the last 6 months of life. We report demographic, social, and clinical correlates of SNF use. We examined the relationship between place of death and hospice use for those residing in nursing homes and the community before the last 6 months of life.

Results: The mean age at death among 5163 individuals was 82.8 years; 54.5% of the cohort were female, and 23.2% had resided in a nursing home. In total, 30.5% had used the SNF benefit in the last 6 months of life, and 9.2% had died while enrolled in the SNF benefit. The use of the SNF benefit was greater among patients who were 85 years or older, had at least a high school education, did not have cancer, resided in a nursing home, used home health services, and were expected to die soon (P < .01 for all). Of community dwellers who had used the SNF benefit, 42.5% died in a nursing home, 10.7% died at home, 38.8% died in the hospital, and 8.0% died elsewhere. In contrast, of community dwellers who did not use the SNF benefit, 5.3% died in a nursing home, 40.6% died at home, 44.3% died in the hospital, and 9.8% died elsewhere.

Conclusions: Almost one-third of older adults receive care in a SNF in the last 6 months of life under the Medicare posthospitalization benefit, and 1 in 11 elders will die while enrolled in the SNF benefit. Palliative care services should be incorporated into SNF-level care.