Biomedical subjects

Karl E Hammermeister

Publications and source records attributed to Karl E Hammermeister.

8 recordsLinked to original sources

PubMed2006

The association between processes, structures and outcomes of secondary prevention care among VA ischemic heart disease patients.

BACKGROUND: Hyperlipidemia and hypertension are well-established risk factors for recurrent cardiovascular events among patients with ischemic heart disease (IHD). Despite national recommendations, concordance with guidelines for LDL cholesterol and blood pressure remains inadequate. The objectives of this study were to 1) determine concordance rates with LDL cholesterol and BP recommendations; and 2) identify patient factors, processes and structures of care associated with guideline concordance among VA IHD patients. METHODS: This was a cross sectional study of veterans with IHD from 8 VA hospitals. Outcomes were concordance with LDL guideline recommendations (LDL<100 mg/dl), and BP recommendations (<140/90 mm Hg). Cumulative logit and hierarchical logistic regression analyses were performed to identify patient factors, processes, and structures of care independently associated with guideline concordance. RESULTS: Of 14,114 veterans with IHD, 55.7% had hypertension, 71.5% had hyperlipidemia, and 41.6% had both conditions. Guideline concordance for LDL and BP were 38.9% and 53.4%, respectively. However, only 21.9% of the patients achieved both LDL <100 mg/dl and BP <140/90 mm Hg. In multivariable analyses, patient factors including older age and the presence of vascular disease were associated with worse guideline concordance. In contrast, diabetes was associated with better guideline concordance. Several process of care variables, including higher number of outpatient visits, higher number of prescribed medications, and a recent cardiac hospitalization were associated with better guideline concordance. Among structures of care, having on-site cardiology was associated with a trend towards better guideline concordance. CONCLUSION: Guideline concordance with secondary prevention measures among IHD patients remains suboptimal. It is hoped that the findings of this study can serve as an impetus for quality improvement efforts to improve upon secondary prevention measures and reduce the morbidity and mortality of patients with known IHD.

Adult↗

PubMed2005

Depression predicts mortality following cardiac valve surgery.

BACKGROUND: Depression is associated with mortality in several cardiovascular populations, but has not been evaluated in patients undergoing cardiac valve surgery. Because identifying nonsurgical mediators of survival is important for accurate risk adjustment and the development of interventions to improve outcomes of care, we evaluated the hypothesis that depression predicts mortality following cardiac valve surgery. METHODS: This prospective cohort study enrolled 648 patients undergoing valve surgery at 14 Veteran Administration hospitals. A preoperative mental health inventory (MHI) depression screen was performed in all patients and patients were classified as depressed or not depressed using the standard MHI cutoff score of less than or equal to 52. Multivariable logistic regression was used to evaluate the association between depression and 6-month all-cause mortality, adjusting for other clinical risk variables. RESULTS: Overall, 29.2% (189/648) of the patients were depressed at baseline. Depressed patients were younger, more frequently had New York Heart Association class III/IV symptoms, and more likely required emergent surgery, preoperative intravenous nitroglycerin, or intraaortic balloon pump. Unadjusted 6-month mortality was 13.2% for depressed patients compared with 7.6% for nondepressed patients (p = 0.03). In multivariable analyses, depression remained significantly associated with mortality (odds ratio 1.90; 95% confidence interval 1.07 to 3.40, p = 0.03). These findings were consistent across subgroups of patients undergoing aortic valve replacement, mitral valve replacement and valve replacement without coronary artery bypass graft. CONCLUSIONS: Preoperative depression is an independent risk factor for mortality following cardiac valve surgery. Depression screening should be incorporated into preoperative risk stratification, and future studies are warranted to determine if preoperative or postoperative interventions to treat depression can improve outcomes.

Adult↗

PubMed2005

Biological age--a concept whose time has come: a preliminary study.

OBJECTIVE: Chronology poorly predicts biological age (BA) or physiologic reserve (PR). An objective approach to the heterogeneity of aging would greatly help clinical decision making in the elderly. MATERIALS AND METHODS: The first pilot study evaluated 130 "healthy" volunteers, ages 70 to 95 years. A summary BA/PR index was developed, using measures of endurance, strength, flexibility, balance, cognition, depression, comorbidity, and exercise. The second study applied the BA/PR concept to prediction of death after a first elective coronary artery bypass graft, using a Veterans Administration database. RESULTS: The BA/PR index was a better predictor of 3-year functional outcomes and death than was chronological age. In the coronary artery bypass graft study, the inclusion of BA/PR variables significantly improved prediction of 6-month and long-term death for Veterans Administration patients. CONCLUSIONS: The usefulness of a biological age (BA/PR) approach in predicting outcomes in the elderly was supported. Needed research should develop tools for routine "tracking" of the aging process.

Activities of Daily Living↗

PubMed2004

Cardiology management improves secondary prevention measures among patients with coronary artery disease.

OBJECTIVES: The goal of this study was to determine if cardiology subspecialty involvement improves the attainment of recommended low-density lipoprotein (LDL) cholesterol and blood pressure (BP) targets in coronary artery disease (CAD) patients. BACKGROUND: The impact of physician specialty on secondary prevention measures for CAD in ambulatory care is unknown. METHODS: This was a retrospective cohort study of 13,995 patients with CAD seen at eight ambulatory care Veteran Affairs facilities from 1998 to 2000. Patients with cardiology involvement were defined as those seen in cardiology clinic in addition to primary care. The main outcomes of interest were LDL cholesterol < or =100 mg/dl and BP < or =130/85 mm Hg. Multivariable hierarchical regression analyses were used to determine the independent association of cardiology involvement with improved LDL cholesterol and BP control. RESULTS: Overall, 3,771 (27.0%) patients had cardiology involvement. A higher proportion of patients with cardiology involvement achieved LDL cholesterol (55.6% vs. 45.6%; p < 0.01) and BP (45.3% vs. 35.9%; p < 0.01) goals. In multivariable hierarchical regression analysis, cardiology involvement was independently associated with better LDL cholesterol (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.40 to 1.82) and BP (OR, 1.52; 95% CI, 1.32 to 1.77) control. The benefit of cardiology involvement was consistent across a range of LDL and BP targets, in analysis of LDL and BP as continuous outcomes, and among subgroups of high-risk patients, including diabetic patients, the elderly, and those with prior revascularization. CONCLUSIONS: Cardiology involvement is associated with better LDL cholesterol and BP control among CAD patients. However, significant room for improvement in secondary prevention measures remains, irrespective of physician specialty.

Adrenergic beta-Antagonists↗

PubMed2004

Predictors of health-related quality of life after coronary artery bypass surgery.

BACKGROUND: Little is known about the determinants of health-related quality of life after coronary artery bypass surgery. We determined the predictors of overall physical and mental health status 6 months after the operation. METHODS: We evaluated 1,973 patients enrolled in a multicenter Veterans Affairs prospective cohort study who completed preoperative and 6-month postoperative Short Form-36 (SF-36) health status surveys. Multiple linear regression was used to identify the significant independent predictors of 6-month physical and mental component summary scores from the SF-36. RESULTS: In multivariable analyses adjusting for baseline health status, significant predictors of postoperative physical health status were a history of neurologic disease, peripheral vascular disease, chronic obstructive pulmonary disease, hypertension, current smoking, forced expiratory volume, left ventricular ejection fraction, and serum creatinine. Significant predictors of postoperative mental health status were a history of psychiatric disease, chronic obstructive pulmonary disease, current smoking, age, and New York Heart Association functional class. CONCLUSIONS: These predictors of health-related quality of life after coronary artery bypass surgery may be useful for preoperative risk assessment and counseling of patients with regard to anticipated health status outcomes. Factors such as current smoking and psychiatric disease may be targets for interventions to improve health-related quality of life outcomes.

Coronary Artery Bypass↗

PubMed2004

Predictors of cognitive decline following coronary artery bypass graft surgery.

BACKGROUND: A significant number of patients develop cognitive impairment that persists for months following coronary artery bypass grafting (CABG) surgery. Our objectives were to identify patient-related risk factors, processes of care, and the occurrence of any perioperative complications associated with cognitive decline. METHODS: Nine hundred thirty-nine patients enrolled in the Processes, Structures, and Outcomes of Care in Cardiac Surgery study undergoing CABG-only surgery at 14 Veterans Administration medical centers between 1992 and 1996 completed a short battery of cognitive tests at baseline and 6-months post-CABG. The composite cognitive score was based on the sum of errors for each individual item in the battery. Multiple linear regression analyses were used to identify independent predictors of the 6-month composite cognitive score. RESULTS: In multivariable analyses, patient characteristics associated with cognitive decline included cerebrovascular disease (p = 0.009), peripheral vascular disease (p = 0.007), history of chronic disabling neurologic illness (p = 0.016), and living alone (p = 0.049), while the number of years of education (p = 0.001) was inversely related to cognitive decline. After adjustment for baseline patient risk factors, the presence of any postoperative complication(s) (p = 0.001) was also associated with cognitive decline while cardiopulmonary bypass time (p = 0.008) was inversely related to cognitive decline. CONCLUSIONS: Patients with noncoronary manifestations of atherosclerosis, chronic disabling neurologic illness, or limited social support are at risk for cognitive decline after CABG surgery. In contrast, more years of education were associated with less cognitive decline. Preoperative assessment of risk factors identified in this study may be useful when counseling patients about the risk for cognitive decline following CABG surgery.

Aged↗

PubMed2004

Relationship between processes of care and coronary bypass operative mortality and morbidity.

BACKGROUND: Information is limited regarding the effects of processes of care on cardiac surgical outcomes. Correspondingly, many recommended cardiac surgical processes of care are derived from animal experiments or clinical judgment. This report from the VA Cooperative Study in Health Services, "Processes, Structures, and Outcomes of Cardiac Surgery," focuses on the relationships between 3 process groups (preoperative evaluation, intraoperative care, and supervision by senior physicians) and a composite outcome, perioperative mortality and morbidity. METHODS: Data on 734 risk, process, and structure variables were collected prospectively on 3,988 patients who underwent coronary artery bypass grafting at 14 VA medical centers between 1992 and 1996. Data reduction was accomplished by examining data completeness and variation across sites and surgeon, using previously published data and clinical judgment. We then applied multivariable logistic regression to the 39 remaining processes of care to determine which were related to the composite outcome after adjusting for 17 patient-related risk factors and controlling for intraoperative complications. RESULTS: Our first analysis showed several measures of operative duration, the use of inotropic agents, transesophageal echo, lowest systemic temperature, and hemoconcentration/ultrafiltration, to be powerful predictors of the composite outcome. Because the use of inotropic agents and operative duration may be related to an intermediate outcome (eg, intraoperative complications), we performed a second analysis omitting these processes. The use of intraoperative transesophageal echo and hemoconcentration/ultrafiltration remained significantly associated with an increased risk of an event (odds ratios 1.60 and 1.36, respectively). CONCLUSIONS: Our results viewed in the context of past studies suggest the possibility that inotropic use, TEE, and hemoconcentration/ultrafiltration may have adverse effects on operative outcome. Further evaluation of these processes of care using observational data, as well as randomized trials when feasible, would be of interest.

Coronary Artery Bypass↗

PubMedDate not supplied

Health-related quality of life predicts mortality in older but not younger patients following cardiac surgery.

The investigators assessed preoperative health-related quality of life as a predictor of 6-month mortality after cardiac surgery in older (65 years of age and older) vs. younger patients. Multivariable regression, stratified by age groups, was used to compare the association between preoperative Physical Component Summary and Mental Component Summary scores from the Short Form-36 health status survey and mortality. In multivariable analyses of older patients, lower preoperative Physical Component Summary (odds ratio, 1.54; 95% confidence interval, 1.19-2.00; p=0.01) and Mental Component Summary (odds ratio, 1.26; 95% confidence interval, 1.06-1.49; p=0.03) scores were independently associated with mortality. In contrast, neither Physical Component Summary (p=0.82) nor Mental Component Summary (p=0.79) scores were associated with mortality in the younger subgroup. This study demonstrated that preoperative health status is an independent predictor of mortality following cardiac surgery in older but not younger patients. Preoperative patient self-report of health status may be particularly useful in refining risk stratification and informing decision-making before and following cardiac surgery in older patients.

Adult↗