Title: The Quality of Care Provided to Hospitalized Patients at the End of Life
Date Posted: July 15, 2010
Authors: Walling AM, Asch SM, Lorenz KA, et al.
Citation: Arch Intern Med 2010;170:1057-1063.
Study Question:
What is the quality of end-of-life care among hospitalized patients?
Methods:
Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators. Patients who died during hospitalization and were hospitalized for at least 3 days between April 2005 and April 2006 in a major university medical center were included in the analysis.
Results:
A total of 496 patients were included in the study population, of which 47% were women. The mean age was 62 years, with 28% being 75 years or older. Primary reasons for hospitalization and death included advanced cancer (21%), end-stage liver disease (16%), end-stage pulmonary disease (11%), end-stage renal disease (9%), and end-stage heart failure (6%). Median hospital length of stay was 11 days, with 63% of patients hospitalized for 10 or more days. Do not resuscitate (DNR) orders were present in 84% of patients, with 28% of orders written on the day of death (median time of DNR orders was 2 days prior to death). Of the 359 patients receiving mechanical ventilation, 46% had ventilator withdrawn prior to death. Family meetings were documented in 55% of patients. Patient preferences for care related to resuscitation status were respected with fidelity. Timely documentation of discussion about patient preferences on admission to the intensive care unit occurred less than 50% of the time. Only 18% of patients had advance directives in their medical record at any point during hospitalization. Only 25% of patients with implantable cardioverter defibrillators, who were expected to die, had documentation regarding deactivation of the device. Only 29% of patients undergoing withdrawal of mechanical ventilation had dyspnea assessments documented in their charts.
Conclusions:
The authors concluded that quality of end-of-life care, as documented in medical charts, can be improved. Advance directives, palliative care plans, and assessment of symptoms such as pain and dyspnea are important components of end-of-life care.
Perspective:
Cardiovascular disease is a leading cause of death. End-of-life care for patients with heart disease, in particular heart failure, is an increasingly common part of hospital management. Yet training in end-of-life care is often not a component of cardiovascular training. Further study of the quality of care related to end-of-life care is needed.
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Title: Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients With Diabetes and Coronary Artery Disease
Date Posted: July 6, 2010
Authors: Cooper-DeHoff RM, Gong Y, Handberg EM, et al.
Citation: JAMA 2010;304:61-68.
Study Question:
Does tight blood pressure (BP) control reduce cardiovascular (CV) outcomes among patient with diabetes and coronary artery disease (CAD)?
Methods:
Data from the International Verapamil SR-Trandolapril (INVEST) trial were used for this analysis. An observational subgroup of 6,400 participants (from the 22,576 INVEST subjects) who were 50 years or older, had diabetes, and had CAD were recruited between September 1997 and December 2000, from 862 sites in 14 countries. Subjects received first-line treatment of either a calcium antagonist or beta-blocker followed by an angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve a systolic BP of <130 mm Hg and a diastolic BP of <85 mm Hg. Patients were categorized by control into three groups: tight control <130 mm Hg, usual control 130 to <140 mm Hg, and uncontrolled ≥140 mm Hg. The primary outcome of interest included all-cause mortality, nonfatal myocardial infarction, or nonfatal stroke.
Results:
A total of 6,400 subjects were included (mean age 66 years, 54% women), of which 35.2% had tight BP control, 30.8% had usual BP control, and 34% had uncontrolled systolic BP. Over 16,893 patients-years of follow-up, cardiovascular outcomes were experienced in 286 (12.7%) subjects who had tight BP control, 249 (12.6%) who had usual BP control, and 431 (19.8%) who had uncontrolled BP. Subjects in the usual control group had fewer CV disease (CVD) events, as compared to those with uncontrolled BP (12.6% vs. 9.8%; hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25-1.71). No significant difference was observed in CVD event rates for those in the usual BP control group compared to those in the tight BP control group (12.6% vs. 12.7%; HR, 1.11; 95% CI, 0.93-1.32). Regarding all-cause mortality, the event rate was 11.0% in the tight control group versus 10.2% in the usual control group (HR, 1.20; 95% CI, 0.99-1.45). Over the extended follow-up period (through 2008), all-cause mortality was higher among the tightly controlled group, as compared to the usual control group (22.8% vs. 21.8%; HR, 1.15; 95% CI, 1.01-1.32).
Conclusions:
The authors concluded that tight control of BP among patients with CAD and diabetes was not associated with fewer CV events compared with usual control.
Perspective:
This important study suggests that BP control among patients with CAD and diabetes should be <140 mm Hg; however, tight control under 130 mm Hg does not provide added benefit.