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Biomedical subjects

T E Kottke

Publications and source records attributed to T E Kottke.

At least 19 recordsLinked to original sources
PubMed1992

Cardiac rehabilitation 1992.

The goal of cardiac rehabilitation is to optimize function through attention to the patient's medical needs, risk factors for recurrent events, physical reconditioning, and psycho-social needs. Medical needs include beta-adrenergic blocking agents and aspirin unless contraindicated, angiotensin converting inhibitors for left ventricular dysfunction, and relief of residual ischemia. Smoking, lipid abnormalities, physical inactivity, and hypertension remain important predictors of reinfarction and death and must be controlled. Obesity must be addressed because it exacerbates these problems. Therefore, the principles of behavior change should be applied to help patients control their risk factors and adopt healthy lifestyles. Smoking cessation and appropriate dietary behaviors can be adopted by the patient while in the hospital. Physical reconditioning can also begin with twice-daily exercises. After discharge from hospital and after an initial submaximal exercise evaluation, the patient will benefit from three sessions per week of outpatient cardiac rehabilitation for six to eight weeks. These sessions should last about an hour and raise the patient's heart rate as much as 30 beats per minute. Along with physical reconditioning, the cardiac rehabilitation program provides an opportunity to address risk factor modification, return to work, return to sexual activity, management of depression and anxiety, and the presence of risk factors in the patient's family. The patient should attend reinforcing sessions every three months for the first year and as necessary after that to control risk factors and reinforce the necessity for physical fitness.

Coronary Disease↗
PubMed1992

A controlled trial to integrate smoking cessation advice into primary care practice: Doctors Helping Smokers, Round III.

BACKGROUND: Although most physicians believe that smoking cessation assistance is important for their patients, the majority of smokers report that they have not received smoking cessation advice from a physician. We therefore tested whether on-site recruitment, training, and organizational assistance in incorporating a smoking intervention system of documented efficacy into nonvolunteer primary care practices would result in higher rates of smoking cessation advice to patients. METHODS: This was a nonrandomized trial comparing all 10 primary care clinics in an intervention area to all 8 primary care clinics from a geographically separate control area. The evaluation was based on the smoking intervention activities of each of the clinics as reported on preintervention and postintervention mail surveys of cohorts of regular smokers seen in the clinics. RESULTS: Preintervention, 22.9% +/- 11.2% of the intervention clinic cohort and 21.9% +/- 9.6% (P = .84) of the control clinic cohort reported that they had been asked about tobacco during a clinic visit in the prior 6 months. Postintervention, the intervention clinic cohort was significantly more likely to report that someone had asked them if they smoked (39.8% +/- 12.3% vs 26.0% +/- 12.2%; P less than .05), that their physician asked them to quit if they were currently smoking (40.5% +/- 12.1% vs 26.4% +/- 14.6%; P less than .05), and that someone had commended them if they had recently quit smoking (28.2% +/- 19.8 vs 11.3% +/- 11.8%; P less than .05). CONCLUSIONS: The intervention significantly increased the rates at which a population of primary care clinics identified their patients who smoked, advised them to quit smoking, and commended those who had recently quit smoking.

Adult↗
PubMed1991

Change in survival from out-of-hospital cardiac arrest and its effect on coronary heart disease mortality, Minneapolis-St. Paul. The Minnesota Heart Survey.

Emergency medical services with advanced life support systems were implemented in the Minneapolis-St. Paul, Minnesota, area in the mid-1970s. To assess the impact of emergency medical services on coronary heart disease mortality, the authors reviewed ambulance records and hospital emergency room logs for possible out-of-hospital cardiac arrest cases in the period 1972-1982. Potential cases, and their survival to discharge, were validated by hospital record review and were checked against Minnesota death certificates for the year of cardiac arrest and the year following cardiac arrest. Age-adjusted rates of survival to 1 year after cardiac arrest (per 100,000 population) for survivors of out-of-hospital cardiac arrest aged 30-74 years increased significantly from 1972 to 1982 for men (1.8 vs. 11.7; p less than 0.00001) and for women (0.5 vs. 3.5; p less than 0.01). Coronary heart disease mortality rates declined in that period by 34.9% for men (from 527.5 per 100,000 to 343.3 per 100,000) and by 41.7% for women (from 168.6 per 100,000 to 98.3 per 100,000). The authors estimate that improved survival from out-of-hospital cardiac arrest contributed 5.4% (9.9 of 184.2) of the mortality decline for men and 4.3% (3.0 of 70.3) of the decline for women. This was a significant contribution to the decline in coronary heart disease mortality, but it explains only a small part of it.

Adult↗
PubMed1990

The potential contribution of cardiac replacement to the control of cardiovascular diseases. A population-based estimate.

The potential number of individuals who might benefit from a cardiac replacement procedure (either cardiac transplantation or insertion of a total artificial heart) was retrospectively estimated from medical records for residents of Olmsted County, Minnesota, who had died during a 5-year period. Residents were divided into two age groups: those younger than 15 years (pediatric) and those 15 to 69 years (adult). During the 5-year period of observation, cardiac disease led to death in 17 of the 8342 live births in Olmsted County. Cardiac disease also caused the deaths of 248 adults meeting the age criteria. Five children and 35 adults met all criteria for cardiac replacement. Extrapolation to the total population of the United States suggests that 2167 children (a 95% confidence interval of 361 to 3972) and 16,500 adults (a 95% confidence interval of 11,456 to 22,959) per year could potentially benefit from cardiac replacement.

Adolescent↗
PubMed1990

Nicotine-replacement therapy with use of a transdermal nicotine patch--a randomized double-blind placebo-controlled trial.

The rate of smoking was significantly reduced in volunteer subjects by providing effective nicotine replacement, self-help material, and weekly visits with a nurse for 6 weeks. Nicotine-replacement therapy with a transdermal nicotine patch (Nicolan) almost doubled the 6-week smoking-cessation rate in comparison with that in a placebo group (77% versus 39%; P = 0.002) among subjects who were smoking at least 20 cigarettes per day at baseline. Although most subjects who used the active nicotine patches had skin reactions, the reactions were primarily mild. For use of both active and placebo patches, the level of patient compliance was high. Among subjects who continued to smoke, the use of cigarettes was decreased to less than 50% of the baseline smoking level in 7 of 7 with active nicotine patches and in 15 of 19 with placebo patches. Outcomes beyond 6 weeks showed a substantial relapse rate in both groups. Thus, when nicotine-replacement therapy is provided, a need exists for concurrent behavioral intervention and training for prevention of a relapse, neither of which was part of this protocol.

Administration, Cutaneous↗
PubMed1990

Effectiveness research and assessment of clinical outcome: a review of Federal Government and medical community involvement.

Because of their concern about the increasing costs of health care, industry and government contractors for health care will attempt to control health-care costs for the foreseeable future. New proposals for cost containment include those that are focused on cost alone--for example, expenditure limits--and those that propose to control costs by limiting medical interventions to those of known efficacy. This latter attempt has come to be known as "effectiveness research." Herein, we briefly review the history of quality assurance and cost-containment efforts in the United States, giving special attention to the current initiative based on effectiveness research. Although the effectiveness research initiative has shortcomings (for example, it will not provide guidance when data are not available), it seems to be superior to the current peer review system because it encourages the development of a knowledge base and deemphasizes punitive measures as a way to ensure quality and control costs. The Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) establishes a federal agency, the Agency for Health Care Policy and Research, within the Public Health Service to focus on effectiveness research.

Attitude of Health Personnel↗
PubMed1990

Beyond efficacy testing: introducing preventive cardiology into primary care.

The interventions of documented efficacy that have been developed for the treatment of cardiovascular disease risk factors have been neither rapidly nor completely incorporated into clinical practice. This may be due to not recognizing that there is a fundamental conflict between the attributes of the ideal protocol for testing the efficacy of an intervention and the attributes of ideal patient care. For example, when testing an intervention for efficacy, benefit to the subject must be made secondary to the goal of increasing the community's fund of knowledge. When caring for patients, increasing the community's fund of knowledge must be secondary to the goal of benefiting the patient who is receiving care. Therefore, the ideal efficacy-testing program is minimally responsive to the needs of the individual subject; the ideal treatment program is maximally responsive to the needs of the individual patient. A second reason for the slow incorporation of preventive cardiology into patient care is the current lack of a supporting structure. An understanding of the attributes of good patient care and the need for a structure to support preventive cardiology interventions should further the incorporation of preventive cardiology interventions into routine patient care while allowing patient care systems to be scrutinized with efficacy-testing protocols.

Cardiology↗
PubMed1990

A systematic primary care office-based smoking cessation program.

There is a large discrepancy between apparent potential and actual practice of smoking cessation activities by physicians. This paper describes the 2-year results of an integrated system to support such physician activities with all of their tobacco-using patients. The system consists of organized identification, progress records, brief physician messages, follow-up, and assistance; it focuses on those most interested in quitting. Introduction of the system to one clinic was associated with an initial threefold to fivefold increase in quit rates of all clinic patients using tobacco. After 2 years, the overall quit rate was approximately 20%, rising to 33% for those tobacco users with more clinic contacts or at least 1 year from the first to the latest contact. Such a program has been well accepted by patients, physicians, and office staff and seems to provide the support needed for a feasible and effective long-term smoking cessation intervention in primary care practices.

Adult↗
PubMed1990

A comparison of two methods to recruit physicians to deliver smoking cessation interventions.

To address the problem of recruiting physicians to deliver smoking cessation interventions, Doctors Helping Smokers included a trial of physician recruitment strategies. In round 1 of Doctors Helping Smokers, three types of informational materials were mailed directly to 1110 family physicians. The physicians were asked to return a postcard if they were interested in participating in a 1-month trial of a smoking cessation intervention. Response did not differ among the three conditions; overall, 9.8% of physicians (95% confidence limits [CL], 8.0, 11.6) responded and 6.0% (95% CL, 4.6, 7.4) eventually participated in the intervention trial. The same procedure was repeated for round 2 of Doctors Helping Smokers with direct mailing to all general internists and cardiologists (n = 1108) on the mailing list of the Minnesota Medical Association. Five percent (95% CL, 3.7, 6.3) of the internists responded and 2.7% (95% CL, 1.7, 3.7) participated in the trial. Recruitment for round 3 made use of repeated face-to-face recruitment efforts at the physician's office through a managed-care organization that held contracts with the physician's clinic to provide care for its enrollees. Six months after the initiation of round 3, 59% (95% CL, 49%, 67%) of the 126 primary care physicians reported that they were giving their patients smoking cessation advice and completing the smoking intervention records. Eighteen months after the initiation of round 3, 56% (95% CL, 47%, 65%) of the 116 primary care physicians who remained in the practice reported continued activity in the project.

Attitude of Health Personnel↗
PubMed1989

A randomized trial to increase smoking intervention by physicians. Doctors Helping Smokers, Round I.

Sixty-six physicians were randomized to three groups to conduct a 1-month campaign to help their patients stop smoking. The workshop group received free patient education materials and a 6-hour training workshop. The materials group received free patient education materials, and the no-assistance group received nothing. A telephone interview was completed with 89% of the 6767 eligible adult patients seen during the month of the campaign. The brief training program and patient education materials marginally increased the smoking intervention activities of volunteer physicians in private practice. Both workshop and materials physicians asked 54% of their smoking patients to stop; no-assistance physicians asked 40%. One year later, 36% of patients who had not even been asked by their doctors if they smoked reported that they had tried to stop smoking. If the physician had asked the patient if he or she smoked, the probability of a quit attempt was 47%. Patients who had been asked if they smoked were more likely to claim to have stopped (13%) than patients who had not been asked (9%). However, the proportion of patients claiming continued abstinence (range, 12% to 14%) was not related to the group of the physician.

Adolescent↗
PubMed1989

The Rochester Coronary Heart Disease Project: effect of cigarette smoking, hypertension, diabetes, and steroidal estrogen use on coronary heart disease among 40- to 59-year-old women, 1960 through 1982.

A population-based case-control study of coronary heart disease (CHD) risk in young women attributable to cigarette smoking, hypertension, diabetes, and steroidal estrogen use was conducted among residents of Rochester, Minnesota. All newly diagnosed cases of CHD (sudden unexpected death [SUD], N = 18; myocardial infarction [MI], N = 90; and angina, N = 133) among female Rochester residents 40 to 59 years of age during the years 1960 through 1982 were identified, and two community control subjects were matched for age and duration of community medical record. The overall adjusted odds ratio (OR) for the association between steroidal estrogen use and definite CHD (MI and SUD) was 0.6 (95% confidence interval [CI] = 0.2 to 1.3). Smoking (OR = 5.1; 95% CI = 2.3 to 11.6), hypertension (OR = 4.8; 95% CI = 2.3 to 10.2), and diabetes (OR = 8.4; 95% CI = 1.6 to 44.5) were strong risk factors for CHD events. If considered causal, cigarette smoking accounted for 64% of all MIs and SUDs in the community, hypertension accounted for 45%, and diabetes accounted for 13%. Although steroidal estrogen exposure reduced CHD among these women by 14%, giving steroidal estrogens to all women in this age group might reduce the population rates of MI by as much as 45%.

Adult↗