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The Framingham risk score predicts 10-year risk for
coronary heart disease (CHD) less accurately in older than younger populations.
This study developed a CHD risk prediction model for use in adults older than
65 years that accounts for deaths from non-CHD causes. Deaths from non-CHD
causes dominated those from CHD when the model was applied to 2 cohorts of
patients, and the model was about as accurate as the Framingham risk score. The
findings illustrate the difficulties in predicting CHD risk in elderly persons
and the need to improve these predictions.
Patients with idiopathic pulmonary fibrosis (IPF)
frequently have debilitating cough that has no effective treatment. In this
randomized, controlled trial, patients with IPF experienced improvement in
cough-specific quality of life and cough severity after thalidomide treatment
compared with placebo. Thalidomide may be an effective therapy for cough in
patients with IPF, but additional studies are needed to confirm the findings in
this small, single-center study.
This review compared transitional care service
models with usual care for patients hospitalized for first or recurrent stroke
or myocardial infarction (MI). Among 44 studies, moderate-strength evidence
showed that hospital-initiated support strategies reduced length of stay for
stroke patients, and low-strength evidence showed that they reduced mortality
for MI patients. Evidence on patient and family education programs and
community-based support interventions was insufficient, and few studies were of
high quality or reported adverse events.
This review examined interventions to improve patient handovers from hospital to primary care. Among 36 trials, many interventions had positive effects on patient care, including medication reconciliation, electronic tools (for summary generation, discharge notifications, and Web access), discharge planning, and shared involvement in follow-up by hospital and community care providers. The evidence suggests that these interventions can reduce hospital use and improve continuity of care and patient status after discharge.
Trial design can lead to biased estimates of intervention effect, but studies have inconsistently identified which design aspects are associated with the greatest risk of bias. This study combined data from 234 unique meta-analyses involving 1973 trials to estimate associations of specific trial characteristics with average bias and between-trial heterogeneity. Intervention effect estimates seemed to be exaggerated in trials with inadequate or unclear random-sequence generation, allocation concealment, or double-blinding. However, these observations occurred primarily in trials with subjective outcomes, with little evidence of bias in trials with objective outcomes, such as mortality.
Identifying high-priority research needs could speed the development and implementation of high-priority, stakeholder-engaged research. The Agency for Healthcare Research and Quality's Evidence-based Practice Center (EPC) Program uses systematic reviews to identify gaps in current evidence. It has developed a systematic process to prioritize these gaps with stakeholder input into clearly defined “future research needs.” This article describes the challenges and lessons learned from an initial effort of 8 EPCs to apply this method to various clinical and policy topics.
The Patient-Centered Outcomes Research Institute
(PCORI), with resources provided through the Patient Protection and Affordable
Care Act, will invest more than $3 billion between now and 2019 in research
that addresses questions of relevance to patients, their caregivers, and
clinicians. This commentary discusses PCORI's recently announced funding
priorities and goals.
Two systematic reviews in this issue examine clinical trials or observational studies that evaluated transitional care interventions and highlight the variability and lack of standardization in the field. Prvu Bettger and colleagues focused on transitions of care after a new acute event, and Hesselink and associates focused on intervention programs aimed at improving the transition to primary care at hospital discharge. The editorialist discusses the findings and how they identify important gaps in research.
In this issue, Krumholz and Selby discuss the newly formed PCORI, which, if successful, could potentially improve the health research landscape not only for PCORI but also for other federal and nonfederal research-funding bodies. The editorialist discusses the potential obstacles that must be overcome to optimize PCORI's success.
The other day one of our students popped by my office asking for a letter of recommendation to support her residency application. I found myself bored by the whole process. Mustering up all of my professionalism, I called myself to order, looking back over the decades to all those who had helped me climb the ladder.
I realize now that it's not a question of whether I failed him, but one of how much and in how many ways. Had my fondness for him made me vulnerable, so that during our many conversations covering topics that ranged from mindless banter to heavy theology, I avoided broachingthe subject of his inevitable death?