Rarely do we find news of interest to home care providers in physician journals but this month’s Journal of the American Medical Association ran stories we found important. JAMA has announced a new monthly series about caring of the elderly. Though aimed at docs, it will have implications for clinicians of all stripes.
In the second excerpt, we were particularly interested in their evidence that low-tech telemedicine, using a telephone, can make measurable changes in physical and emotional improvement for post-op heart patients. The third one, we readily admit, is a bit self-serving. Like most office workers, we have been looking for an excuse to feel less guilty about how much coffee is ingested around here.
JAMA sends us regular news flashes. We will continue to keep an eye out for relevant items.
JAMA Launches New Series on Caring of the Aging Patient
CHICAGO – 12/29/09 – JAMA is launching a new series, “Care of the Aging Patient: From Evidence to Action.”
“The aging of the global population will be a hallmark of the 21st century, when average lifespan may reach 100 years in some countries, at least for women. Worldwide, the proportion of the population aged 60 years or older is expected to increase from 10 percent worldwide in 2005 to 22 percent in 2050, with the steepest rise in the next 25 years. Individuals aged 85 years or older are the most rapidly increasing segment of many populations,” according to an editorial in the December 23/30 issue of JAMA.
C. Seth Landefeld, M.D., of the University of California, San Francisco, and colleagues write that aging will shape the lives of patients and the practice of medicine, and that physicians will spend more time caring for older individuals. “Although physicians are knowledgeable about the pathophysiology, diagnosis, and management of organ-specific diseases such as cataract, coronary artery disease, and pneumonia, many geriatric syndromes are not straightforward and do not fit the conventional paradigm of disease.”
“The Institute of Medicine’s 2008 report Retooling for an Aging America concluded, ‘The health care workforce … is not prepared to deliver the best care to older patients.’ This new series takes a step to address this problem.”
The overall goal of this series will be to help improve clinical practice and inform policy in care of older individuals, especially those who have started to lose their independence or are at risk of doing so. “Using the real stories of patients and interviews with them, the new series will analyze how to put existing evidence into practice to address pressing questions that arise for older patients, their families, and their physicians. By focusing on older patients’ specific problems, the articles will explore themes that develop with aging,” the authors write.
The first 12 articles will explore the course of aging, from the first hints of frailty through events such as difficulty driving a car to the progressive restriction of activities that results from a steady decline. “The series aims to provide clinicians with pragmatic tools and methods for translating published evidence into daily practice, or if evidence does not exist, recommendations with a rationale and a potential research agenda.”
In the first article in the series, David Reuben, M.D., of the University of California, Los Angeles, discusses the approach to care of older patients beginning with a consideration of life expectancy and patient goals. Such an approach helps tailor the patient’s visit to issues of greatest importance to the patient and interventions to maximize prevention, independence, and quality of life. An accompanying commentary by Christine Cassel, M.D., President of the American Board of Internal Medicine, addresses necessary changes in workforce support for primary care, training requirements, payment reform, research, and systems to improve care of older adults.
This new series is made possible by funding from The SCAN Foundation.
Telephone-Delivered Care for Treating Depression After Coronary Artery Bypass Graft Surgery Appears to Improve Outcomes
CHICAGO – 12/29/09 – Patients who received telephone-delivered collaborative care for treatment of depression after coronary artery bypass graft surgery reported greater improvement in measures of quality of life, physical functioning and mood than patients who received usual care, according to a study in the November 18 issue of JAMA.
Coronary artery bypass graft (CABG) surgery is one of the most common and costly medical procedures performed in the United States. As many as half of CABG patients report depressive symptoms after surgery, and are also more likely to experience a decreased health-related quality of life (HRQL) and functional status, according to background information in the article.
Several trials for treatment of depression have been conducted in cardiac populations, but most achieved less than anticipated benefits with regard to reducing mood symptoms. “Moreover, none used the proven effective collaborative care approach recently recommended by a National Institutes of Health expert consensus panel,” the authors write. Collaborative care emphasizes a flexible real-world treatment package that involves active follow-up by a nonphysician care manager who adheres to evidence-based treatment protocols.
Bruce L. Rollman, M.D., M.P.H., of the University of Pittsburgh School of Medicine, and colleagues conducted a randomized trial to test the effectiveness of telephone-delivered collaborative care for post-CABG depression vs. usual physician care. The study included 302 post-CABG patients with depression (150, intervention; 152, usual care) and a comparison group of 151 randomly sampled post-CABG patients without depression, recruited between March 2004 and September 2007, and observed as outpatients until June 2008. Measures of HRQL, mood symptoms, functioning status and hospital readmissions were gauged via various surveys or tests.
Intervention patients received eight months of telephone-delivered collaborative care, in which a nurse care manager telephoned patients to review their psychiatric history, provide basic psychoeducation about depression and its effect on cardiac disease, and describe treatment options. The nurses worked with patients’ primary care physicians and were supervised by a psychiatrist and primary care physician from this study.
The researchers found that intervention patients reported greater improvements in mental HRQL, physical functioning and mood symptoms. Overall, 50 percent of intervention patients reported a 50 percent or greater reduction in mood symptoms from baseline to 8-month follow-up vs. 29.6 percent of patients in usual care. “Men with depression were particularly likely to benefit from the intervention. However, the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group,” the authors write.
“Since a substantial minority of patients did not benefit from our depression intervention, it is vital to identify post-CABG patients most likely to become treatment resistant so as to develop more effective treatments for them. Identifying the intervention components that maximally contribute to our outcomes is also of great interest. However, collaborative care is a complex intervention involving a number of separate mechanisms that have proven difficult to disentangle from the nonspecific effects of increased attention by the care manager.”
“Additional research is necessary to develop improved treatments for women and patients with resistant depression, and to examine the economic effect of this intervention,” the researchers conclude.
Regular Coffee, Decaf and Tea All Associated With Reduced Risk for Diabetes
CHICAGO – 12/29/09 – Individuals who drink more coffee (regular or decaffeinated) or tea appear to have a lower risk of developing type 2 diabetes, according to an analysis of previous studies reported in the December 14/28 issue of Archives of Internal Medicine.
By the year 2025, approximately 380 million individuals worldwide will be affected by type 2 diabetes, according to background information in the article. “Despite considerable research attention, the role of specific dietary and lifestyle factors remains uncertain, although obesity and physical inactivity have consistently been reported to raise the risk of diabetes mellitus,” the authors write. A previously published meta-analysis suggested drinking more coffee may be linked with a reduced risk, but the amount of available information has more than doubled since.
Rachel Huxley, D.Phil, of The George Institute for International Health, University of Sydney, Australia, and colleagues identified 18 studies involving 457,922 participants and assessing the association between coffee consumption and diabetes risk published between 1966 and 2009. Six studies involving 225,516 individuals also included information about decaffeinated coffee, whereas seven studies with 286,701 participants reported on tea consumption.
When the authors combined and analyzed the data, they found that each additional cup of coffee consumed in a day was associated with a 7 percent reduction in the excess risk of diabetes. Individuals who drank three to four cups per day had an approximately 25 percent lower risk than those who drank between zero and two cups per day.
In addition, in the studies that assessed decaffeinated coffee consumption, those who drank more than three to four cups per day had about a one-third lower risk of diabetes than those who drank none. Those who drank more than three to four cups of tea had a one-fifth lower risk than those who drank no tea.
“That the apparent protective effect of tea and coffee consumption appears to be independent of a number of potential confounding variables raises the possibility of direct biological effects,” the authors write. Because of the association between decaffeinated coffee and diabetes risk, the association is unlikely to be solely related to caffeine. Other compounds in coffee and tea—including magnesium, antioxidants known as lignans or chlorogenic acids—may be involved, the authors note.
“If such beneficial effects were observed in interventional trials to be real, the implications for the millions of individuals who have diabetes mellitus, or who are at future risk of developing it, would be substantial,” they conclude. “For example, the identification of the active components of these beverages would open up new therapeutic pathways for the primary prevention of diabetes mellitus. It could also be envisaged that we will advise our patients most at risk for diabetes mellitus to increase their consumption of tea and coffee in addition to increasing their levels of physical activity and weight loss.”
JAMA added this editor’s note: Dr. Huxley is supported by a Career Development Award from the National Heart Foundation of Australia. This work was additionally supported by a grant from the National Health and Medical Research Council of Australia; a Research Career Development Fellowship from the UK Wellcome Trust; and a research grant from Institut Servier, France and Assistance Publique-Hopitaux de Paris. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
