JAMA : the journal of the American Medical Association
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Multicenter Study
Association between hospital process performance and outcomes among patients with acute coronary syndromes.
Selected care processes are increasingly being used to measure hospital quality; however, data regarding the association between hospital process performance and outcomes are limited. ⋯ A significant association between care process and outcomes was found, supporting the use of broad, guideline-based performance metrics as a means of assessing and helping improve hospital quality.
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Despite there being millions of pacemaker and implantable cardioverter-defibrillator (ICD) generator implants worldwide, little is known about device reliability. ⋯ Pacemaker reliability has improved markedly. In contrast, after more than a decade of improving device reliability, the ICD malfunction rate transiently increased before experiencing substantial reductions in the latter 2 study years. Whether increasing device sophistication accounts for the observed decrease in reliability is not known. Continued monitoring of pacemaker and ICD performance is required.
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In January 2002, the US Food and Drug Administration (FDA) issued a draft guidance requiring more detailed financial conflict of interest disclosure at advisory committee meetings. ⋯ Disclosures of conflicts of interest at drug advisory committee meetings are common, often of considerable monetary value, and rarely result in recusal of advisory committee members. A weak relationship between certain types of conflicts and voting behaviors was detected, but excluding advisory committee members and voting consultants with conflicts would not have altered the overall vote outcome at any meeting studied.
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Pacemakers and implantable cardioverter-defibrillators (ICDs) are complex medical devices proven to reduce mortality in specific high-risk patient populations. It is not known if increasing device complexity is associated with decreased reliability. ⋯ This study demonstrates that thousands of patients have been affected by pacemaker and ICD malfunctions, the pacemaker malfunction replacement rate has decreased, the ICD malfunction replacement rate increased during the latter half of the study, and the ICD malfunction replacement rate is significantly higher than that for pacemakers. Although pacemakers and ICDs are important life-sustaining devices that have saved many lives, careful monitoring of device performance is still required.
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Case Reports
Using clinical guidelines designed for older adults with diabetes mellitus and complex health status.
Increasingly, adults are living to an advanced age. While many enjoy good health, nearly 50% of adults older than 65 years have 3 or more chronic medical conditions. Furthermore, within any age-sex cohort, older adults exhibit widely heterogeneous health status--ranging from robust to frail. ⋯ Most current health care guidelines are disease-specific and do not address this complexity and heterogeneity, thus limiting their utility for guiding physicians in the care of older adult patients. The "Guidelines for Improving the Care of Older Persons With Diabetes Mellitus" are the first guidelines to specifically address this complexity and provide guidance to physicians who must prioritize therapies and goals for older adults with diabetes, comorbid medical conditions, and geriatric syndromes. By providing a rationale for prioritizing recommendations and the inclusion of geriatric syndromes that impact the patient's overall health and diabetic care, these guidelines may serve as a model for the development of other guidelines targeting older adults with complex health status.