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Sumit R Majumdar

Publications and source records attributed to Sumit R Majumdar.

71 records · Page 4Linked to original sources
PubMed2004

Hypertension management: the care gap between clinical guidelines and clinical practice.

OBJECTIVE: To evaluate how well hypertension is managed in HMO patients and to assess opportunities for improvement. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: The study population included HMO members (age 45-84 years) who had at least 1 ambulatory encounter with an ICD-9-CM diagnosis code of essential hypertension during the first 6 months of 1999. Medical records were reviewed to obtain information on blood pressure measurements, sex, age, coexisting medical conditions, smoking status, and changes made to the antihypertensive drug regimen. RESULTS: We identified 681 members with 3347 encounters related to hypertension management during 1999. Overall, 74 (11%) patients were at target blood pressure for all visits and 260 (38%) were at target blood pressure for at least 50% of the visits; 222 (33%) patients were not at target blood pressure for any visit. A history of coronary artery disease or cerebrovascular disease was associated with better blood pressure control (defined as being at goal levels during at least 50% of visits), while being older (age > or = 75) or having diabetes mellitus was associated with poorer control. Medication regimen intensifications occurred in 10% of visits with systolic blood pressure levels of 140-149 mm Hg, compared with 45% of visits with levels of > or = 180 mm Hg. Medication regimen intensifications occurred in 21% of visits with diastolic blood pressure levels of 90-99 mm Hg and 43% of visits with levels of > or = 100 mm Hg. CONCLUSION: Efforts are required to reduce "therapeutic inertia," particularly in patients with modestly elevated systolic blood pressure levels.

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PubMed2003

Health-related quality of life deficits associated with varying degrees of disease severity in type 2 diabetes.

BACKGROUND: Diabetes is a chronic medical condition accompanied by a considerable health-related quality of life (HRQL) burden. The purpose of this analysis was to use generic measures of HRQL to describe HRQL deficits associated with varying degrees of severity of type 2 diabetes. METHODS: The RAND-12 physical and mental health composites (PHC and MHC, respectively) and Health Utilities Index Mark 3 (HUI3) were self-completed by 372 subjects enrolled in a prospective, controlled study of an intervention to improve care for individuals with type 2 diabetes in rural communities. Analysis of covariance was used to assess differences in HRQL according to disease severity and control of blood glucose. Disease severity was defined in terms of treatment intensity, emergency room visits and absenteeism from work specifically attributable to diabetes. To control for potential confounding, the analysis was adjusted for important sociodemographic and clinical characteristics. RESULTS: The PHC and MHC were significantly lower for individuals treated with insulin as compared to diet alone (PHC: 41.01 vs 45.11, MHC: 43.23 vs 47.00, p < 0.05). Individuals treated with insulin had lower scores on the vision, emotion and pain attributes of the HUI3 than individuals managed with oral medication or diet. The PHC, MHC, pain attribute and overall score on the HUI3 captured substantial decrements in HRQL associated with absenteeism from work due to diabetes, while the burden associated with emergency room utilization for diabetes was seen in the PHC and HUI3 pain attribute. CONCLUSIONS: We concluded that generic measures of HRQL captured deficits associated with more severe disease in type 2 diabetes.

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PubMed2003

Stroke: strategies for primary prevention.

Stroke is a leading cause of morbidity and mortality in North America. Primary prevention of stroke includes lifestyle modifications and measures to control blood pressure, cholesterol levels, diabetes mellitus, and atrial fibrillation. Lowering blood pressure in patients with hypertension prevents both hemorrhagic and ischemic stroke (relative risk reduction, 35 to 45 percent). Observational studies suggest that higher cholesterol levels are associated with an increased risk of ischemic stroke, and treatment with statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) may reduce the risk of fatal and nonfatal stroke by 25 percent. Although high-quality evidence linking tighter glucose control with stroke reduction is lacking, good glucose control and aggressive treatment of hypertension and hyperlipidemia in patients with diabetes mellitus are recommended. The risk of stroke in patients with atrial fibrillation and the role of anticoagulation depend on factors such as age and the presence of comorbid conditions. Controversy exists about the roles of angiotensin-converting enzyme inhibitors and aspirin in the primary prevention of stroke.

Humans↗
PubMed2003

Synergy between publication and promotion: comparing adoption of new evidence in Canada and the United States.

PURPOSE: Few studies have examined the effect of new evidence from clinical trials on physician practice. We took advantage of differences in promotional activity in Canada and the United States for the Heart Outcomes Prevention and Evaluation (HOPE) study and the Randomized Aldactone Evaluation Study (RALES) to determine if publication of new evidence changes practice, and the extent to which promotion influences adoption of new evidence. METHODS: We used longitudinal dispensing data, collected from 1998 to 2001, to examine changes in prescribing patterns for ramipril and other angiotensin-converting enzyme (ACE) inhibitors before and after the HOPE study. We also obtained estimates for promotional expenditures. We stratified analyses by country, to isolate the effect of promotion, and used interrupted time series methods to adjust for pre-existing prescribing trends. Similar analyses were conducted for spironolactone use before and after RALES. RESULTS: Publication of the HOPE study results was associated with rapid increases in the use of ramipril. After adjusting for pre-existing prescribing trends, ramipril prescribing increased by 12% per month (P = 0.001) in Canada versus 5% per month (P = 0.001) in the United States after the study results were presented and published. One year later, ramipril accounted for 30% of the ACE inhibitor market in Canada versus 6% in the United States. The year before publication of these results, expenditures for detailing increased by 20% in Canada (to 18 US dollars per physician) but decreased by 7% in the United States (to 13 US dollars per physician); the year after publication, spending increased to 27 US dollars per physician in Canada versus 23 US dollars per physician in the United States. In the absence of promotional activity for RALES in either country, publication of results was associated with more modest but similar increases of 2% per month (P = 0.001) in spironolactone use in both countries. CONCLUSION: Publication of new evidence is associated with modest changes in practice. Promotional activity appears to increase the adoption of evidence. Rather than relying on the publication of articles and creation of guidelines, those wishing to accelerate the adoption of new evidence may need to undertake more active promotion.

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PubMed2003

Low frequency of treatment of osteoporosis among postmenopausal women following a fracture.

BACKGROUND: Osteoporosis is a major cause of morbidity. Treatment of osteoporosis reduces the risk of fracture, particularly for postmenopausal women with a history of fracture. METHODS: A retrospective study was conducted using the automated databases of 7 health maintenance organizations to evaluate the use of drugs recommended for secondary prevention of osteoporotic fracture. Women 60 years and older with an inpatient or outpatient diagnostic code for a fracture of the hip, vertebra, or wrist between October 1, 1994, and September 30, 1996, and at least 1 year of continuous enrollment with a drug benefit plan following the date of fracture, were identified. The frequency of use of medications for the treatment of osteoporosis (estrogen replacement therapy, bisphosphonates, and calcitonin) during the 1-year period following the date of the initial fracture was estimated overall and according to patient age, fracture site, and year of fracture. RESULTS: During the study period, 3492 women 60 years and older were diagnosed with a fracture of the hip, vertebra, or wrist, and met the inclusion criteria. Of these patients, 822 (24%) received a drug for osteoporosis treatment during the year following the fracture. The proportion of women receiving treatment for osteoporosis was approximately 2-fold higher among those with a fracture of the vertebra (44%) than among those with a fracture of the hip (21%) or wrist (23%) (P<.001). Of the 2605 women who had not been treated for osteoporosis in the 90 days before a fracture, 14% received treatment for osteoporosis in the year following a fracture. Increasing age was associated with a reduced likelihood of receiving osteoporosis treatment (P<.001). CONCLUSIONS: Most of the older women who had experienced a fracture of the hip, vertebra, or wrist did not receive drug treatment for osteoporosis within 1 year following the fracture. Interventions to improve the detection and treatment of osteoporosis in high-risk patients need to be developed.

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PubMed2003

Chronic acid-related disorders are common and underinvestigated.

OBJECTIVES: The aims of this study were as follows: to establish the prevalence of chronic acid-related disorders in a managed care population; to describe these patients; and to examine rates of adherence to current guidelines for investigation of dyspepsia and peptic ulcer disease. METHODS: The design was a population-based cohort study. The sample was drawn from 216,720 adult (aged >18 yr) members of a managed care organization that had an electronic medical record linked to administrative and pharmacy databases. We included adults with continuous enrollment from July, 1998, to January, 2000, who were dispensed histamine-2 blockers or proton-pump inhibitors, or both, for > or =1 yr. Dispensing data, sociodemographic and clinical information, comorbidities, and investigations were collected and analyzed. RESULTS: The final cohort consisted of 5064 patients; 64% were aged > or =50 yr, 47% were male, and 11% were African American. The prevalence of chronic acid-related disorders was 2.3%. Gastroesophageal reflux disease (59%) was the most common condition, followed by dyspepsia (35% of cohort; 18% investigated by endoscopy). There were 917 dyspepsia patients > or =50 yr who had not been investigated by endoscopy (81% of dyspepsia patients in this age group). There were 97 patients with peptic ulcer disease who did not have a documented test for Helicobacter pylori (34% of patients with peptic ulcer disease). CONCLUSIONS: Chronic acid-related disorders are common in primary care, and many patients use acid suppressing medications on a long-term basis. Nevertheless, according to current practice guidelines, our patients were underinvestigated. Future guidelines should specifically address the management of patients who use acid suppressing medications on a chronic basis.

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PubMed2003

Compliance with clinical practice guidelines for type 2 diabetes in rural patients: treatment gaps and opportunities for improvement.

The level of compliance with clinical practice guidelines for patients with type 2 diabetes was evaluated in 368 patients from two health regions in rural northern Alberta, Canada. Data were collected from patient interviews, drug histories, physical and laboratory assessments, and a self-report questionnaire to assess clinical status, indicators of diabetes management, and health care utilization. Treatment of three clinical indicators of diabetes--hemoglobin A1c (A1C), blood pressure, and low-density lipoprotein cholesterol (LDL)--has been shown to reduce the morbidity and mortality associated with type 2 diabetes. Mean +/- SD values for this cohort of patients were as follows: A1C 7.25% +/- 1.54%, blood pressure 131.7 +/- 18.2/76.2 +/- 12.7 mm Hg, and LDL 105.2 +/- 32 mg/dl. Despite these results, only 10.4% of the patients met all three recommended targets for control of glycemia: A1C below 7%, blood pressure below 130/85 mm Hg, and LDL below 100 mg/dl. Of patients not at target levels, 14.4%, 27.5%, and 86.7% reported receiving no therapy for hyperglycemia, hypertension, and dyslipidemia, respectively. Of those taking oral hypoglycemic agents who were not at target levels, only 35% were receiving combination therapy. Of patients at or above LDL target levels, 87% were not receiving any therapy. Only 22% of patients were taking aspirin, although this therapy would be recommended for the entire cohort according to clinical practice guidelines. Despite the availability of proved effective therapies, treatment gaps were present for this cohort of patients.

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PubMed2003

Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes.

OBJECTIVE: Despite good evidence and clinical practice guidelines, studies document that treatment of type 2 diabetes is less than optimal. Lack of resources or limited access may put patients in rural communities at particular risk for suboptimal care. RESEARCH DESIGN AND METHODS: We conducted a prospective, before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service (intervention) for improving the quality of care for rural patients with type 2 diabetes. Our intervention consisted of six monthly visits by a traveling team of specialist physicians, nurses, dieticians, and a pharmacist. The core of this service was specialist-to-rural primary care physician academic group detailing. Two comparable regions in Northern Alberta were randomly allocated to control or intervention. Data were collected before and 6 months after intervention in a representative volunteer sample. The primary outcome was a 10% improvement in any one of the following: blood pressure, total cholesterol, or HbA(1c). RESULTS: Our analysis included 200 intervention and 179 control subjects; 14 subjects were at all three primary outcome targets at baseline. The intervention was associated with a trend toward improvement in primary outcome at 6 months (44% intervention vs. 37% control; odds ratio 1.32, 95% CI 0.87-1.99). The intervention was associated with a significant improvement in blood pressure (42% intervention vs. 25% control, P = 0.004); however, there were only small, nonsignificant changes in cholesterol or HbA(1c). The intervention was associated with a significant increase in satisfaction with diabetes care. Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results. CONCLUSIONS: A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients. Future studies need to involve longer timelines and larger sample sizes.

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PubMed2002

Accuracy of the preoperative assessment in predicting pulmonary risk after nonthoracic surgery.

We examined the accuracy of preoperative assessment in predicting postoperative pulmonary risk in a prospective cohort of 272 consecutive patients referred for evaluation before nonthoracic surgery. Outcomes were assessed by an independent investigator who was blinded to the preoperative data. There were 22 (8%) postoperative pulmonary complications. Statistically significant predictors of pulmonary complications (all p < or = 0.005) were as follows: hypercapnea of 45 mm Hg or more (odds ratio, 61.0), a FVC of less than 1.5 L/minute (odds ratio, 11.1), a maximal laryngeal height of 4 cm or less (odds ratio, 6.9), a forced expiratory time of 9 seconds or more (odds ratio, 5.7), smoking of 40 pack-years or more (odds ratio, 5.7), and a body mass index of 30 or more (odds ratio, 4.1). Multiple regression analyses revealed three preoperative clinical factors that are independently associated with pulmonary complications: an age of 65 years or more (odds ratio, 1.8; p = 0.02), smoking of 40 pack-years or more (odds ratio, 1.9; p = 0.02), and maximum laryngeal height of 4 cm or less (odds ratio, 2.0; p = 0.007). Thus, preoperative factors can identify those patients referred to pulmonologists or internists who are at increased risk for pulmonary complications after nonthoracic surgery.

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PubMed2002

New evidence for stroke prevention: scientific review.

CONTEXT: Stroke is a major cause of morbidity and mortality, and the application of evidence for stroke prevention varies considerably. OBJECTIVE: To review the most recent, high-quality evidence for primary and secondary stroke prevention. DATA SOURCES AND STUDY SELECTION: Searches of MEDLINE, The Cochrane Library, and the ACP Journal Club were performed to identify English-language articles published from 1998 to 2001 that focused on primary and secondary stroke prevention. The references of each retrieved article were scanned, and experts in the field were contacted to identify additional relevant articles. DATA EXTRACTION: Each of the articles was appraised, and its quality was graded with levels of evidence based on specific scientific methods that affect a study's validity. DATA SYNTHESIS: For primary prevention of stroke, adequate blood pressure reduction, and treatment of hyperlipidemia, use of antithrombotic therapy in patients with atrial fibrillation and of antiplatelet therapy in patients with myocardial infarction are effective and supported by evidence from several randomized trials. Effective strategies for the secondary prevention of stroke include treatment of hypertension and hyperlipidemia, antithrombotic therapy for patients with atrial fibrillation, antiplatelet therapy, and carotid endarterectomy in patients with severe carotid artery stenosis. CONCLUSIONS: Stroke is a major public health concern, and a significant body of evidence supports many primary and secondary prevention strategies.

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PubMed2002

New evidence for stroke prevention: clinical applications.

Stroke is a leading cause of morbidity and mortality in most developed nations. There is a significant body of evidence supporting strategies that target primary and secondary stroke prevention. This evidence cannot be broadly applied to all patients, and each patient's situation and values must be considered with regard to shared evidence-based decision making. Several models can be used to apply evidence to individual patients, including formal clinical decision analysis, decision aids, or simpler tools such as the likelihood of being helped vs harmed. Various programmatic models of providing patient care in stroke prevention may also be useful; these include specialized clinics or disease-management programs, anticoagulation management services, and self-testing and management of anticoagulation by patients.

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PubMed2002

Do the investigative sites that take part in a positive clinical trial translate that evidence into practice?

PURPOSE: The earliest awareness of new evidence should beat the trial sites that first generated the evidence. We hypothesized that sites that had taken part in the Survival and Ventricular Enlargement (SAVE) trial, which demonstrated that angiotensin-converting enzyme (ACE) inhibitors were beneficial following myocardial infarction, would be more likely to adopt their use in this group of patients. SUBJECTS AND METHODS: We performed a cross-sectional analysis of data collected for the 25,886 North American patients with myocardial infarction enrolled in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) study from 1990 to 1993. Patients were treated at 659 hospitals, 22 of which had also taken part in SAVE. One third of patients were enrolled after SAVE was published in 1992. The primary outcome was use of an ACE inhibitor at discharge. We analyzed the data using hierarchical models and multivariate regression. RESULTS: Patients treated at sites that had taken part in SAVE were not more likely to receive an ACE inhibitor at discharge than were patients treated at non-SAVE sites (226/1415 [16%] vs. 3671/24,471 [15%]; odds ratio [OR] = 1.1; 95% confidence interval [CI]: 0.8 to 1.4; P = 0.67). Although patients with heart failure were more likely to receive ACE inhibitors than were those without heart failure, there was no difference between SAVE and non-SAVE sites (90/297 [30%] vs. 1322/4405 [30%]; P = 0.75). Use of ACE inhibitors increased following the publication of the SAVE trial, but again there was no significant difference in adoption of the drug between SAVE and non-SAVE sites. CONCLUSION: Sites that had taken part in SAVE were no more likely to adopt ACE inhibitors for patients with myocardial infarction than were sites that had not taken part. If those who generated the evidence are slow to translate it into practice, it is unlikely that passive forms of dissemination can improve the quality of care. To accelerate adoption of new evidence, we need to understand factors other than knowledge and awareness that influence practice.

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PubMed2002

Predicting pulmonary complications after nonthoracic surgery: a systematic review of blinded studies.

PURPOSE: To determine the performance of variables commonly used in the prediction of postoperative pulmonary complications in patients undergoing nonthoracic surgery. METHODS: We conducted a systematic review of the literature in English, using MEDLINE (1966-2001), manual searches of identified articles, and contact with content experts. All studies reporting independent and blinded comparisons of preoperative or operative factors with postoperative pulmonary complications were included. Two reviewers independently abstracted inclusion and exclusion criteria, study designs, patient characteristics, predictors of interest, and the nature and occurrence of postoperative pulmonary complications. RESULTS: Seven studies fulfilled the inclusion criteria. The definition of postoperative pulmonary complications differed among studies, and the incidence of postoperative pulmonary complications varied from 2% to 19%. Of the 28 preoperative or operative predictors that were evaluated in the 7 studies, 16 were associated significantly with postoperative pulmonary complications, although only 2 (duration of anesthesia and postoperative nasogastric tube placement) were significant in more than one study. The positive (2.2 to 5.1) and negative (0.2 to 0.8) likelihood ratios for these 16 variables suggest that they have only modest predictive value. Neither hypercarbia nor reduced spirometry values were independently associated with an increased risk of postoperative pulmonary complications. CONCLUSION: Few studies have rigorously evaluated the performance of the preoperative or operative variables in the prediction of postoperative pulmonary complications. Prospective studies with independent and blinded comparisons of these variables with postoperative outcomes are needed.

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PubMed2002

How well are hypertension, hyperlipidemia, diabetes, and smoking managed after a stroke or transient ischemic attack?

BACKGROUND AND PURPOSE: Stroke prevention clinics (SPCs) are not usually involved with the active management of hypertension, hyperlipidemia, diabetes, and smoking. The effect of consultations generated at SPCs on the adequacy of the management of these risk factors for stroke has not been well described, and few studies have long-term follow-up. METHODS: We performed a prospective study of 119 consecutive patients referred to an SPC for secondary prevention. One year after their baseline visit, patients were re-evaluated for the adequacy of the management of the above risk factors, and the proportion of improvement was assessed. RESULTS: One-hundred twelve patients returned for their 1-year follow-up visit. Sixty-six were male, and the average age was 65 years. Hypertension was present in 83 patients, hyperlipidemia in 92, diabetes in 26, and smoking in 38, and 80 had multiple risk factors. At baseline, 66% of patients with hypertension, 17% of patients with hyperlipidemia, and 23% of diabetics had adequate management of their respective risk factors. During 1 year of follow-up, hypertension management improved 20% (P<0.001) and lipid management improved 32% (P<0.001). There was no significant improvement in diabetes management or smoking cessation. CONCLUSIONS: Although our understanding of the benefit of addressing hypertension, hyperlipidemia, diabetes, and smoking for secondary prevention of stroke is evolving, we found marked room for improvement in the management of these four risk factors. SPCs may need to be more actively involved in the management of these modifiable risk factors, if we are to significantly impact the risk of recurrent stroke.

Adult↗
PubMed2002

Decreased mortality associated with the use of metformin compared with sulfonylurea monotherapy in type 2 diabetes.

OBJECTIVE: The aim of this study was to examine the relationship between use of metformin and sulfonylurea and mortality in new users of these agents. RESEARCH DESIGN AND METHODS: Saskatchewan Health databases were used to examine population-based mortality rates for new users of oral antidiabetic agents. Individuals with prescriptions for sulfonylurea or metformin in 1991-1996 and no use in the year prior were identified as new users. Prescription records were prospectively followed for 1-9 years; subjects with any insulin use were excluded. Causes of death were identified based on ICD-9 codes in an electronic vital statistics database. Multivariate logistic regression and survival analyses were used to assess the differences in mortality between drug cohorts, after adjusting for potential confounding variables. RESULTS: The total study sample comprised 12,272 new users of oral antidiabetic agents; the average length of follow-up was 5.1 (SD 2.2) years. In subjects with at least 1 year of drug exposure and no insulin use, mortality rates were 750/3,033 (24.7%) for those receiving sulfonylurea monotherapy, 159/1,150 (13.8%) for those receiving metformin monotherapy, and 635/4,683 (13.6%) for those receiving combination therapy over an average 5.1 (SD 2.2) years of follow-up. The adjusted odds ratio (OR) for all-cause mortality for metformin monotherapy was 0.60 (95% CI 0.49-0.74) compared with sulfonylurea monotherapy. Sulfonylurea plus metformin combination therapy was also associated with reduced all-cause mortality (OR 0.66, 95% CI 0.58-0.75). Reduced cardiovascular-related mortality rates were also observed in metformin users compared with sulfonylurea monotherapy users. CONCLUSIONS: Metformin therapy, alone or in combination with sulfonylurea, was associated with reduced all-cause and cardiovascular mortality compared with sulfonylurea monotherapy among new users of these agents.

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