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Biomedical subjects

M H Chin

Publications and source records attributed to M H Chin.

36 records · Page 2Linked to original sources
PubMed1999

Appropriateness of medication selection for older persons in an urban academic emergency department.

OBJECTIVES: To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes. METHODS: The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy-nine percent of the patients were African-American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug-disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health-related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study. RESULTS: Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug-disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug-disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death. CONCLUSIONS: Suboptimal medication selection was fairly common and was associated with worse patient-reported health-related quality of life.

Accidental Falls↗
PubMed1998

Gender differences in 1-year survival and quality of life among patients admitted with congestive heart failure.

OBJECTIVES: Gender differences in 1-year survival and health-related quality of life (HRQOL) among patients admitted with heart failure were determined. METHODS: Subjects of this prospective cohort study were 435 patients admitted nonelectively between February 2, 1993 and February 2, 1994 to an urban university hospital with shortness of breath or fatigue and evidence of heart failure on admission chest radiograph. Survival was calculated among all patients, and health-related quality of life was calculated among 259 (68%) consenting participants as measured by the Medical Outcomes Study Short Form-36 and Short Form-36 Physical and Mental Component Summary scales. RESULTS: By 1 year, 106 (24%) patients had died, regardless of gender. Independent correlates of death were increasing Charlson Comorbidity Index score, initial serum sodium of 135 mmol/L or less, and white race. Among the 179 (90%) of 200 survivors who responded at all time points, health-related quality of life scores improved from admission but were still generally low, particularly among women. Even after adjusting for clinical and socioeconomic variables as well as baseline health-related quality-of-life scores, women still had less improvement at 1 year than men for the Physical Component Summary scale. Women rated the quality of inpatient care lower than men and also tended to rate the quality of follow-up outpatient care lower. CONCLUSIONS: One-year mortality was high and health-related quality of life was low in patients admitted with heart failure. Women had less improvement in physical health status and perceived their quality of care to be lower and thus may require interventions.

Aged↗
PubMed1998

Differences among geriatricians, general internists, and cardiologists in the care of patients with heart failure: a cautionary tale of quality assessment.

OBJECTIVES: To describe differences in the characteristics, processes of care, and resource utilization of patients with heart failure cared for by geriatricians, general internists, cardiologists, and combinations of physicians. DESIGN: A retrospective cohort study. SETTING: An urban academic medical center. PARTICIPANTS: A total of 439 outpatients with a billing diagnosis of heart failure or cardiomyopathy who were treated by geriatricians, general internists, cardiologists, and combinations of physicians. MEASUREMENTS: Demographic and clinical characteristics, medication use, diagnostic testing, hospitalizations, and inpatient and outpatient costs were measured. RESULTS: Compared with patients of cardiologists, patients cared for by geriatricians were older, more likely to have hypertension, diastolic dysfunction, and high comorbidity, and less likely to undergo echocardiography, cardiac catheterization, and electrocardiography. Use of angiotensin-converting enzyme inhibitors was similar among patients with reduced systolic function. Patients cared for by geriatricians had the same costs, rates of hospitalization, and likelihood of being symptomatic as patients of cardiologists. CONCLUSIONS: The processes of care for patients with heart failure seen solely by geriatricians differ from those for patients seen by other physicians, but the case-mix also varies. Assessment of left ventricular function by geriatricians probably needs to be increased. However, although they were older and had more comorbidity, patients of geriatricians had total costs and symptomatology similar to those of patients of cardiologists. Future work is needed to identify those patients most likely to benefit from treatment by geriatricians and to determine how care can be optimally coordinated among different types of physicians and health providers.

Academic Medical Centers↗
PubMed1998

Diabetes in the African-American Medicare population. Morbidity, quality of care, and resource utilization.

OBJECTIVE: To determine whether African-American Medicare recipients with diabetes are at increased risk for morbidity, poor quality of care, and high resource utilization. RESEARCH DESIGN AND METHODS: We analyzed 1,376 patients with diabetes who were > or = 65 years of age and in the 1993 Medicare Current Beneficiary Survey. Morbidity measures were the Katz Index of Activities of Daily Living, Instrumental Activities of Daily Living, overall health perception, Charlson Comorbidity Index score, and diabetic complications. Quality of care standards were glycosylated hemoglobin measurements, ophthalmological visits, lipid testing, mammography, influenza vaccination, readmission within 30 days of hospital discharge, and outpatient visits within 4 weeks of hospital discharge. We stratified Medicare reimbursement by type of service and adjusted for sex, education, and age in multivariable analyses. RESULTS: Compared with white patients, African-American patients had worse health perception and lower quality of care. They were more likely to visit the emergency department and had fewer physician visits per year. African-Americans had higher reimbursement for home health services, but total reimbursement was similar after case-mix adjustment. CONCLUSIONS: Improved access to preventive care for older African-Americans with diabetes may improve health perception and use of the emergency department. The potential effect on total reimbursement is unclear. Future policy interventions to improve quality of care among Medicare patients with diabetes should especially target African-Americans.

Black or African American↗
PubMed1997

Correlates of early hospital readmission or death in patients with congestive heart failure.

Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of < or = 100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients.

Aged↗
PubMed1997

Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure.

OBJECTIVE: To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication. DESIGN: Survey of a national systematic sample of physicians. PARTICIPANTS: Five hundred family practitioners, 500 general internists, and 500 cardiologists. MEASUREMENTS AND MAIN RESULTS: Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%). CONCLUSIONS: Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.

Adult↗
PubMed1997

Utilization and dosing of angiotensin-converting enzyme inhibitors for heart failure. Effect of physician specialty and patient characteristics.

To determine if physician specialty is associated with underutilization and underdosing of angiotensin-converting enzyme inhibitors among patients with heart failure, we reviewed the charts of 214 outpatients with decreased systolic function at an urban academic medical center. Regardless of whether patients were cared for by cardiologists, generalist physicians, or a combination of the two specialities, approximately 75% of the patients were taking an angiotensin-converting enzyme inhibitor. However, only approximately 60% of these patients were taking dosages proved to be efficacious in trials. Emphasis on adequate dosing is needed among all specialty groups.

Aged↗
PubMed1997

Factors contributing to the hospitalization of patients with congestive heart failure.

OBJECTIVES: This study identifies acute precipitants of hospitalization and evaluates utilization of angiotension-converting enzyme inhibitors in patients admitted with congestive heart failure. METHODS: Cross-sectional chart-review study was done of 435 patients admitted nonelectively from February 1993 to February 1994 to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure. RESULTS: The most common identifiable abnormalities associated with clinical deterioration prior to admission were acute anginal chest pain (33%), respiratory infection (16%), uncontrolled hypertension with initial systolic blood pressure > or = 180 mm Hg (15%), atrial arrhythmia with heart rate > or = 120 (8%), and noncompliance with medications (15%) or diet (6%); in 34% of patients, no clear cause could be identified. After exclusion of those who were already on a different vasodilator or who had relative contraindications, 18 (32%) of the patients with ejection fractions < or = 0.35 measured prior to admission were not taking an angiotensin-converting enzyme inhibitor on presentation to the hospital. CONCLUSIONS: Interventions to improve compliance, the control of hypertension, and the appropriate use of angiotensin-converting enzyme inhibitors may prevent many hospitalizations of heart-failure patients.

Aged↗
PubMed1997

Health outcomes and managed care: discussing the hidden issues.

Too often the debate over health outcomes and managed care has glossed over a series of complex social, political, and ethical issues. Exciting advances in outcomes research have raised hopes for logical medical reform. However, science alone will not optimize our patients' health, since value judgements are necessary and integral parts of attempts to improve health outcomes within managed care organizations. Therefore, to form healthcare policy that is both fair and efficient, we must examine the fundamental values and ethical concerns that are imbedded in our efforts to shape care. We must openly discuss the hidden issues including: (1) trade-offs between standardization of care and provider-patient autonomy; (2) effects of financial incentives on physicians' professionalism; (3) opportunity costs inherent in the design of insurance plans; (4) responsibilities of managed care plans for the health of the public; (5) judicious and valid uses of data systems; and (6) the politics of uncertainty.

Data Collection↗
PubMed1996

Correlates of major complications or death in patients admitted to the hospital with congestive heart failure.

BACKGROUND: When triaging a patient who has heart failure, the physician must estimate the patient's shortterm risk of a major complication or death. METHODS: Prospective cohort study of 435 patients admitted nonelectively to an urban university hospital between February 2, 1993, and February 2, 1994, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph. RESULTS: Major adverse events occurred in 18% of patients who had ejection fractions less than 0.50, 16% of those with ejection fractions of 0.50 or more, and 19% of those with previous heart failure, ejection fractions of 0.50 or more, and no significant valvular disease. In multivariate analyses of all patients, independent correlates (P < or = .01) of major complications or death during hospitalization were initial systolic blood pressure of 90 mm Hg or less (adjusted odds ratio [OR], 5.5; 95% confidence interval [CI], 1.7-17.1), respiratory rate more than 30 breaths per minute on admission to the hospital (OR, 4.6; 95% CI, 2.4-8.8), serum sodium level of 135 mmol/L or less (OR, 2.2; 95% CI, 1.3-4.0), and ST-T wave changes on initial electrocardiogram neither known to be old nor attributable to digoxin (OR, 5.1; 95% CI, 2.9-8.9). However, even patients with none of these 4 risk factors had a 6% rate of a major complication or death. CONCLUSIONS: No truly low-risk group existed. Patients without hypotension, tachypnea, hyponatremia, or electrocardiographic changes of ischemia represent the best candidates for triage to less intensely monitored settings, but clinical judgment is essential.

Aged↗
PubMed1996

The unusual binding properties of the endothelin receptor antagonist CGS 27830 distinguishes receptor/agonist interactions.

CGS 27830 [meso-1,4-dihydro-5-methoxycarbonyl-2,6-dimethyl-4-(3- nitrophenyl)-3-pyridine carboxylic acid anhydride] is a nonpeptidic, insurmountable, endothelin (ET) receptor antagonist with approximately 10- to 20-fold selectivity for ETA receptors. CGS 27830 exhibits unusual binding properties which depend on the receptor and ligand: standard saturation binding experiments (coincubation of membranes with ligand in the absence or presence of antagonist) suggest that CGS 27830 is a competitive inhibitor of [125I]IRL 1620 binding to ETB receptors in rat cerebellar membranes (i.e., there was a change of apparent Kd with no change of maximum binding), but a noncompetitive inhibitor of [125I]IRL 1620 binding to ETB receptors in rat lung membranes (i.e., significant loss of total binding was observed). Although the antagonist appears to be a noncompetitive inhibitor of [125I]IRL 1620 binding to ETB receptors in rat lung membranes, CGS 27830 appears to be a competitive inhibitor of [125I]ET-1 binding to the same receptors as well as to ETA receptors in A7r5 cell membranes. Thus, CGS 27830 can distinguish [125I]IRL 1620 binding to ETB receptors in rat cerebellar and lung membranes, but not ET-1 binding to ETB receptors in these tissues. These unusual binding properties demonstrate that rat lung and cerebellum ETB receptors interact differently with IRL 1620 or ET-1.

Animals↗
PubMed1995

Endothelin-1 induces gene expression through stimulation of endothelin type A receptors in normal rat kidney cells.

RNA blots of total cellular RNA isolated from quiescent and endothelin (ET-1)-stimulated normal rat kidney (NRK) cells demonstrated that ET-1 induced the expression of c-jun, jun B, and c-fos mRNA in a time-dependent manner with maximal expression of mRNA by 1 hr after the addition of ET-1. Five hundred picomolar ET-1 was sufficient to induce maximal mRNA expression. These data agreed with saturation experiments which demonstrated that maximal binding of [125I]ET-1 was achieved at concentrations greater than 100 pM. The Kd and Bmax values for [125I]ET-1 binding to NRK membranes were 20.5 pM and 22.2 fmol/mg protein, respectively. Competition experiments for the binding of [125I]ET-1 to NRK membranes demonstrated that ET-1 was a more potent inhibitor (Ki = 0.047 nM) than ET-3 (Ki = 10.8 nM). No specific binding of [125I]ET-3 (40 or 500 pM) to NRK membranes could be observed. The expression of c-jun, jun B, and c-fos mRNA was inhibited by the endothelin type A receptor (ET)-selective antagonist, BQ-123. Thus, these data demonstrate that ET-1 mediates the expression of immediate response gene mRNA in NRK cells via the ETA receptor. ET-1 stimulation of NRK cells also upregulated EGF receptors, providing a possible mechanism for ET-1 complementation of epidermal growth factor (EGF) mitogenicity in NRK cells.

Animals↗
PubMed1994

Correlates of major complications and mortality in patients presenting to the emergency department with chest pain and more than bibasilar rales.

OBJECTIVE: To identify correlates of major complications and mortality in patients presenting to the emergency department with chest pain and more than bibasilar rales. DESIGN: Prospective cohort study. SETTING: The emergency departments of three university and four community hospitals. PATIENTS: Five hundred patients more than 30 years of age presenting to the emergency departments between 1984 and 1985 with a chief complaint of chest pain not explained by obvious trauma or chest x-ray abnormalities, and more than bibasilar rales on physical examination. MEASUREMENTS AND MAIN RESULTS: A standard data form was used to collect the history, physical examination, vital sign, and electrocardiographic findings. Chart review was carried out to record complications and mortality. One hundred eleven (22%) of the patients had a major complication (ventricular fibrillation, Mobitz II heart block, complete heart block, atrioventricular dissociation, cardiogenic shock, cardiac arrest, endotracheal intubation, intra-aortic balloon pump) or died, 160 (32%) were diagnosed as having myocardial infarction, and 58 (12%) died. Of those patients who had major complications or who died, the first complication occurred within six hours of hospital admission for 32% of the patients and within 24 hours for 47% of the patients. Univariate correlates (p < 0.10) of a major complication or death were entered into a stepwise logistic regression model. In the multivariate model, ST elevation or Q waves not known to be old [adjusted odds ratio (OR) 5.8, 95% confidence interval (CI) 3.0-11.1], ST-T changes of ischemia not known to be old (OR 2.6, 95% CI 1.5-4.6), systolic blood pressure < or = 120 mm Hg (OR 3.2, 95% CI 1.9-5.6), and age > 70 years (OR 1.8, 95% CI 1.1-3.0) were correlates of a major complication or death. CONCLUSION: For patients presenting to the emergency department with chest pain and more than bibasilar rales, major electrocardiographic changes, systolic blood pressure < or = 120 mm Hg, and age > 70 years were correlated with a higher risk of a major complication or death.

Aged↗
PubMedDate not supplied

Developing a conceptual framework for understanding illness and attitudes in older, urban African Americans with diabetes.

PURPOSE: This study was conducted to better understand how older African Americans with diabetes view their illness, and to develop a conceptual framework for approaching their care. METHODS: Researchers conducted interviews of 19 African American patients 65 years or older who attended clinics at an urban academic medical center. The mean age of the patients was 73 years, 58% were female, 63% had a complication from diabetes, and 58% were taking insulin. Patients were asked open-ended questions about how diabetes affected their lives and their attitudes toward treatment. Data were analyzed through a grounded-theory perspective. RESULTS: Patients showed variation in the degree to which they believed that diabetes affected their lives and how aggressive they wished treatment to be. Themes included issues of quality of life, health beliefs, and the social context. Paradoxical, contradictory statements were common, expressing ambivalence and uncertainty regarding the effect of the illness and the treatment. CONCLUSIONS: Wide variation exists in the attitudes of older African Americans toward their diabetes and treatment. Patients frequently expressed ambivalence toward the care of their illness. Providers should explore these issues and help patients resolve their ambivalence if patient preferences are to be respected in the overall treatment plan.

Black or African American↗
PubMedDate not supplied

Nursing activities and acute confusional states in elderly hip-fractured patients.

Confusion in 91 hospitalized patients over 60 years of age who had sustained hip fracture and undergone subsequent surgical repair was examined in seven hospitals in five states. The relationship of nursing activities, patient, surgical, and environmental variables to the extent of confusion apparent in the sample was explored. Data were gathered by record review, patient testing, observation, and interview. Patient testing and interview were carried out on the first, third, and fifth postoperative days; the patient's caregiver on those days was also interviewed. The major dependent variables used in multiple regression analysis were memory (immediate and recent), observed behavior, and patient's self-report of mental clarity. Results showed that the most consistent predictors of postoperative confusion were the presence of confusion on admission to the hospital or confusion during the preoperative period. Greater postoperative mobility and freedom from urinary problems resulted in less confusion. Being male and of increased age were risk factors. The presence of timepieces and patients' use of television were associated with higher levels of mental clarity. Patients in private rooms tended to do better on memory testing than patients in rooms shared with others. Nursing personnel's major action in response to patient confusion was that of conscious attention to orientation, explanation, or reassurance. Use of restraints was relatively frequent.

Cognition Disorders↗