Mary Ann Moon

Rates of bacterial meningitis dropped markedly among all age groups in the United States during the past decade but have declined most strikingly in children, according to a report in the May 26 issue of the New England Journal of Medicine.

This trend is probably the result of the success of pneumococcal and Hib conjugate vaccines in preventing these infections in early childhood. The epidemiology of bacterial meningitis has shifted, with the most obvious change being the increase in the average patient age at diagnosis, according to Dr. Michael C. Thigpen of the Centers for Disease Control and Prevention, Atlanta, and his associates.

The investigators tracked changes in the epidemiology of bacterial meningitis cases from 1998 through 2007 using data from two surveillance systems, one laboratory based and the other population based, in the CDC’s Emerging Infections Program network. The network covered approximately 17.4 million people residing in eight regions of the country during the study period.

The researchers identified 3,188 cases of bacterial meningitis resulting from the five most common causative organisims: Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, group B streptococcus, or Listeria monocytogenes. The overall fatality rate was 15%.

The overall incidence of these infections declined from 2.00 cases per 100,000 people to 1.38 per 100,000 – approximately 30%.

Rates of meningitis declined most dramatically among children, probably because of the introduction of the PCV7 vaccine. This decline correlated with a rise in the median age of bacterial meningitis patients, from about 30 years to 42 years.

The incidence of bacterial meningitis also declined among adults aged 65 and older and may decline further in this age group because of reduced exposure as more "children are vaccinated with the newly licensed PCV13," Dr. Thigpen and his colleagues said (N. Engl. J. Med. 2011;364:2016-25).

Nevertheless, the case fatality rate did not change significantly. It was 15.7% in 1998 and 14.3% in 2007.

Although the epidemiology of bacterial meningitis has changed, the ranking of causative organisms has not. "For clinicians, [this suggests] that current treatment guidelines ... targeting the major pathogenic causes are still appropriate."

S. pneumoniae was the most common causative pathogen among adults as well as children aged 1-11 years. Group B strep accounted for most cases among infants, and that rate did not decrease.

The rate of N. meningitidis infection decreased, but that organism still accounted for most cases of bacterial meningitis that developed in adolescents. "As the proportion of children receiving MCV4 continues to increase, we expect additional reductions in the incidence of meningococcal disease," the investigators said.

This study probably underestimates the true burden of bacterial meningitis for three main reasons.

First, the databases only included culture-proven cases, and the accuracy of that identification "depends on the diagnostic and therapeutic practices of those caring for patients," they said.

Second, the databases did not cover all the possible pathogens that cause bacterial meningitis, such as Escherichia coli and some species of staph.

Third, the databases do not routinely collect information on cases acquired in health care settings, "which may account for up to 40% of cases," Dr. Thigpen and his associates said.

The study was supported by the Centers for Disease Control and Prevention. Some of Dr. Thigpen’s associates reported financial ties to Merck, Wyeth, Sanofi Pasteur, Novartis, GlaxoSmithKline, and Pfizer.

Rates of bacterial meningitis dropped markedly among all age groups in the United States during the past decade but have declined most strikingly in children, according to a report in the May 26 issue of the New England Journal of Medicine.

This trend is probably the result of the success of pneumococcal and Hib conjugate vaccines in preventing these infections in early childhood. The epidemiology of bacterial meningitis has shifted, with the most obvious change being the increase in the average patient age at diagnosis, according to Dr. Michael C. Thigpen of the Centers for Disease Control and Prevention, Atlanta, and his associates.

The investigators tracked changes in the epidemiology of bacterial meningitis cases from 1998 through 2007 using data from two surveillance systems, one laboratory based and the other population based, in the CDC’s Emerging Infections Program network. The network covered approximately 17.4 million people residing in eight regions of the country during the study period.

The researchers identified 3,188 cases of bacterial meningitis resulting from the five most common causative organisims: Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, group B streptococcus, or Listeria monocytogenes. The overall fatality rate was 15%.

The overall incidence of these infections declined from 2.00 cases per 100,000 people to 1.38 per 100,000 – approximately 30%.

Rates of meningitis declined most dramatically among children, probably because of the introduction of the PCV7 vaccine. This decline correlated with a rise in the median age of bacterial meningitis patients, from about 30 years to 42 years.

The incidence of bacterial meningitis also declined among adults aged 65 and older and may decline further in this age group because of reduced exposure as more "children are vaccinated with the newly licensed PCV13," Dr. Thigpen and his colleagues said (N. Engl. J. Med. 2011;364:2016-25).

Nevertheless, the case fatality rate did not change significantly. It was 15.7% in 1998 and 14.3% in 2007.

Although the epidemiology of bacterial meningitis has changed, the ranking of causative organisms has not. "For clinicians, [this suggests] that current treatment guidelines ... targeting the major pathogenic causes are still appropriate."

S. pneumoniae was the most common causative pathogen among adults as well as children aged 1-11 years. Group B strep accounted for most cases among infants, and that rate did not decrease.

The rate of N. meningitidis infection decreased, but that organism still accounted for most cases of bacterial meningitis that developed in adolescents. "As the proportion of children receiving MCV4 continues to increase, we expect additional reductions in the incidence of meningococcal disease," the investigators said.

This study probably underestimates the true burden of bacterial meningitis for three main reasons.

First, the databases only included culture-proven cases, and the accuracy of that identification "depends on the diagnostic and therapeutic practices of those caring for patients," they said.

Second, the databases did not cover all the possible pathogens that cause bacterial meningitis, such as Escherichia coli and some species of staph.

Third, the databases do not routinely collect information on cases acquired in health care settings, "which may account for up to 40% of cases," Dr. Thigpen and his associates said.

The study was supported by the Centers for Disease Control and Prevention. Some of Dr. Thigpen’s associates reported financial ties to Merck, Wyeth, Sanofi Pasteur, Novartis, GlaxoSmithKline, and Pfizer.

Rates of bacterial meningitis dropped markedly among all age groups in the United States during the past decade but have declined most strikingly in children, according to a report in the May 26 issue of the New England Journal of Medicine.

This trend is probably the result of the success of pneumococcal and Hib conjugate vaccines in preventing these infections in early childhood. The epidemiology of bacterial meningitis has shifted, with the most obvious change being the increase in the average patient age at diagnosis, according to Dr. Michael C. Thigpen of the Centers for Disease Control and Prevention, Atlanta, and his associates.

The investigators tracked changes in the epidemiology of bacterial meningitis cases from 1998 through 2007 using data from two surveillance systems, one laboratory based and the other population based, in the CDC’s Emerging Infections Program network. The network covered approximately 17.4 million people residing in eight regions of the country during the study period.

The researchers identified 3,188 cases of bacterial meningitis resulting from the five most common causative organisims: Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, group B streptococcus, or Listeria monocytogenes. The overall fatality rate was 15%.

The overall incidence of these infections declined from 2.00 cases per 100,000 people to 1.38 per 100,000 – approximately 30%.

Rates of meningitis declined most dramatically among children, probably because of the introduction of the PCV7 vaccine. This decline correlated with a rise in the median age of bacterial meningitis patients, from about 30 years to 42 years.

The incidence of bacterial meningitis also declined among adults aged 65 and older and may decline further in this age group because of reduced exposure as more "children are vaccinated with the newly licensed PCV13," Dr. Thigpen and his colleagues said (N. Engl. J. Med. 2011;364:2016-25).

Nevertheless, the case fatality rate did not change significantly. It was 15.7% in 1998 and 14.3% in 2007.

Although the epidemiology of bacterial meningitis has changed, the ranking of causative organisms has not. "For clinicians, [this suggests] that current treatment guidelines ... targeting the major pathogenic causes are still appropriate."

S. pneumoniae was the most common causative pathogen among adults as well as children aged 1-11 years. Group B strep accounted for most cases among infants, and that rate did not decrease.

The rate of N. meningitidis infection decreased, but that organism still accounted for most cases of bacterial meningitis that developed in adolescents. "As the proportion of children receiving MCV4 continues to increase, we expect additional reductions in the incidence of meningococcal disease," the investigators said.

This study probably underestimates the true burden of bacterial meningitis for three main reasons.

First, the databases only included culture-proven cases, and the accuracy of that identification "depends on the diagnostic and therapeutic practices of those caring for patients," they said.

Second, the databases did not cover all the possible pathogens that cause bacterial meningitis, such as Escherichia coli and some species of staph.

Third, the databases do not routinely collect information on cases acquired in health care settings, "which may account for up to 40% of cases," Dr. Thigpen and his associates said.

The study was supported by the Centers for Disease Control and Prevention. Some of Dr. Thigpen’s associates reported financial ties to Merck, Wyeth, Sanofi Pasteur, Novartis, GlaxoSmithKline, and Pfizer.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

Medicare patients in areas with the highest levels of ambulatory primary care had lower mortality rates and fewer preventable hospitalizations than did those who lived in areas with less primary care, according to a report in the May 25 issue of JAMA.

But more primary care didn’t always mean more physician head count: The improvements came in areas with the most "primary care physician ambulatory care clinical effort," rather than simply the highest number of primary care physicians.

"Our findings suggest that a higher local workforce of primary care physicians has a generally positive benefit for [patient] populations, but that this association may not simply be the result of having more physicians trained in primary care in the area," said Chiang-Hua Chang, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and associates (JAMA 2011;305:2096-2105).

Most studies of the issue have found an association between a greater number of primary care physicians per population and better health outcomes, and almost all have based their conclusions on simple head counts of primary care physicians derived from the American Medical Association Masterfile.

However, such counts don’t accurately reflect the number of physicians trained in primary care who actually provide ambulatory primary care in their communities, the investigators noted.

Many physicians designate their specialty as "primary care" in the AMA Masterfile while they practice as hospitalists or physicians in emergency departments. Others are counted as being full-time primary care practitioners when, in fact, they are retired or work only part time. Still others are counted as primary care physicians when their specialty is not actually primary care, when they see no ambulatory patients, or when their patients do not reside in the community being counted as their "per-population" base.

To address those inaccuracies, Dr. Chang and colleagues assessed outcomes in a 20% national sample of fee-for-service Medicare beneficiaries (more than 5 million patients) using two strategies:

– A simple head count of 155,729 physicians listed as family physicians or general internists in the 2007 AMA Masterfile in several designated geographic service areas.

– An estimate of the ambulatory clinical full-time equivalents (FTEs) of primary care physicians derived from office- and clinic-based Medicare claims from the same designated geographic service areas.

As the researchers suspected, the use of a simple head count of primary care physicians yielded a "modest" association between the number of primary caregivers and improved patients outcomes, including lower mortality.

But using the more accurate estimate of FTEs of primary care physicians yielded a much stronger association, the investigators said.

Not only did patients residing in the highest quintile of primary care FTEs have 5% lower mortality rates, but they also had 9% fewer "highly preventable" hospitalizations for disorders such as pneumonia, asthma, hypertension, angina, diabetes, urinary infection, or dehydration.

The costs of care were slightly higher in areas with the highest level of primary care FTEs, but that was likely because the spending for primary physicians’ early detection, prevention, and coordination of care was slightly higher than the costs of acute hospitalization, Dr. Chang and associates said.

"Our study offers the cautionary note that having more physicians trained in primary care practicing in an area, by itself, does not ensure substantially lower mortality, fewer hospitalizations, or lower costs," the investigators noted. "Increasing the training capacity of family medicine and internal medicine may have disappointing [results] if the resulting physicians are primary care in name only."

The study findings also demonstrate that "research and health care planning that relies solely on the AMA Masterfile for primary physician counts will not accurately measure the primary care workforce," they said.

This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Aging. Dr. Chang’s associates reported ties to numerous health care entities.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

New-onset atrial fibrillation raises mortality risk, even among healthy middle-aged women with a low burden of cardiovascular disease, according to a report in the May 25 issue of JAMA.

However, the absolute excess in mortality attributable to atrial fibrillation (AF) is a "fairly low" 2% in this population, said Dr. David Conen of University Hospital Basel (Switzerland) and his associates.

To assess the risk of adverse events related to new-onset AF in a large cohort of patients with low cardiovascular risk, the investigators analyzed data from 34,722 subjects enrolled in the Women’s Health Study. The WHS furnished detailed medical information on female health care professionals who were aged 45 years and older at baseline in 1993 and were followed prospectively through 2010.

During a median follow-up of 15 years, 1,011 (2.9%) of these women developed new-onset AF. A total of 63 of these women died during the study period, including 4 (6.3%) who died within 30 days of receiving the diagnosis of AF.

"The age-adjusted relative risk of all-cause, cardiovascular, and noncardiovascular mortality was significantly higher among women with new-onset AF" than among those without AF, Dr. Conen and his colleagues said (JAMA 2011;305:2080-7).

The risk was "substantially higher shortly after AF diagnosis" and appeared to be related to the occurrence of nonfatal cardiovascular events – chiefly stroke, heart failure, and myocardial infarction – prior to death. This raises the possibility that "associated comorbidities at the time of AF diagnosis may be responsible for at least a portion of the excess death risk in these individuals," they said.

"As both [congestive heart failure] and stroke are at least partly preventable through blood pressure controls and anticoagulation, our data reinforce the importance of strict risk factor control in AF patients," the investigators noted.

Even though the increase in mortality risk was significant, the absolute excess in mortality was not high. "We estimated that after taking [CV risk factors] into account, approximately 2% of all deaths could be attributed to incident AF," they said.

In secondary analyses, they assessed mortality risks according to subtypes of AF.

The researchers found that cardiovascular mortality, but not total or noncardiovascular mortality, was significantly increased in the 65% of women who had paroxysmal AF. Although the number of events in this subgroup was small, "these data raise the possibility that individuals with paroxysmal AF may have a lower mortality risk than those with other AF patterns," Dr. Conen and his associates said.

In the subgroup of 74 women who had lone AF, none died or had a stroke during follow-up, and only 2 developed heart failure. "Although this represents the largest prospective sample of women with lone AF reported so far, the number is still too small and follow-up is not long enough to draw definite conclusions about long-term outcomes. Nevertheless, these data are consistent with prior observations that lone AF may be a benign disease, at least in the short term," they said.

The study was supported by the National Heart, Lung, and Blood Institute. The WHS was supported by the NHLBI and the National Cancer Institute. Dr. Conen and his associates reported ties to numerous industry sources.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Both short- and long-acting inhaled anticholinergic medications appear to raise the risk of acute urinary retention in men taking the drugs for treatment of chronic obstructive pulmonary disease, according to a report in the May 23 issue of the Archives of Internal Medicine.

Men who take both types of anticholinergics concomitantly and men who have benign prostatic hypertrophy (BPH) are at highest risk for developing acute urinary retention, which is considered a urologic emergency, said Dr. Anne Stephenson of St. Michael’s Hospital, Toronto, and her associates.

"Physicians and the public need to be aware of the potential for this significant adverse event so that preventive measures and potential therapy can be considered," they said.

Until now, it has been "uncertain" whether inhaled anticholinergics caused detrimental urologic effects. Canadian, European, and American practice guidelines say little about possible adverse effects on prostatic symptoms, and clinical studies offer conflicting results.

To examine the association between exposure to inhaled anticholinergics and the development of acute urinary retention, Dr. Stephenson and her colleagues performed a population-based case-control study, first identifying all 563,705 Ontario residents aged 66 years and older who had COPD and whose records could be followed in a medical database for a median of 5 years.

During that time, 9,432 of the men and 1,806 of the women developed a first episode of acute urinary retention. These cases were matched with 46,865 men and 9,020 women with COPD who did not develop acute urinary retention and served as control subjects.

Men who used inhaled anticholinergics were at significantly increased risk of developing acute urinary retention, but women were not.

Men who initiated inhaled anticholinergic therapy during the study period had more than a 40% higher chance of developing acute urinary retention than were men who didn’t use the drugs. This was true with either short-acting agents (ipratropium products) or a long-acting agent (tiotropium bromide).

Men who initiated combination therapy with both short- and long-acting inhaled anticholinergics were at 169% higher risk than were those who didn’t take the drugs, suggesting a dose-response relationship.

Men who were already taking inhaled anticholinergics at baseline rather than initiating the therapy were at slightly lower but still significantly increased risk of developing acute urinary retention, with an odds ratio of 1.36.

Men with BPH who began taking the drugs had an 80% greater chance of developing acute urinary retention, compared with nonusers. "According to our risk estimates, for men with BPH newly initiating a regimen of inhaled anticholinergics, 1 in 514 will experience this adverse event," the investigators said (Arch. Intern. Med. 2011;171:914-20).

Among new users of the drugs, acute urinary retention tended to develop within 30 days (median, 14 days), "further strengthening a causal relationship.

"These data suggest that [patients] may benefit from close monitoring for signs and symptoms of impending urinary retention within the first month of starting inhaled anticholinergics," they said.

Moreover, any patient taking these drugs who develops urinary changes should be carefully evaluated for possible preventive or therapeutic interventions, Dr. Stephenson and her associates added.

"We suggest that the association between respiratory inhaler use and bladder dysfunction may be underappreciated by the medical profession and by the public. ... Physicians should highlight for patients the possible connection" to urinary symptoms such as incomplete voiding, urinary incontinence, and decreased urinary flow.

This study was somewhat limited in that there were no data available on patient-related variables such as lung function, smoking history, renal impairment, and severity of COPD, all of which could be confounders.

"The lack of effect among women ... could be a reflection of the small sample size within this subgroup." Also, women are known to have substantially lower rates of urinary retention than men, most likely because of anatomical differences in the urinary tract.

Dr. Stephenson’s study was funded by the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care. No financial conflicts of interest were reported.

Both short- and long-acting inhaled anticholinergic medications appear to raise the risk of acute urinary retention in men taking the drugs for treatment of chronic obstructive pulmonary disease, according to a report in the May 23 issue of the Archives of Internal Medicine.

Men who take both types of anticholinergics concomitantly and men who have benign prostatic hypertrophy (BPH) are at highest risk for developing acute urinary retention, which is considered a urologic emergency, said Dr. Anne Stephenson of St. Michael’s Hospital, Toronto, and her associates.

"Physicians and the public need to be aware of the potential for this significant adverse event so that preventive measures and potential therapy can be considered," they said.

Until now, it has been "uncertain" whether inhaled anticholinergics caused detrimental urologic effects. Canadian, European, and American practice guidelines say little about possible adverse effects on prostatic symptoms, and clinical studies offer conflicting results.

To examine the association between exposure to inhaled anticholinergics and the development of acute urinary retention, Dr. Stephenson and her colleagues performed a population-based case-control study, first identifying all 563,705 Ontario residents aged 66 years and older who had COPD and whose records could be followed in a medical database for a median of 5 years.

During that time, 9,432 of the men and 1,806 of the women developed a first episode of acute urinary retention. These cases were matched with 46,865 men and 9,020 women with COPD who did not develop acute urinary retention and served as control subjects.

Men who used inhaled anticholinergics were at significantly increased risk of developing acute urinary retention, but women were not.

Men who initiated inhaled anticholinergic therapy during the study period had more than a 40% higher chance of developing acute urinary retention than were men who didn’t use the drugs. This was true with either short-acting agents (ipratropium products) or a long-acting agent (tiotropium bromide).

Men who initiated combination therapy with both short- and long-acting inhaled anticholinergics were at 169% higher risk than were those who didn’t take the drugs, suggesting a dose-response relationship.

Men who were already taking inhaled anticholinergics at baseline rather than initiating the therapy were at slightly lower but still significantly increased risk of developing acute urinary retention, with an odds ratio of 1.36.

Men with BPH who began taking the drugs had an 80% greater chance of developing acute urinary retention, compared with nonusers. "According to our risk estimates, for men with BPH newly initiating a regimen of inhaled anticholinergics, 1 in 514 will experience this adverse event," the investigators said (Arch. Intern. Med. 2011;171:914-20).

Among new users of the drugs, acute urinary retention tended to develop within 30 days (median, 14 days), "further strengthening a causal relationship.

"These data suggest that [patients] may benefit from close monitoring for signs and symptoms of impending urinary retention within the first month of starting inhaled anticholinergics," they said.

Moreover, any patient taking these drugs who develops urinary changes should be carefully evaluated for possible preventive or therapeutic interventions, Dr. Stephenson and her associates added.

"We suggest that the association between respiratory inhaler use and bladder dysfunction may be underappreciated by the medical profession and by the public. ... Physicians should highlight for patients the possible connection" to urinary symptoms such as incomplete voiding, urinary incontinence, and decreased urinary flow.

This study was somewhat limited in that there were no data available on patient-related variables such as lung function, smoking history, renal impairment, and severity of COPD, all of which could be confounders.

"The lack of effect among women ... could be a reflection of the small sample size within this subgroup." Also, women are known to have substantially lower rates of urinary retention than men, most likely because of anatomical differences in the urinary tract.

Dr. Stephenson’s study was funded by the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care. No financial conflicts of interest were reported.

Both short- and long-acting inhaled anticholinergic medications appear to raise the risk of acute urinary retention in men taking the drugs for treatment of chronic obstructive pulmonary disease, according to a report in the May 23 issue of the Archives of Internal Medicine.

Men who take both types of anticholinergics concomitantly and men who have benign prostatic hypertrophy (BPH) are at highest risk for developing acute urinary retention, which is considered a urologic emergency, said Dr. Anne Stephenson of St. Michael’s Hospital, Toronto, and her associates.

"Physicians and the public need to be aware of the potential for this significant adverse event so that preventive measures and potential therapy can be considered," they said.

Until now, it has been "uncertain" whether inhaled anticholinergics caused detrimental urologic effects. Canadian, European, and American practice guidelines say little about possible adverse effects on prostatic symptoms, and clinical studies offer conflicting results.

To examine the association between exposure to inhaled anticholinergics and the development of acute urinary retention, Dr. Stephenson and her colleagues performed a population-based case-control study, first identifying all 563,705 Ontario residents aged 66 years and older who had COPD and whose records could be followed in a medical database for a median of 5 years.

During that time, 9,432 of the men and 1,806 of the women developed a first episode of acute urinary retention. These cases were matched with 46,865 men and 9,020 women with COPD who did not develop acute urinary retention and served as control subjects.

Men who used inhaled anticholinergics were at significantly increased risk of developing acute urinary retention, but women were not.

Men who initiated inhaled anticholinergic therapy during the study period had more than a 40% higher chance of developing acute urinary retention than were men who didn’t use the drugs. This was true with either short-acting agents (ipratropium products) or a long-acting agent (tiotropium bromide).

Men who initiated combination therapy with both short- and long-acting inhaled anticholinergics were at 169% higher risk than were those who didn’t take the drugs, suggesting a dose-response relationship.

Men who were already taking inhaled anticholinergics at baseline rather than initiating the therapy were at slightly lower but still significantly increased risk of developing acute urinary retention, with an odds ratio of 1.36.

Men with BPH who began taking the drugs had an 80% greater chance of developing acute urinary retention, compared with nonusers. "According to our risk estimates, for men with BPH newly initiating a regimen of inhaled anticholinergics, 1 in 514 will experience this adverse event," the investigators said (Arch. Intern. Med. 2011;171:914-20).

Among new users of the drugs, acute urinary retention tended to develop within 30 days (median, 14 days), "further strengthening a causal relationship.

"These data suggest that [patients] may benefit from close monitoring for signs and symptoms of impending urinary retention within the first month of starting inhaled anticholinergics," they said.

Moreover, any patient taking these drugs who develops urinary changes should be carefully evaluated for possible preventive or therapeutic interventions, Dr. Stephenson and her associates added.

"We suggest that the association between respiratory inhaler use and bladder dysfunction may be underappreciated by the medical profession and by the public. ... Physicians should highlight for patients the possible connection" to urinary symptoms such as incomplete voiding, urinary incontinence, and decreased urinary flow.

This study was somewhat limited in that there were no data available on patient-related variables such as lung function, smoking history, renal impairment, and severity of COPD, all of which could be confounders.

"The lack of effect among women ... could be a reflection of the small sample size within this subgroup." Also, women are known to have substantially lower rates of urinary retention than men, most likely because of anatomical differences in the urinary tract.

Dr. Stephenson’s study was funded by the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care. No financial conflicts of interest were reported.