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A recent patient satisfaction survey that ranked nursing care as the most important factor within inpatient pediatric care settings comes as no surprise to the chair of SHM’s Nurse Practitioner/Physician Assistant Committee.

Published online last month in the American Journal of Medical Quality, the retrospective study found that patient satisfaction for pediatric care varies widely depending on “which departmental setting patients receive treatment within a healthcare system,” study authors noted.

“Communication is one of the most important things,” says committee chair Tracy Cardin, ACNP-BC, FHM. “And nursing is sort of our designee sometimes in the communication of the plan of care. You can go over something with a patient and the family for a minute or so, or five, or even 10. But, really, it’s the nurses who reinforce the message.”

For the study, researchers at Nemours/Alfred I. duPont Hospital for Children in Delaware reviewed more than 27,000 patient satisfaction survey results over a three-year period at facilities of the Nemours Children’s Health System in the Delaware Valley and Jefferson University Hospitals in Philadelphia. Families rated their satisfaction on a five-point scale for various factors including physician care, nurse care, and personal concern.

The researchers say knowing what kinds of care expectations patients have in different settings, be it the emergency department or an inpatient ward, could help tailor interventions.

Cardin is hopeful that’s true, but she notes that patient satisfaction is a complex issue. A hospitalist could deliver perfect care, but if the patient had a bad experience at the hospital’s front door, the actual care delivery scores may be affected.

“It would be nice if there were just one variable to manipulate,” she says. “There are so many different impacts on [satisfaction]. What do we really have the ability to control?”

View our website for more information on inpatient satisfaction.

A recent patient satisfaction survey that ranked nursing care as the most important factor within inpatient pediatric care settings comes as no surprise to the chair of SHM’s Nurse Practitioner/Physician Assistant Committee.

Published online last month in the American Journal of Medical Quality, the retrospective study found that patient satisfaction for pediatric care varies widely depending on “which departmental setting patients receive treatment within a healthcare system,” study authors noted.

“Communication is one of the most important things,” says committee chair Tracy Cardin, ACNP-BC, FHM. “And nursing is sort of our designee sometimes in the communication of the plan of care. You can go over something with a patient and the family for a minute or so, or five, or even 10. But, really, it’s the nurses who reinforce the message.”

For the study, researchers at Nemours/Alfred I. duPont Hospital for Children in Delaware reviewed more than 27,000 patient satisfaction survey results over a three-year period at facilities of the Nemours Children’s Health System in the Delaware Valley and Jefferson University Hospitals in Philadelphia. Families rated their satisfaction on a five-point scale for various factors including physician care, nurse care, and personal concern.

The researchers say knowing what kinds of care expectations patients have in different settings, be it the emergency department or an inpatient ward, could help tailor interventions.

Cardin is hopeful that’s true, but she notes that patient satisfaction is a complex issue. A hospitalist could deliver perfect care, but if the patient had a bad experience at the hospital’s front door, the actual care delivery scores may be affected.

“It would be nice if there were just one variable to manipulate,” she says. “There are so many different impacts on [satisfaction]. What do we really have the ability to control?”

View our website for more information on inpatient satisfaction.

A recent patient satisfaction survey that ranked nursing care as the most important factor within inpatient pediatric care settings comes as no surprise to the chair of SHM’s Nurse Practitioner/Physician Assistant Committee.

Published online last month in the American Journal of Medical Quality, the retrospective study found that patient satisfaction for pediatric care varies widely depending on “which departmental setting patients receive treatment within a healthcare system,” study authors noted.

“Communication is one of the most important things,” says committee chair Tracy Cardin, ACNP-BC, FHM. “And nursing is sort of our designee sometimes in the communication of the plan of care. You can go over something with a patient and the family for a minute or so, or five, or even 10. But, really, it’s the nurses who reinforce the message.”

For the study, researchers at Nemours/Alfred I. duPont Hospital for Children in Delaware reviewed more than 27,000 patient satisfaction survey results over a three-year period at facilities of the Nemours Children’s Health System in the Delaware Valley and Jefferson University Hospitals in Philadelphia. Families rated their satisfaction on a five-point scale for various factors including physician care, nurse care, and personal concern.

The researchers say knowing what kinds of care expectations patients have in different settings, be it the emergency department or an inpatient ward, could help tailor interventions.

Cardin is hopeful that’s true, but she notes that patient satisfaction is a complex issue. A hospitalist could deliver perfect care, but if the patient had a bad experience at the hospital’s front door, the actual care delivery scores may be affected.

“It would be nice if there were just one variable to manipulate,” she says. “There are so many different impacts on [satisfaction]. What do we really have the ability to control?”

View our website for more information on inpatient satisfaction.

NEW YORK - Catheter ablation is favored for the management of most forms of supraventricular tachycardia (SVT) in adults, according to revised guidelines from the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS).

SVT affects 2.25 in 1000 individuals in the general population, with about 89,000 new cases of paroxysmal SVT (PSVT) per year. Women are twice as likely as men and individuals older than 65 are more than five times as likely as younger people to develop PSVT.

To provide a contemporary guideline for managing adults with all types of SVT except atrial fibrillation, ACC/AHA/HRS have now updated their 2003 guidelines.

Included are recommendations for managing sinus tachyarrhythmias, nonsinus focal atrial tachycardia and multifocal atrial tachycardia (MAT), atrioventricular nodal reentrant tachycardia (AVNRT), manifest and concealed accessory pathways, atrial flutter, and junctional tachycardia.

"Despite a 12-year gap in the update for these guidelines, there have been very few advances in antiarrhythmic drug therapy to offer patients with SVT," Dr. Gregory F. Michaud, director of the Center for Advanced Management of Atrial Fibrillation at Brigham and Women's Hospital in Boston, said by email.

"Catheter ablation has taken a stronger foothold in the chronic treatment of SVT and as such many physicians and patients are opting for invasive therapy earlier in the course of therapy," said Dr. Michaud, who wasn't involved in the guidelines.

The guidelines recommend vagal maneuvers, various drugs, and/or cardioversion as acute treatments, depending on the specific cause of SVT.

For most forms of symptomatic SVT, including those of unknown mechanism, the guidelines recommend electrophysiological (EP) studies and catheter ablation as definitive treatment for patients willing to undergo them, especially if medical therapy is ineffective.

Cardiac mapping is performed during EP studies to identify the site of origin of the arrhythmia or areas of critical conduction to allow targeting of ablation.

"One exception is inappropriate sinus tachycardia (IST) for which a more effective drug, ivabradine, is now available in the United States," Dr. Michaud said. "Catheter ablation is generally ineffective for IST patients."

Besides evaluation and treatment of possible reversible causes of IST, the guidelines recommend ivabradine, beta blockers, or their combination.

"SVT is generally not a life-threatening condition and treatment is based on eliminating symptoms and improving patient quality of life," Dr. Michaud explained. "However, physicians should be aware of three conditions associated with SVT that may be serious. First, sudden death is associated with the WPW (Wolff-Parkinson-White) syndrome and these patients, even if asymptomatic, should be referred to a cardiac electrophysiologist to consider management options."

He continued, "Second, SVT can cause cardiomyopathy and heart failure when incessant, even if the patient is asymptomatic. These patients should also be referred to a cardiac electrophysiologist to consider definitive therapy.

Third, patients with atrial flutter should be considered for oral anticoagulation to prevent stroke using the CHADS-Vasc risk scoring system, just as you would for patients with atrial fibrillation."

Dr. Michaud added, "Putting aside cost as an issue, there is significant regional variability in the accessibility of electrophysiologists or cardiologists with arrhythmia expertise. In my area, for instance, electrophysiologists are plentiful, and patients with SVT are often sent to us directly for further evaluation and treatment. Furthermore, training in arrhythmia management has become the purview of clinical cardiac electrophysiology, and many recently trained cardiologists are not as comfortable as their predecessors in managing patients with SVT."

The full report appears in the September 23 Journal of the American College of Cardiology online and was copublished in Circulation and Heart Rhythm.

Dr. Richard L. Page and Dr. Jose A. Joglar, chair and vice chair of the writing committee, did not respond to a request for comments.

NEW YORK - Catheter ablation is favored for the management of most forms of supraventricular tachycardia (SVT) in adults, according to revised guidelines from the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS).

SVT affects 2.25 in 1000 individuals in the general population, with about 89,000 new cases of paroxysmal SVT (PSVT) per year. Women are twice as likely as men and individuals older than 65 are more than five times as likely as younger people to develop PSVT.

To provide a contemporary guideline for managing adults with all types of SVT except atrial fibrillation, ACC/AHA/HRS have now updated their 2003 guidelines.

Included are recommendations for managing sinus tachyarrhythmias, nonsinus focal atrial tachycardia and multifocal atrial tachycardia (MAT), atrioventricular nodal reentrant tachycardia (AVNRT), manifest and concealed accessory pathways, atrial flutter, and junctional tachycardia.

"Despite a 12-year gap in the update for these guidelines, there have been very few advances in antiarrhythmic drug therapy to offer patients with SVT," Dr. Gregory F. Michaud, director of the Center for Advanced Management of Atrial Fibrillation at Brigham and Women's Hospital in Boston, said by email.

"Catheter ablation has taken a stronger foothold in the chronic treatment of SVT and as such many physicians and patients are opting for invasive therapy earlier in the course of therapy," said Dr. Michaud, who wasn't involved in the guidelines.

The guidelines recommend vagal maneuvers, various drugs, and/or cardioversion as acute treatments, depending on the specific cause of SVT.

For most forms of symptomatic SVT, including those of unknown mechanism, the guidelines recommend electrophysiological (EP) studies and catheter ablation as definitive treatment for patients willing to undergo them, especially if medical therapy is ineffective.

Cardiac mapping is performed during EP studies to identify the site of origin of the arrhythmia or areas of critical conduction to allow targeting of ablation.

"One exception is inappropriate sinus tachycardia (IST) for which a more effective drug, ivabradine, is now available in the United States," Dr. Michaud said. "Catheter ablation is generally ineffective for IST patients."

Besides evaluation and treatment of possible reversible causes of IST, the guidelines recommend ivabradine, beta blockers, or their combination.

"SVT is generally not a life-threatening condition and treatment is based on eliminating symptoms and improving patient quality of life," Dr. Michaud explained. "However, physicians should be aware of three conditions associated with SVT that may be serious. First, sudden death is associated with the WPW (Wolff-Parkinson-White) syndrome and these patients, even if asymptomatic, should be referred to a cardiac electrophysiologist to consider management options."

He continued, "Second, SVT can cause cardiomyopathy and heart failure when incessant, even if the patient is asymptomatic. These patients should also be referred to a cardiac electrophysiologist to consider definitive therapy.

Third, patients with atrial flutter should be considered for oral anticoagulation to prevent stroke using the CHADS-Vasc risk scoring system, just as you would for patients with atrial fibrillation."

Dr. Michaud added, "Putting aside cost as an issue, there is significant regional variability in the accessibility of electrophysiologists or cardiologists with arrhythmia expertise. In my area, for instance, electrophysiologists are plentiful, and patients with SVT are often sent to us directly for further evaluation and treatment. Furthermore, training in arrhythmia management has become the purview of clinical cardiac electrophysiology, and many recently trained cardiologists are not as comfortable as their predecessors in managing patients with SVT."

The full report appears in the September 23 Journal of the American College of Cardiology online and was copublished in Circulation and Heart Rhythm.

Dr. Richard L. Page and Dr. Jose A. Joglar, chair and vice chair of the writing committee, did not respond to a request for comments.

NEW YORK - Catheter ablation is favored for the management of most forms of supraventricular tachycardia (SVT) in adults, according to revised guidelines from the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS).

SVT affects 2.25 in 1000 individuals in the general population, with about 89,000 new cases of paroxysmal SVT (PSVT) per year. Women are twice as likely as men and individuals older than 65 are more than five times as likely as younger people to develop PSVT.

To provide a contemporary guideline for managing adults with all types of SVT except atrial fibrillation, ACC/AHA/HRS have now updated their 2003 guidelines.

Included are recommendations for managing sinus tachyarrhythmias, nonsinus focal atrial tachycardia and multifocal atrial tachycardia (MAT), atrioventricular nodal reentrant tachycardia (AVNRT), manifest and concealed accessory pathways, atrial flutter, and junctional tachycardia.

"Despite a 12-year gap in the update for these guidelines, there have been very few advances in antiarrhythmic drug therapy to offer patients with SVT," Dr. Gregory F. Michaud, director of the Center for Advanced Management of Atrial Fibrillation at Brigham and Women's Hospital in Boston, said by email.

"Catheter ablation has taken a stronger foothold in the chronic treatment of SVT and as such many physicians and patients are opting for invasive therapy earlier in the course of therapy," said Dr. Michaud, who wasn't involved in the guidelines.

The guidelines recommend vagal maneuvers, various drugs, and/or cardioversion as acute treatments, depending on the specific cause of SVT.

For most forms of symptomatic SVT, including those of unknown mechanism, the guidelines recommend electrophysiological (EP) studies and catheter ablation as definitive treatment for patients willing to undergo them, especially if medical therapy is ineffective.

Cardiac mapping is performed during EP studies to identify the site of origin of the arrhythmia or areas of critical conduction to allow targeting of ablation.

"One exception is inappropriate sinus tachycardia (IST) for which a more effective drug, ivabradine, is now available in the United States," Dr. Michaud said. "Catheter ablation is generally ineffective for IST patients."

Besides evaluation and treatment of possible reversible causes of IST, the guidelines recommend ivabradine, beta blockers, or their combination.

"SVT is generally not a life-threatening condition and treatment is based on eliminating symptoms and improving patient quality of life," Dr. Michaud explained. "However, physicians should be aware of three conditions associated with SVT that may be serious. First, sudden death is associated with the WPW (Wolff-Parkinson-White) syndrome and these patients, even if asymptomatic, should be referred to a cardiac electrophysiologist to consider management options."

He continued, "Second, SVT can cause cardiomyopathy and heart failure when incessant, even if the patient is asymptomatic. These patients should also be referred to a cardiac electrophysiologist to consider definitive therapy.

Third, patients with atrial flutter should be considered for oral anticoagulation to prevent stroke using the CHADS-Vasc risk scoring system, just as you would for patients with atrial fibrillation."

Dr. Michaud added, "Putting aside cost as an issue, there is significant regional variability in the accessibility of electrophysiologists or cardiologists with arrhythmia expertise. In my area, for instance, electrophysiologists are plentiful, and patients with SVT are often sent to us directly for further evaluation and treatment. Furthermore, training in arrhythmia management has become the purview of clinical cardiac electrophysiology, and many recently trained cardiologists are not as comfortable as their predecessors in managing patients with SVT."

The full report appears in the September 23 Journal of the American College of Cardiology online and was copublished in Circulation and Heart Rhythm.

Dr. Richard L. Page and Dr. Jose A. Joglar, chair and vice chair of the writing committee, did not respond to a request for comments.

NEW YORK - Hospital resources, and not necessarily patient characteristics, may be causing safety-net hospitals to deliver inferior surgical outcomes at increased cost in elective surgical procedures, according to a new study.

"Analysis of Medicare Hospital Compare data revealed that safety-net hospitals perform worse on Surgical Care Improvement Project (SCIP) measures and have less efficient emergency departments throughput," first author Dr. Richard S. Hoehn from the University of Cincinnati, Ohio, said by email. "This last category indicates that these hospitals have insufficient staffing and/or resources to handle their patient burden."

"Safety-net hospitals care for a vulnerable population and maintain an open door to all patients, regardless of their ability to pay. Our study of nine major surgical procedures at academic medical centers in the United States found that hospitals with the highest safety net burden have the most patients of low socioeconomic status, extreme severity of illness, and in need of urgent surgery," Dr. Hoehn said.

"These hospitals also had the worst mortality and readmission rates and highest costs for most procedures. After controlling for patient age, race, severity of illness, and socioeconomic status, safety-net hospitals still had worse outcomes. Their inferior mortality and readmission rates were somewhat reduced, but the increased costs observed at these centers persisted, implying that other characteristics intrinsic to safety-net hospitals are associated with increased costs," he added.

Dr. Hoehn and colleagues analyzed outcomes for nine surgical procedures at 231 hospitals in the University HealthSystem Consortium over a four-year period ending in 2012, accounting for more than 12.6 million patient encounters. They sorted the hospitals into high safety-net burden (HBH) versus hospitals with low (LBH) or medium (MBH) safety-net burden.

They found the HBHs overall to have the most patients likely to be young, black, have the lowest socioeconomic status, and have the highest severity of illness and the highest cost for surgical care (p<0.01 for all). They also had the highest proportion of patient-emergent cases and the longest lengths of stay (p<0.01 for all).

After the researchers adjusted for patient characteristics and hospital volume, the HBHs still had higher odds ratios of mortality for three procedures (OR, 1.81 to 2.08, p<0.05), readmission for two procedures (OR, 1.19 to 1.30, p<0.05), and the highest cost of care for seven procedures (risk ratios, 1.23 to 1.35, p<0.05).

Postoperative mortality was worse for colectomy, esophagectomy, pancreaticoduodenectomy, and ventral hernia repair. Readmission odds were higher for coronary artery bypass, colectomy, kidney transplant, and ventral hernia repair.

"[W]hen assessing markers of emergency department throughput, HBHs were inferior to LBHs in all measures, including time from arrival to evaluation, admission decision time, times from arrival to departure for discharged and admitted patients, time for pain medicine administration to patients with long-bone fractures, and patients who left without being seen (p <= 0.002 for all)," the researchers write in JAMA Surgery, online October 14.

In an accompanying editorial, Dr. Larry R. Kaiser of Temple University School of Medicine, Philadelphia, and colleagues note, "At best, emergency department throughput as a surrogate for staffing adequacy and systems efficiency is an indirect estimate of these important hospital factors. Deficiencies in documentation and coding may or may not be influenced by overall hospital performance but could have a significant influence on expected rates of death and complications."

Dr. Kaiser said by email, "Physicians and surgeons should be very careful in drawing substantive conclusions from the study because of factors we don't know about these patients. Let the message be greater resources should be provided to those hospitals bearing the burden of caring for this underserved population of patients who, if anything, are more complex than commercially insured patients with similar problems."

"It's important to acknowledge that this study is not trying to criticize safety-net hospitals," Dr. Hoehn emphasized. "We are trying to highlight the unique situation these providers face, and also show that current policy changes that financially penalize these hospitals may adversely impact surgical care and further exacerbate the disparities in health care that already exist in our country. Safety-net hospitals in America have always been important institutions that train doctors and care for indigent patients, and our goal is to find a way to preserve this model in the face of changing healthcare policy."

Dr. Hoehn continued, "There are two options to improve the care at these centers: either close these hospitals and send their patients elsewhere or invest in initiatives that will allow these hospitals to improve not only their outcomes but also their efficiency. To do this, we must better understand their needs."

Dr. Kaiser said, "Continued scrutiny of outcomes with transparency and sharing of data with all those involved in the care of patients will result in continued quality improvement. Participation in [universal health care] that allows institutions to benchmark their data with similar institutions will tend to push those who need improvement to continue to improve."

"There must be a concerted effort among all involved in caring for patients at an institution to continue to improve quality. The designation of a chief quality officer working in concert with the chief medical officer also is critically important in working toward improved quality. But all of this depends on accurate recording and reporting of quality metrics," he concluded.

NEW YORK - Hospital resources, and not necessarily patient characteristics, may be causing safety-net hospitals to deliver inferior surgical outcomes at increased cost in elective surgical procedures, according to a new study.

"Analysis of Medicare Hospital Compare data revealed that safety-net hospitals perform worse on Surgical Care Improvement Project (SCIP) measures and have less efficient emergency departments throughput," first author Dr. Richard S. Hoehn from the University of Cincinnati, Ohio, said by email. "This last category indicates that these hospitals have insufficient staffing and/or resources to handle their patient burden."

"Safety-net hospitals care for a vulnerable population and maintain an open door to all patients, regardless of their ability to pay. Our study of nine major surgical procedures at academic medical centers in the United States found that hospitals with the highest safety net burden have the most patients of low socioeconomic status, extreme severity of illness, and in need of urgent surgery," Dr. Hoehn said.

"These hospitals also had the worst mortality and readmission rates and highest costs for most procedures. After controlling for patient age, race, severity of illness, and socioeconomic status, safety-net hospitals still had worse outcomes. Their inferior mortality and readmission rates were somewhat reduced, but the increased costs observed at these centers persisted, implying that other characteristics intrinsic to safety-net hospitals are associated with increased costs," he added.

Dr. Hoehn and colleagues analyzed outcomes for nine surgical procedures at 231 hospitals in the University HealthSystem Consortium over a four-year period ending in 2012, accounting for more than 12.6 million patient encounters. They sorted the hospitals into high safety-net burden (HBH) versus hospitals with low (LBH) or medium (MBH) safety-net burden.

They found the HBHs overall to have the most patients likely to be young, black, have the lowest socioeconomic status, and have the highest severity of illness and the highest cost for surgical care (p<0.01 for all). They also had the highest proportion of patient-emergent cases and the longest lengths of stay (p<0.01 for all).

After the researchers adjusted for patient characteristics and hospital volume, the HBHs still had higher odds ratios of mortality for three procedures (OR, 1.81 to 2.08, p<0.05), readmission for two procedures (OR, 1.19 to 1.30, p<0.05), and the highest cost of care for seven procedures (risk ratios, 1.23 to 1.35, p<0.05).

Postoperative mortality was worse for colectomy, esophagectomy, pancreaticoduodenectomy, and ventral hernia repair. Readmission odds were higher for coronary artery bypass, colectomy, kidney transplant, and ventral hernia repair.

"[W]hen assessing markers of emergency department throughput, HBHs were inferior to LBHs in all measures, including time from arrival to evaluation, admission decision time, times from arrival to departure for discharged and admitted patients, time for pain medicine administration to patients with long-bone fractures, and patients who left without being seen (p <= 0.002 for all)," the researchers write in JAMA Surgery, online October 14.

In an accompanying editorial, Dr. Larry R. Kaiser of Temple University School of Medicine, Philadelphia, and colleagues note, "At best, emergency department throughput as a surrogate for staffing adequacy and systems efficiency is an indirect estimate of these important hospital factors. Deficiencies in documentation and coding may or may not be influenced by overall hospital performance but could have a significant influence on expected rates of death and complications."

Dr. Kaiser said by email, "Physicians and surgeons should be very careful in drawing substantive conclusions from the study because of factors we don't know about these patients. Let the message be greater resources should be provided to those hospitals bearing the burden of caring for this underserved population of patients who, if anything, are more complex than commercially insured patients with similar problems."

"It's important to acknowledge that this study is not trying to criticize safety-net hospitals," Dr. Hoehn emphasized. "We are trying to highlight the unique situation these providers face, and also show that current policy changes that financially penalize these hospitals may adversely impact surgical care and further exacerbate the disparities in health care that already exist in our country. Safety-net hospitals in America have always been important institutions that train doctors and care for indigent patients, and our goal is to find a way to preserve this model in the face of changing healthcare policy."

Dr. Hoehn continued, "There are two options to improve the care at these centers: either close these hospitals and send their patients elsewhere or invest in initiatives that will allow these hospitals to improve not only their outcomes but also their efficiency. To do this, we must better understand their needs."

Dr. Kaiser said, "Continued scrutiny of outcomes with transparency and sharing of data with all those involved in the care of patients will result in continued quality improvement. Participation in [universal health care] that allows institutions to benchmark their data with similar institutions will tend to push those who need improvement to continue to improve."

"There must be a concerted effort among all involved in caring for patients at an institution to continue to improve quality. The designation of a chief quality officer working in concert with the chief medical officer also is critically important in working toward improved quality. But all of this depends on accurate recording and reporting of quality metrics," he concluded.

NEW YORK - Hospital resources, and not necessarily patient characteristics, may be causing safety-net hospitals to deliver inferior surgical outcomes at increased cost in elective surgical procedures, according to a new study.

"Analysis of Medicare Hospital Compare data revealed that safety-net hospitals perform worse on Surgical Care Improvement Project (SCIP) measures and have less efficient emergency departments throughput," first author Dr. Richard S. Hoehn from the University of Cincinnati, Ohio, said by email. "This last category indicates that these hospitals have insufficient staffing and/or resources to handle their patient burden."

"Safety-net hospitals care for a vulnerable population and maintain an open door to all patients, regardless of their ability to pay. Our study of nine major surgical procedures at academic medical centers in the United States found that hospitals with the highest safety net burden have the most patients of low socioeconomic status, extreme severity of illness, and in need of urgent surgery," Dr. Hoehn said.

"These hospitals also had the worst mortality and readmission rates and highest costs for most procedures. After controlling for patient age, race, severity of illness, and socioeconomic status, safety-net hospitals still had worse outcomes. Their inferior mortality and readmission rates were somewhat reduced, but the increased costs observed at these centers persisted, implying that other characteristics intrinsic to safety-net hospitals are associated with increased costs," he added.

Dr. Hoehn and colleagues analyzed outcomes for nine surgical procedures at 231 hospitals in the University HealthSystem Consortium over a four-year period ending in 2012, accounting for more than 12.6 million patient encounters. They sorted the hospitals into high safety-net burden (HBH) versus hospitals with low (LBH) or medium (MBH) safety-net burden.

They found the HBHs overall to have the most patients likely to be young, black, have the lowest socioeconomic status, and have the highest severity of illness and the highest cost for surgical care (p<0.01 for all). They also had the highest proportion of patient-emergent cases and the longest lengths of stay (p<0.01 for all).

After the researchers adjusted for patient characteristics and hospital volume, the HBHs still had higher odds ratios of mortality for three procedures (OR, 1.81 to 2.08, p<0.05), readmission for two procedures (OR, 1.19 to 1.30, p<0.05), and the highest cost of care for seven procedures (risk ratios, 1.23 to 1.35, p<0.05).

Postoperative mortality was worse for colectomy, esophagectomy, pancreaticoduodenectomy, and ventral hernia repair. Readmission odds were higher for coronary artery bypass, colectomy, kidney transplant, and ventral hernia repair.

"[W]hen assessing markers of emergency department throughput, HBHs were inferior to LBHs in all measures, including time from arrival to evaluation, admission decision time, times from arrival to departure for discharged and admitted patients, time for pain medicine administration to patients with long-bone fractures, and patients who left without being seen (p <= 0.002 for all)," the researchers write in JAMA Surgery, online October 14.

In an accompanying editorial, Dr. Larry R. Kaiser of Temple University School of Medicine, Philadelphia, and colleagues note, "At best, emergency department throughput as a surrogate for staffing adequacy and systems efficiency is an indirect estimate of these important hospital factors. Deficiencies in documentation and coding may or may not be influenced by overall hospital performance but could have a significant influence on expected rates of death and complications."

Dr. Kaiser said by email, "Physicians and surgeons should be very careful in drawing substantive conclusions from the study because of factors we don't know about these patients. Let the message be greater resources should be provided to those hospitals bearing the burden of caring for this underserved population of patients who, if anything, are more complex than commercially insured patients with similar problems."

"It's important to acknowledge that this study is not trying to criticize safety-net hospitals," Dr. Hoehn emphasized. "We are trying to highlight the unique situation these providers face, and also show that current policy changes that financially penalize these hospitals may adversely impact surgical care and further exacerbate the disparities in health care that already exist in our country. Safety-net hospitals in America have always been important institutions that train doctors and care for indigent patients, and our goal is to find a way to preserve this model in the face of changing healthcare policy."

Dr. Hoehn continued, "There are two options to improve the care at these centers: either close these hospitals and send their patients elsewhere or invest in initiatives that will allow these hospitals to improve not only their outcomes but also their efficiency. To do this, we must better understand their needs."

Dr. Kaiser said, "Continued scrutiny of outcomes with transparency and sharing of data with all those involved in the care of patients will result in continued quality improvement. Participation in [universal health care] that allows institutions to benchmark their data with similar institutions will tend to push those who need improvement to continue to improve."

"There must be a concerted effort among all involved in caring for patients at an institution to continue to improve quality. The designation of a chief quality officer working in concert with the chief medical officer also is critically important in working toward improved quality. But all of this depends on accurate recording and reporting of quality metrics," he concluded.

Two medical students who participated in SHM's inaugural Student Hospitalist program, Mimi Zander, now a second year student at Touro College of Osteopathic Medicine in New York City, and Frank Zadravecz, a second year student at the University of Illinois College of Medicine at Chicago, share their thoughts about their part in the future of hospital medicine.

Two medical students who participated in SHM's inaugural Student Hospitalist program, Mimi Zander, now a second year student at Touro College of Osteopathic Medicine in New York City, and Frank Zadravecz, a second year student at the University of Illinois College of Medicine at Chicago, share their thoughts about their part in the future of hospital medicine.

Two medical students who participated in SHM's inaugural Student Hospitalist program, Mimi Zander, now a second year student at Touro College of Osteopathic Medicine in New York City, and Frank Zadravecz, a second year student at the University of Illinois College of Medicine at Chicago, share their thoughts about their part in the future of hospital medicine.

Families may spend almost twice as much caring for dementia patients at the end of life than they might if their loved one suffered from a different disease, a U.S. study suggests.

Costs paid by Medicare, the U.S. health insurance program for the elderly, were similar over the final five years of life for patients with dementia, heart disease, cancer and other conditions, according to the study published in the Annals of Internal Medicine.

But the average out-of-pocket costs absorbed by families of dementia patients totaled $61,522 over those five years, far greater than the typical tab of $34,068 for patients without dementia.

"Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision to bathing and feeding, may span several years," lead author Dr. Amy Kelley of the Icahn School of Medicine at Mount Sinai in New York said by email.

To assess the financial toll dementia takes on families, Dr. Kelley and colleagues analyzed Medicare spending and out-of-pocket costs for about 1,700 people aged 70 and older who died between 2005 and 2010.

Over the five years prior to each patient's date of death, the average total cost, including what Medicare covered as well as what families paid, was about $287,000 for dementia patients. That compares with roughly $175,000 for heart disease, $173,000 for cancer, and $197,000 for people who died of other causes.

Families caring for dementia patients also spent a greater proportion of their wealth than families helping loved ones with other conditions. The financial burden as a proportion of wealth was even more pronounced for patients who were black, had less than a high school education, or were unmarried or widowed women.

Shortcomings of the study include the possibility that insurance payments may have been underestimated as well as the lack of data on wages family members may have lost while caring for their loved ones, the authors acknowledge.

In addition, researchers measured only the probability of dementia and not whether the patients actually had dementia, the authors note. Few death certificates for patients with dementia will list that as the primary cause; instead, they report the problem that actually caused the patient to die, such as pneumonia.

Even so, the study findings highlight a financial burden posed by end-of-life care for elderly dementia patients that care reverberate through multiple generations, noted Carol Levine, director of the Families and Health Care Project at the United Hospital Fund, an independent policy group in New York City.

"There is a cascading effect: the financial drain for the older person's care means fewer resources not only for the caregiver but also for the younger generation's education and future prospects," Levine, who wasn't involved in the study, said by email.

"The immediate need for assistance is so compelling that future needs are often disregarded," Levine added. "The impact is greatest on families with the fewest resources to start with."

Many families also run into financial trouble because they mistakenly believe Medicare will pay for long term care services, said Dr. Mark Lachs, an expert in aging and finances at Weill Cornell Medical College in New York who wasn't involved in the study.

Families may consider long term care insurance to cover this gap in Medicare benefits, Dr. Lachs said by email.

Policy changes that might pay family members to be dementia caregivers would also help ease the financial strain, Dr. Lachs added.

Families may spend almost twice as much caring for dementia patients at the end of life than they might if their loved one suffered from a different disease, a U.S. study suggests.

Costs paid by Medicare, the U.S. health insurance program for the elderly, were similar over the final five years of life for patients with dementia, heart disease, cancer and other conditions, according to the study published in the Annals of Internal Medicine.

But the average out-of-pocket costs absorbed by families of dementia patients totaled $61,522 over those five years, far greater than the typical tab of $34,068 for patients without dementia.

"Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision to bathing and feeding, may span several years," lead author Dr. Amy Kelley of the Icahn School of Medicine at Mount Sinai in New York said by email.

To assess the financial toll dementia takes on families, Dr. Kelley and colleagues analyzed Medicare spending and out-of-pocket costs for about 1,700 people aged 70 and older who died between 2005 and 2010.

Over the five years prior to each patient's date of death, the average total cost, including what Medicare covered as well as what families paid, was about $287,000 for dementia patients. That compares with roughly $175,000 for heart disease, $173,000 for cancer, and $197,000 for people who died of other causes.

Families caring for dementia patients also spent a greater proportion of their wealth than families helping loved ones with other conditions. The financial burden as a proportion of wealth was even more pronounced for patients who were black, had less than a high school education, or were unmarried or widowed women.

Shortcomings of the study include the possibility that insurance payments may have been underestimated as well as the lack of data on wages family members may have lost while caring for their loved ones, the authors acknowledge.

In addition, researchers measured only the probability of dementia and not whether the patients actually had dementia, the authors note. Few death certificates for patients with dementia will list that as the primary cause; instead, they report the problem that actually caused the patient to die, such as pneumonia.

Even so, the study findings highlight a financial burden posed by end-of-life care for elderly dementia patients that care reverberate through multiple generations, noted Carol Levine, director of the Families and Health Care Project at the United Hospital Fund, an independent policy group in New York City.

"There is a cascading effect: the financial drain for the older person's care means fewer resources not only for the caregiver but also for the younger generation's education and future prospects," Levine, who wasn't involved in the study, said by email.

"The immediate need for assistance is so compelling that future needs are often disregarded," Levine added. "The impact is greatest on families with the fewest resources to start with."

Many families also run into financial trouble because they mistakenly believe Medicare will pay for long term care services, said Dr. Mark Lachs, an expert in aging and finances at Weill Cornell Medical College in New York who wasn't involved in the study.

Families may consider long term care insurance to cover this gap in Medicare benefits, Dr. Lachs said by email.

Policy changes that might pay family members to be dementia caregivers would also help ease the financial strain, Dr. Lachs added.

Families may spend almost twice as much caring for dementia patients at the end of life than they might if their loved one suffered from a different disease, a U.S. study suggests.

Costs paid by Medicare, the U.S. health insurance program for the elderly, were similar over the final five years of life for patients with dementia, heart disease, cancer and other conditions, according to the study published in the Annals of Internal Medicine.

But the average out-of-pocket costs absorbed by families of dementia patients totaled $61,522 over those five years, far greater than the typical tab of $34,068 for patients without dementia.

"Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision to bathing and feeding, may span several years," lead author Dr. Amy Kelley of the Icahn School of Medicine at Mount Sinai in New York said by email.

To assess the financial toll dementia takes on families, Dr. Kelley and colleagues analyzed Medicare spending and out-of-pocket costs for about 1,700 people aged 70 and older who died between 2005 and 2010.

Over the five years prior to each patient's date of death, the average total cost, including what Medicare covered as well as what families paid, was about $287,000 for dementia patients. That compares with roughly $175,000 for heart disease, $173,000 for cancer, and $197,000 for people who died of other causes.

Families caring for dementia patients also spent a greater proportion of their wealth than families helping loved ones with other conditions. The financial burden as a proportion of wealth was even more pronounced for patients who were black, had less than a high school education, or were unmarried or widowed women.

Shortcomings of the study include the possibility that insurance payments may have been underestimated as well as the lack of data on wages family members may have lost while caring for their loved ones, the authors acknowledge.

In addition, researchers measured only the probability of dementia and not whether the patients actually had dementia, the authors note. Few death certificates for patients with dementia will list that as the primary cause; instead, they report the problem that actually caused the patient to die, such as pneumonia.

Even so, the study findings highlight a financial burden posed by end-of-life care for elderly dementia patients that care reverberate through multiple generations, noted Carol Levine, director of the Families and Health Care Project at the United Hospital Fund, an independent policy group in New York City.

"There is a cascading effect: the financial drain for the older person's care means fewer resources not only for the caregiver but also for the younger generation's education and future prospects," Levine, who wasn't involved in the study, said by email.

"The immediate need for assistance is so compelling that future needs are often disregarded," Levine added. "The impact is greatest on families with the fewest resources to start with."

Many families also run into financial trouble because they mistakenly believe Medicare will pay for long term care services, said Dr. Mark Lachs, an expert in aging and finances at Weill Cornell Medical College in New York who wasn't involved in the study.

Families may consider long term care insurance to cover this gap in Medicare benefits, Dr. Lachs said by email.

Policy changes that might pay family members to be dementia caregivers would also help ease the financial strain, Dr. Lachs added.

NEW YORK - Outpatient care may cost more when hospitals own the medical practices or employ the physicians, a U.S. study suggests.

Hospital employment of doctors and ownership of physician practices has grown over the past decade as health care providers seek to curb expenses with economies of scale and deliver better-coordinated treatment to patients.

Research reported in an article online October 19 in JAMA Internal Medicine examined how the rise of tighter financial integration between doctors and hospitals affected costs for people enrolled in private health insurance plans from 2008 to 2012.

In communities with the sharpest increase in financial integration between doctors and hospitals over the study period, average annual outpatient costs for each person with private health insurance increased by $75, while the amount of outpatient services they used was little changed.

"We document an increase in spending driven by prices, without any change in utilization," lead author Hannah Neprash, a health policy researcher at Harvard University in Boston, said by email.

"Some price increases may be acceptable - particularly if they are accompanied with improved quality of care," Neprash added. This study, however, didn't look at changes in quality associated with physician-hospital integration, she said.

Using Medicare claims data for 240 metropolitan areas nationwide, the researchers identified physicians who were either directly employed by hospitals or who worked for practices owned by hospitals.

Overall, the proportion of physicians with close financial ties to hospitals rose from 18% in 2008 to 21.3% in 2012.

Next, the researchers analyzed spending and prices for nearly 7.4 million non-elderly adults in these regions with two common types of private health insurance coverage: preferred-provider organizations (PPO) or point-of-service (POS) plans. These types of insurance may tie patients' out-of-pocket fees to the prices doctors charge.

The cost increase seen with greater financial integration of doctors and hospitals was confined to outpatient spending, bringing the average outpatient cost per enrollee in the PPO and POS plans in 2012 to about $2,400.

The average cost of $872 for inpatient treatments, however, was unaffected by financial ties between doctors and hospitals, the study found.

One shortcoming of the study is that the researchers didn't assess quality of care, the authors acknowledge. Better quality outpatient care might justify higher prices, they note.

Newer payment arrangements, however, are starting to hold providers more accountable for both inpatient and outpatient spending and for outcomes, senior study author Dr. J. Michael McWilliams of Harvard Medical School and Brigham and Women's Hospital in Boston, said by email.

Over time, this means "physician-hospital integration could conceivably offer some distinct efficiencies in terms of higher quality of care at a lower cost," Dr. McWilliams said.

Still, price hikes for people with private insurance - often provided to U.S. workers by their employers - are probably going to lead to higher out-of-pocket costs for patients, noted Dr. James Reschovsky and Dr. Eugene Rich of Mathematica Policy Research in Washington, D.C., in an accompanying editorial.

"The higher prices in hospital outpatient departments are passed on to employers in the form of higher premiums, and ultimately to workers in the form of less generous health benefits, higher premium cost sharing, or lower wages," Dr. Reschovsky said by email. "Certainly patients with co-insurance would pay more out-of-pocket when the price of service is higher."

The Robert Wood Johnson Foundation supported this research. One coauthor reported being formerly employed by Truven Health Analytics.

NEW YORK - Outpatient care may cost more when hospitals own the medical practices or employ the physicians, a U.S. study suggests.

Hospital employment of doctors and ownership of physician practices has grown over the past decade as health care providers seek to curb expenses with economies of scale and deliver better-coordinated treatment to patients.

Research reported in an article online October 19 in JAMA Internal Medicine examined how the rise of tighter financial integration between doctors and hospitals affected costs for people enrolled in private health insurance plans from 2008 to 2012.

In communities with the sharpest increase in financial integration between doctors and hospitals over the study period, average annual outpatient costs for each person with private health insurance increased by $75, while the amount of outpatient services they used was little changed.

"We document an increase in spending driven by prices, without any change in utilization," lead author Hannah Neprash, a health policy researcher at Harvard University in Boston, said by email.

"Some price increases may be acceptable - particularly if they are accompanied with improved quality of care," Neprash added. This study, however, didn't look at changes in quality associated with physician-hospital integration, she said.

Using Medicare claims data for 240 metropolitan areas nationwide, the researchers identified physicians who were either directly employed by hospitals or who worked for practices owned by hospitals.

Overall, the proportion of physicians with close financial ties to hospitals rose from 18% in 2008 to 21.3% in 2012.

Next, the researchers analyzed spending and prices for nearly 7.4 million non-elderly adults in these regions with two common types of private health insurance coverage: preferred-provider organizations (PPO) or point-of-service (POS) plans. These types of insurance may tie patients' out-of-pocket fees to the prices doctors charge.

The cost increase seen with greater financial integration of doctors and hospitals was confined to outpatient spending, bringing the average outpatient cost per enrollee in the PPO and POS plans in 2012 to about $2,400.

The average cost of $872 for inpatient treatments, however, was unaffected by financial ties between doctors and hospitals, the study found.

One shortcoming of the study is that the researchers didn't assess quality of care, the authors acknowledge. Better quality outpatient care might justify higher prices, they note.

Newer payment arrangements, however, are starting to hold providers more accountable for both inpatient and outpatient spending and for outcomes, senior study author Dr. J. Michael McWilliams of Harvard Medical School and Brigham and Women's Hospital in Boston, said by email.

Over time, this means "physician-hospital integration could conceivably offer some distinct efficiencies in terms of higher quality of care at a lower cost," Dr. McWilliams said.

Still, price hikes for people with private insurance - often provided to U.S. workers by their employers - are probably going to lead to higher out-of-pocket costs for patients, noted Dr. James Reschovsky and Dr. Eugene Rich of Mathematica Policy Research in Washington, D.C., in an accompanying editorial.

"The higher prices in hospital outpatient departments are passed on to employers in the form of higher premiums, and ultimately to workers in the form of less generous health benefits, higher premium cost sharing, or lower wages," Dr. Reschovsky said by email. "Certainly patients with co-insurance would pay more out-of-pocket when the price of service is higher."

The Robert Wood Johnson Foundation supported this research. One coauthor reported being formerly employed by Truven Health Analytics.

NEW YORK - Outpatient care may cost more when hospitals own the medical practices or employ the physicians, a U.S. study suggests.

Hospital employment of doctors and ownership of physician practices has grown over the past decade as health care providers seek to curb expenses with economies of scale and deliver better-coordinated treatment to patients.

Research reported in an article online October 19 in JAMA Internal Medicine examined how the rise of tighter financial integration between doctors and hospitals affected costs for people enrolled in private health insurance plans from 2008 to 2012.

In communities with the sharpest increase in financial integration between doctors and hospitals over the study period, average annual outpatient costs for each person with private health insurance increased by $75, while the amount of outpatient services they used was little changed.

"We document an increase in spending driven by prices, without any change in utilization," lead author Hannah Neprash, a health policy researcher at Harvard University in Boston, said by email.

"Some price increases may be acceptable - particularly if they are accompanied with improved quality of care," Neprash added. This study, however, didn't look at changes in quality associated with physician-hospital integration, she said.

Using Medicare claims data for 240 metropolitan areas nationwide, the researchers identified physicians who were either directly employed by hospitals or who worked for practices owned by hospitals.

Overall, the proportion of physicians with close financial ties to hospitals rose from 18% in 2008 to 21.3% in 2012.

Next, the researchers analyzed spending and prices for nearly 7.4 million non-elderly adults in these regions with two common types of private health insurance coverage: preferred-provider organizations (PPO) or point-of-service (POS) plans. These types of insurance may tie patients' out-of-pocket fees to the prices doctors charge.

The cost increase seen with greater financial integration of doctors and hospitals was confined to outpatient spending, bringing the average outpatient cost per enrollee in the PPO and POS plans in 2012 to about $2,400.

The average cost of $872 for inpatient treatments, however, was unaffected by financial ties between doctors and hospitals, the study found.

One shortcoming of the study is that the researchers didn't assess quality of care, the authors acknowledge. Better quality outpatient care might justify higher prices, they note.

Newer payment arrangements, however, are starting to hold providers more accountable for both inpatient and outpatient spending and for outcomes, senior study author Dr. J. Michael McWilliams of Harvard Medical School and Brigham and Women's Hospital in Boston, said by email.

Over time, this means "physician-hospital integration could conceivably offer some distinct efficiencies in terms of higher quality of care at a lower cost," Dr. McWilliams said.

Still, price hikes for people with private insurance - often provided to U.S. workers by their employers - are probably going to lead to higher out-of-pocket costs for patients, noted Dr. James Reschovsky and Dr. Eugene Rich of Mathematica Policy Research in Washington, D.C., in an accompanying editorial.

"The higher prices in hospital outpatient departments are passed on to employers in the form of higher premiums, and ultimately to workers in the form of less generous health benefits, higher premium cost sharing, or lower wages," Dr. Reschovsky said by email. "Certainly patients with co-insurance would pay more out-of-pocket when the price of service is higher."

The Robert Wood Johnson Foundation supported this research. One coauthor reported being formerly employed by Truven Health Analytics.

NEW YORK - People with type 2 diabetes are 15 percent more likely to die from any cause and 14 percent more likely to die from a cardiovascular cause than non-diabetics at any given time, according to data from several Swedish registries.

The rates are significantly lower than previous estimates. Fifteen years ago, research was suggesting that having diabetes doubled the risk of premature death.

But the new study also found that the risk was dramatically elevated among people whose type 2 diabetes appeared by age 54. The worse their glycemic control and the more evidence of renal problems, the higher the risk.

In contrast, by age 75, type 2 diabetes posed little additional risk for people with good control and no kidney issues, according to the results.

"The overall increased risk of 15 percent among type 2 diabetics in general is a very low figure that has not been found in earlier type 2 diabetes studies," coauthor Dr. Marcus Lind of Uddevalla Hospital said in a telephone interview.

"The other thing that was interesting is that when we looked at patients with good glycemic control and no renal complications, if they were 75 years age, they had a lower risk than those in the general population. That hasn't been shown before," he said.

"What we are seeing is, if you are younger, aggressive management makes a difference," said Dr. Robert Ratner, chief scientific and medical officer of the American Diabetes Association, who was not involved in the research. At age 75, "you don't have to worry about it as much."

The study, published in the October 29 New England Journal of Medicine, is the largest to date to look at premature death in general - and death from cardiovascular causes in particular - among people with type 2 diabetes.

It compared more than 435,000 diabetics who were followed for a mean of 4.6 years with more than 2 million matched controls who were tracked for a mean of 4.8 years. The diabetics had had glucose problems for an average of 5.7 years.

In terms of actual death rates, cardiovascular mortality during the study period was 7.9 percent for diabetics versus 6.1 percent for controls (adjusted hazard ratio, 1.14; 95 percent confidence interval: 1.13-1.15). The respective rates for death from any cause were 17.7 percent and 14.5 percent (aHR, 1.15; 95 percent CI: 1.14-1.16).

For patients under age 55 with glycated hemoglobin levels below 7.0 percent, the risk of death from any cause nearly doubled (aHR, 1.92; 95 percent CI: 1.75-2.11).

"Those who are younger than 55, those who have target glycemic control and no signs of any renal complications, they had a clearly-elevated risk," said Dr. Lind.

But for people over 75, the hazard was actually 5 percent lower than it was for people without diabetes (aHR, 0.95; 95 percent CI: 0.94-0.96).

When the research team factored in people with normoalbuminuria, the risks were slightly mitigated.

Heart attack was the most common cause of death among diabetics.

When glycated hemoglobin levels were at 9.7 percent and higher for people below age 55, the hazard of death from any cause more than quadrupled. The hazard of death from cardiovascular causes rose more than five-fold.

Once again, the danger was far less extreme for people over 75, the researchers found.

"Excess mortality in type 2 diabetes was substantially higher with worsening glycemic control, severe renal complications, impaired renal function, and younger age," they concluded.

Renal function is a key element, Dr. Ratner said.

The study "reinforces the importance of early aggressive management of diabetes in order to prevent premature death and the fact is that the prevention of renal disease is probably the most potent thing we can do to reduce cardiovascular events," he said.

Dr. Lind said the risk may appear lower in the elderly because older people with diabetes are more likely to be getting aggressive treatment for their high blood pressure and high lipid levels, therapy that other people who also have hypertension and high cholesterol levels might not be receiving.

"I think that's the reason the rates are a bit lower" for seniors, he said.

Dr. Ratner said he believes the data for older diabetics simply reflects the fact that "you're seeing the survival cohort. They've made it past the difficult time."

We're all going to die, he said. "The issue is when does it happen? With diabetes, it's happening years ahead of time - in their 50s and early 60s, more so than when they reach 75. The younger you are, the greater that risk. That's when aggressive therapy should be given."

NEW YORK - People with type 2 diabetes are 15 percent more likely to die from any cause and 14 percent more likely to die from a cardiovascular cause than non-diabetics at any given time, according to data from several Swedish registries.

The rates are significantly lower than previous estimates. Fifteen years ago, research was suggesting that having diabetes doubled the risk of premature death.

But the new study also found that the risk was dramatically elevated among people whose type 2 diabetes appeared by age 54. The worse their glycemic control and the more evidence of renal problems, the higher the risk.

In contrast, by age 75, type 2 diabetes posed little additional risk for people with good control and no kidney issues, according to the results.

"The overall increased risk of 15 percent among type 2 diabetics in general is a very low figure that has not been found in earlier type 2 diabetes studies," coauthor Dr. Marcus Lind of Uddevalla Hospital said in a telephone interview.

"The other thing that was interesting is that when we looked at patients with good glycemic control and no renal complications, if they were 75 years age, they had a lower risk than those in the general population. That hasn't been shown before," he said.

"What we are seeing is, if you are younger, aggressive management makes a difference," said Dr. Robert Ratner, chief scientific and medical officer of the American Diabetes Association, who was not involved in the research. At age 75, "you don't have to worry about it as much."

The study, published in the October 29 New England Journal of Medicine, is the largest to date to look at premature death in general - and death from cardiovascular causes in particular - among people with type 2 diabetes.

It compared more than 435,000 diabetics who were followed for a mean of 4.6 years with more than 2 million matched controls who were tracked for a mean of 4.8 years. The diabetics had had glucose problems for an average of 5.7 years.

In terms of actual death rates, cardiovascular mortality during the study period was 7.9 percent for diabetics versus 6.1 percent for controls (adjusted hazard ratio, 1.14; 95 percent confidence interval: 1.13-1.15). The respective rates for death from any cause were 17.7 percent and 14.5 percent (aHR, 1.15; 95 percent CI: 1.14-1.16).

For patients under age 55 with glycated hemoglobin levels below 7.0 percent, the risk of death from any cause nearly doubled (aHR, 1.92; 95 percent CI: 1.75-2.11).

"Those who are younger than 55, those who have target glycemic control and no signs of any renal complications, they had a clearly-elevated risk," said Dr. Lind.

But for people over 75, the hazard was actually 5 percent lower than it was for people without diabetes (aHR, 0.95; 95 percent CI: 0.94-0.96).

When the research team factored in people with normoalbuminuria, the risks were slightly mitigated.

Heart attack was the most common cause of death among diabetics.

When glycated hemoglobin levels were at 9.7 percent and higher for people below age 55, the hazard of death from any cause more than quadrupled. The hazard of death from cardiovascular causes rose more than five-fold.

Once again, the danger was far less extreme for people over 75, the researchers found.

"Excess mortality in type 2 diabetes was substantially higher with worsening glycemic control, severe renal complications, impaired renal function, and younger age," they concluded.

Renal function is a key element, Dr. Ratner said.

The study "reinforces the importance of early aggressive management of diabetes in order to prevent premature death and the fact is that the prevention of renal disease is probably the most potent thing we can do to reduce cardiovascular events," he said.

Dr. Lind said the risk may appear lower in the elderly because older people with diabetes are more likely to be getting aggressive treatment for their high blood pressure and high lipid levels, therapy that other people who also have hypertension and high cholesterol levels might not be receiving.

"I think that's the reason the rates are a bit lower" for seniors, he said.

Dr. Ratner said he believes the data for older diabetics simply reflects the fact that "you're seeing the survival cohort. They've made it past the difficult time."

We're all going to die, he said. "The issue is when does it happen? With diabetes, it's happening years ahead of time - in their 50s and early 60s, more so than when they reach 75. The younger you are, the greater that risk. That's when aggressive therapy should be given."

NEW YORK - People with type 2 diabetes are 15 percent more likely to die from any cause and 14 percent more likely to die from a cardiovascular cause than non-diabetics at any given time, according to data from several Swedish registries.

The rates are significantly lower than previous estimates. Fifteen years ago, research was suggesting that having diabetes doubled the risk of premature death.

But the new study also found that the risk was dramatically elevated among people whose type 2 diabetes appeared by age 54. The worse their glycemic control and the more evidence of renal problems, the higher the risk.

In contrast, by age 75, type 2 diabetes posed little additional risk for people with good control and no kidney issues, according to the results.

"The overall increased risk of 15 percent among type 2 diabetics in general is a very low figure that has not been found in earlier type 2 diabetes studies," coauthor Dr. Marcus Lind of Uddevalla Hospital said in a telephone interview.

"The other thing that was interesting is that when we looked at patients with good glycemic control and no renal complications, if they were 75 years age, they had a lower risk than those in the general population. That hasn't been shown before," he said.

"What we are seeing is, if you are younger, aggressive management makes a difference," said Dr. Robert Ratner, chief scientific and medical officer of the American Diabetes Association, who was not involved in the research. At age 75, "you don't have to worry about it as much."

The study, published in the October 29 New England Journal of Medicine, is the largest to date to look at premature death in general - and death from cardiovascular causes in particular - among people with type 2 diabetes.

It compared more than 435,000 diabetics who were followed for a mean of 4.6 years with more than 2 million matched controls who were tracked for a mean of 4.8 years. The diabetics had had glucose problems for an average of 5.7 years.

In terms of actual death rates, cardiovascular mortality during the study period was 7.9 percent for diabetics versus 6.1 percent for controls (adjusted hazard ratio, 1.14; 95 percent confidence interval: 1.13-1.15). The respective rates for death from any cause were 17.7 percent and 14.5 percent (aHR, 1.15; 95 percent CI: 1.14-1.16).

For patients under age 55 with glycated hemoglobin levels below 7.0 percent, the risk of death from any cause nearly doubled (aHR, 1.92; 95 percent CI: 1.75-2.11).

"Those who are younger than 55, those who have target glycemic control and no signs of any renal complications, they had a clearly-elevated risk," said Dr. Lind.

But for people over 75, the hazard was actually 5 percent lower than it was for people without diabetes (aHR, 0.95; 95 percent CI: 0.94-0.96).

When the research team factored in people with normoalbuminuria, the risks were slightly mitigated.

Heart attack was the most common cause of death among diabetics.

When glycated hemoglobin levels were at 9.7 percent and higher for people below age 55, the hazard of death from any cause more than quadrupled. The hazard of death from cardiovascular causes rose more than five-fold.

Once again, the danger was far less extreme for people over 75, the researchers found.

"Excess mortality in type 2 diabetes was substantially higher with worsening glycemic control, severe renal complications, impaired renal function, and younger age," they concluded.

Renal function is a key element, Dr. Ratner said.

The study "reinforces the importance of early aggressive management of diabetes in order to prevent premature death and the fact is that the prevention of renal disease is probably the most potent thing we can do to reduce cardiovascular events," he said.

Dr. Lind said the risk may appear lower in the elderly because older people with diabetes are more likely to be getting aggressive treatment for their high blood pressure and high lipid levels, therapy that other people who also have hypertension and high cholesterol levels might not be receiving.

"I think that's the reason the rates are a bit lower" for seniors, he said.

Dr. Ratner said he believes the data for older diabetics simply reflects the fact that "you're seeing the survival cohort. They've made it past the difficult time."

We're all going to die, he said. "The issue is when does it happen? With diabetes, it's happening years ahead of time - in their 50s and early 60s, more so than when they reach 75. The younger you are, the greater that risk. That's when aggressive therapy should be given."

NEW YORK - Initiation of antipsychotic or antidepressant drug treatment is linked to a reduction in hospitalizations for patients with schizophrenia, according to a new study.

"Use of sulpiride, mirtazapine, venlafaxine, and clozapine-aripiprazole and clozapine amisulpride combinations were associated with fewer subsequent admission-days in patients with schizophrenia," Dr. Rudolf N. Cardinal of the Behavioral and Clinical Neuroscience Institute, University of Cambridge, UK, said by email.

"These studies are correlative and do not prove causation," he cautioned.

Dr. Cardinal and colleagues analyzed eight years' of admission records at a secondary mental health care institution in Cambridgeshire. The analysis included nearly 1,500 patients with a diagnosis of schizophrenia and a median follow-up of five years.

In mirror-image analysis covering two years before and after therapy initiation, the researchers found treatment with amisulpride, aripiprazole, clozapine, fluoxetine, mirtazapine, olanzapine, quetiapine, and sulpiride was associated with fewer subsequent admissions in one year.

The association persisted in a "more stringent" two-year analysis for aripiprazole, clozapine, and sulpiride.

Using regression analysis, the researchers found a continued reduction in admissions with sulpiride and mirtazapine (estimated mean change, -20.4 and -11.6 days/year, respectively).

Treatment with clozapine-aripiprazole and clozapine-amisulpride combinations as well as venlafaxine was associated with significantly fewer hospitalized days (-17.7, -13.8, and -12.3 days/year, respectively).

Overall, the mean admission rate was 26.8 days/year.

"This analysis focused on patients with more severe disease, in that they had at least one hospital admission in the pre-drug period," the researchers note in the article online October 21 in NPJ Schizophrenia.

"Larger correlative studies are required to corroborate these effects, followed by randomized controlled trials if appropriate," Dr. Cardinal said. "We are all very keen that these are not misrepresented as causal-grade findings."

The authors reported no funding. One coauthor reported receiving research funding from Genus Pharmaceuticals and consulting fees from Roche/Genentech.

NEW YORK - Initiation of antipsychotic or antidepressant drug treatment is linked to a reduction in hospitalizations for patients with schizophrenia, according to a new study.

"Use of sulpiride, mirtazapine, venlafaxine, and clozapine-aripiprazole and clozapine amisulpride combinations were associated with fewer subsequent admission-days in patients with schizophrenia," Dr. Rudolf N. Cardinal of the Behavioral and Clinical Neuroscience Institute, University of Cambridge, UK, said by email.

"These studies are correlative and do not prove causation," he cautioned.

Dr. Cardinal and colleagues analyzed eight years' of admission records at a secondary mental health care institution in Cambridgeshire. The analysis included nearly 1,500 patients with a diagnosis of schizophrenia and a median follow-up of five years.

In mirror-image analysis covering two years before and after therapy initiation, the researchers found treatment with amisulpride, aripiprazole, clozapine, fluoxetine, mirtazapine, olanzapine, quetiapine, and sulpiride was associated with fewer subsequent admissions in one year.

The association persisted in a "more stringent" two-year analysis for aripiprazole, clozapine, and sulpiride.

Using regression analysis, the researchers found a continued reduction in admissions with sulpiride and mirtazapine (estimated mean change, -20.4 and -11.6 days/year, respectively).

Treatment with clozapine-aripiprazole and clozapine-amisulpride combinations as well as venlafaxine was associated with significantly fewer hospitalized days (-17.7, -13.8, and -12.3 days/year, respectively).

Overall, the mean admission rate was 26.8 days/year.

"This analysis focused on patients with more severe disease, in that they had at least one hospital admission in the pre-drug period," the researchers note in the article online October 21 in NPJ Schizophrenia.

"Larger correlative studies are required to corroborate these effects, followed by randomized controlled trials if appropriate," Dr. Cardinal said. "We are all very keen that these are not misrepresented as causal-grade findings."

The authors reported no funding. One coauthor reported receiving research funding from Genus Pharmaceuticals and consulting fees from Roche/Genentech.

NEW YORK - Initiation of antipsychotic or antidepressant drug treatment is linked to a reduction in hospitalizations for patients with schizophrenia, according to a new study.

"Use of sulpiride, mirtazapine, venlafaxine, and clozapine-aripiprazole and clozapine amisulpride combinations were associated with fewer subsequent admission-days in patients with schizophrenia," Dr. Rudolf N. Cardinal of the Behavioral and Clinical Neuroscience Institute, University of Cambridge, UK, said by email.

"These studies are correlative and do not prove causation," he cautioned.

Dr. Cardinal and colleagues analyzed eight years' of admission records at a secondary mental health care institution in Cambridgeshire. The analysis included nearly 1,500 patients with a diagnosis of schizophrenia and a median follow-up of five years.

In mirror-image analysis covering two years before and after therapy initiation, the researchers found treatment with amisulpride, aripiprazole, clozapine, fluoxetine, mirtazapine, olanzapine, quetiapine, and sulpiride was associated with fewer subsequent admissions in one year.

The association persisted in a "more stringent" two-year analysis for aripiprazole, clozapine, and sulpiride.

Using regression analysis, the researchers found a continued reduction in admissions with sulpiride and mirtazapine (estimated mean change, -20.4 and -11.6 days/year, respectively).

Treatment with clozapine-aripiprazole and clozapine-amisulpride combinations as well as venlafaxine was associated with significantly fewer hospitalized days (-17.7, -13.8, and -12.3 days/year, respectively).

Overall, the mean admission rate was 26.8 days/year.

"This analysis focused on patients with more severe disease, in that they had at least one hospital admission in the pre-drug period," the researchers note in the article online October 21 in NPJ Schizophrenia.

"Larger correlative studies are required to corroborate these effects, followed by randomized controlled trials if appropriate," Dr. Cardinal said. "We are all very keen that these are not misrepresented as causal-grade findings."

The authors reported no funding. One coauthor reported receiving research funding from Genus Pharmaceuticals and consulting fees from Roche/Genentech.

Seize the opportunity to present your research, innovative ideas, and clinical stories to a national audience at HM16. Visit the submission site for full details. To ensure success, SHM strongly recommends that you complete your submission well ahead of the deadline of Wednesday, Dec. 1, 2015, at 11:30 p.m. EST. For details, visit www.hospitalmedicine2016.org.

Seize the opportunity to present your research, innovative ideas, and clinical stories to a national audience at HM16. Visit the submission site for full details. To ensure success, SHM strongly recommends that you complete your submission well ahead of the deadline of Wednesday, Dec. 1, 2015, at 11:30 p.m. EST. For details, visit www.hospitalmedicine2016.org.

Seize the opportunity to present your research, innovative ideas, and clinical stories to a national audience at HM16. Visit the submission site for full details. To ensure success, SHM strongly recommends that you complete your submission well ahead of the deadline of Wednesday, Dec. 1, 2015, at 11:30 p.m. EST. For details, visit www.hospitalmedicine2016.org.

NEW YORK - Atrial fibrillation (AF) is associated with an increased risk of dementia, especially in younger individuals, according to results from the Rotterdam Study.

"When we started this study, we hypothesized that the hazard of atrial fibrillation would be higher with longer exposure, but to find such a strong exposure-time association in younger participants was striking," said Dr. Frank J. Wolters from Erasmus Medical Center in Rotterdam, the Netherlands.

"It emphasizes that prevention of dementia doesn't start when people report to their physician with mild memory complaints, but years, if not decades before, by identifying those at risk and optimizing preventive strategies," he said by email.

An earlier report from the Rotterdam Study showed that AF is more prevalent in people with dementia, but the cross-sectional design did not allow conclusions regarding a causal relationship.

Dr. Wolters's team investigated the association between AF and dementia during a follow up of 20 years of nearly 6,200 participants in the Rotterdam Study.

About 5% of the participants had AF at baseline, and 15.3% of these individuals developed dementia during more than 81,000 person-years of follow-up.

Another 11.7% developed AF later, and 15.0% developed dementia during more than 79,000 person-years, the researchers report in JAMA Neurology, online September 21.

People who had AF at the start of the study had a 34% increased risk of dementia (compared with those who did not have prevalent AF), and people who developed AF during follow-up had a 23% increased risk of dementia (compared with those who did not have incident AF).

The association between AF and dementia was strongest in persons younger than the median age (67 years), and in these younger participants, the risk of dementia was higher with increasing duration of AF.

"As we found atrial fibrillation to increase the risk of dementia independent of clinical stroke, either chronic hypoperfusion or more acutely silent infarcts or perhaps cortical microinfarcts could account for the increased risk of dementia," Dr. Wolters said.

"A few observational studies have suggested beneficialeffect of treatment of atrial fibrillation on the risk of dementia, but more evidence on treatment efficacy is sorely needed. This includes insight into whether optimal treatment consists of anticoagulation, heart rhythm, or rate control," he noted.

"With regard to treatment of atrial fibrillation, until further evidence on efficacy becomes available, it is worth realizing that optimal adherence to current guidelines may contribute to prevention of cognitive decline in addition to prevention of stroke," Dr. Wolters added. "Although we found the strongest associations between atrial fibrillation and dementia for younger people, the need to determine treatment efficacy is just as profound in the elderly."

Dr. Sanjay Dixit, director of cardiac electrophysiology at Philadelphia VA Medical Center in Pennsylvania, said by email, "Although the association between AF and dementia has been shown, it's difficult to establish cause and effect. As I point out in my previous review, obstructive sleep apnea (OSA) is considered to be a major contributor to the development of neurocognitive decline and dementia. OSA is very common in the AF population and many consider this to be (a) risk factor in the development of AF. So the question remains whether AF is the cause of dementia or other co-morbidities such as OSA that frequently co-exist in the AF population."

"Look for AF in patients with dementia and also caution patients with AF of the possibility of developing this condition in the future," Dr. Dixit advised. "Since catheter ablation therapy has been shown to have better outcomes for long-term control of AF than drugs, physicians should discuss this with patients and consider referring them to cardiac electrophysiologists early in the course of the disease."

Dr. T. Jared Bunch, director of heart rhythm services for Intermountain Healthcare, Murray, Utah, said by email, "It is great to see another confirmatory study that found essentially the same thing we did 5 years ago. These data in aggregate make the likelihood of the association much more compelling."

"What is interesting in our subsequent work is the patients more sensitive to poor warfarin management (low times in therapeutic range) were at the highest relative risk of dementia compared to older patients," Dr. Bunch explained. "Now we all need to start to unravel the mechanisms behind it and find avenues of preventative treatment. The choice and manner of anticoagulant treatment is one and allowing faster heart rates is another."

Dr. Shih-An Chen and Dr. Tzu-Fan Chao from Taipei Veterans General Hospital, Taipei, Taiwan, who recently reported on the independent association between AF and dementia, struck a more cautious note.

"Only when a lower risk of dementia can be achieved by AF ablation in the prospective and randomized trial can we conclude that AF is the direct cause of dementia," they said in a joint email. "It should also be noted that the development of dementia is multifactorial, and AF only represents one of them."

NEW YORK - Atrial fibrillation (AF) is associated with an increased risk of dementia, especially in younger individuals, according to results from the Rotterdam Study.

"When we started this study, we hypothesized that the hazard of atrial fibrillation would be higher with longer exposure, but to find such a strong exposure-time association in younger participants was striking," said Dr. Frank J. Wolters from Erasmus Medical Center in Rotterdam, the Netherlands.

"It emphasizes that prevention of dementia doesn't start when people report to their physician with mild memory complaints, but years, if not decades before, by identifying those at risk and optimizing preventive strategies," he said by email.

An earlier report from the Rotterdam Study showed that AF is more prevalent in people with dementia, but the cross-sectional design did not allow conclusions regarding a causal relationship.

Dr. Wolters's team investigated the association between AF and dementia during a follow up of 20 years of nearly 6,200 participants in the Rotterdam Study.

About 5% of the participants had AF at baseline, and 15.3% of these individuals developed dementia during more than 81,000 person-years of follow-up.

Another 11.7% developed AF later, and 15.0% developed dementia during more than 79,000 person-years, the researchers report in JAMA Neurology, online September 21.

People who had AF at the start of the study had a 34% increased risk of dementia (compared with those who did not have prevalent AF), and people who developed AF during follow-up had a 23% increased risk of dementia (compared with those who did not have incident AF).

The association between AF and dementia was strongest in persons younger than the median age (67 years), and in these younger participants, the risk of dementia was higher with increasing duration of AF.

"As we found atrial fibrillation to increase the risk of dementia independent of clinical stroke, either chronic hypoperfusion or more acutely silent infarcts or perhaps cortical microinfarcts could account for the increased risk of dementia," Dr. Wolters said.

"A few observational studies have suggested beneficialeffect of treatment of atrial fibrillation on the risk of dementia, but more evidence on treatment efficacy is sorely needed. This includes insight into whether optimal treatment consists of anticoagulation, heart rhythm, or rate control," he noted.

"With regard to treatment of atrial fibrillation, until further evidence on efficacy becomes available, it is worth realizing that optimal adherence to current guidelines may contribute to prevention of cognitive decline in addition to prevention of stroke," Dr. Wolters added. "Although we found the strongest associations between atrial fibrillation and dementia for younger people, the need to determine treatment efficacy is just as profound in the elderly."

Dr. Sanjay Dixit, director of cardiac electrophysiology at Philadelphia VA Medical Center in Pennsylvania, said by email, "Although the association between AF and dementia has been shown, it's difficult to establish cause and effect. As I point out in my previous review, obstructive sleep apnea (OSA) is considered to be a major contributor to the development of neurocognitive decline and dementia. OSA is very common in the AF population and many consider this to be (a) risk factor in the development of AF. So the question remains whether AF is the cause of dementia or other co-morbidities such as OSA that frequently co-exist in the AF population."

"Look for AF in patients with dementia and also caution patients with AF of the possibility of developing this condition in the future," Dr. Dixit advised. "Since catheter ablation therapy has been shown to have better outcomes for long-term control of AF than drugs, physicians should discuss this with patients and consider referring them to cardiac electrophysiologists early in the course of the disease."

Dr. T. Jared Bunch, director of heart rhythm services for Intermountain Healthcare, Murray, Utah, said by email, "It is great to see another confirmatory study that found essentially the same thing we did 5 years ago. These data in aggregate make the likelihood of the association much more compelling."

"What is interesting in our subsequent work is the patients more sensitive to poor warfarin management (low times in therapeutic range) were at the highest relative risk of dementia compared to older patients," Dr. Bunch explained. "Now we all need to start to unravel the mechanisms behind it and find avenues of preventative treatment. The choice and manner of anticoagulant treatment is one and allowing faster heart rates is another."

Dr. Shih-An Chen and Dr. Tzu-Fan Chao from Taipei Veterans General Hospital, Taipei, Taiwan, who recently reported on the independent association between AF and dementia, struck a more cautious note.

"Only when a lower risk of dementia can be achieved by AF ablation in the prospective and randomized trial can we conclude that AF is the direct cause of dementia," they said in a joint email. "It should also be noted that the development of dementia is multifactorial, and AF only represents one of them."

NEW YORK - Atrial fibrillation (AF) is associated with an increased risk of dementia, especially in younger individuals, according to results from the Rotterdam Study.

"When we started this study, we hypothesized that the hazard of atrial fibrillation would be higher with longer exposure, but to find such a strong exposure-time association in younger participants was striking," said Dr. Frank J. Wolters from Erasmus Medical Center in Rotterdam, the Netherlands.

"It emphasizes that prevention of dementia doesn't start when people report to their physician with mild memory complaints, but years, if not decades before, by identifying those at risk and optimizing preventive strategies," he said by email.

An earlier report from the Rotterdam Study showed that AF is more prevalent in people with dementia, but the cross-sectional design did not allow conclusions regarding a causal relationship.

Dr. Wolters's team investigated the association between AF and dementia during a follow up of 20 years of nearly 6,200 participants in the Rotterdam Study.

About 5% of the participants had AF at baseline, and 15.3% of these individuals developed dementia during more than 81,000 person-years of follow-up.

Another 11.7% developed AF later, and 15.0% developed dementia during more than 79,000 person-years, the researchers report in JAMA Neurology, online September 21.

People who had AF at the start of the study had a 34% increased risk of dementia (compared with those who did not have prevalent AF), and people who developed AF during follow-up had a 23% increased risk of dementia (compared with those who did not have incident AF).

The association between AF and dementia was strongest in persons younger than the median age (67 years), and in these younger participants, the risk of dementia was higher with increasing duration of AF.

"As we found atrial fibrillation to increase the risk of dementia independent of clinical stroke, either chronic hypoperfusion or more acutely silent infarcts or perhaps cortical microinfarcts could account for the increased risk of dementia," Dr. Wolters said.

"A few observational studies have suggested beneficialeffect of treatment of atrial fibrillation on the risk of dementia, but more evidence on treatment efficacy is sorely needed. This includes insight into whether optimal treatment consists of anticoagulation, heart rhythm, or rate control," he noted.

"With regard to treatment of atrial fibrillation, until further evidence on efficacy becomes available, it is worth realizing that optimal adherence to current guidelines may contribute to prevention of cognitive decline in addition to prevention of stroke," Dr. Wolters added. "Although we found the strongest associations between atrial fibrillation and dementia for younger people, the need to determine treatment efficacy is just as profound in the elderly."

Dr. Sanjay Dixit, director of cardiac electrophysiology at Philadelphia VA Medical Center in Pennsylvania, said by email, "Although the association between AF and dementia has been shown, it's difficult to establish cause and effect. As I point out in my previous review, obstructive sleep apnea (OSA) is considered to be a major contributor to the development of neurocognitive decline and dementia. OSA is very common in the AF population and many consider this to be (a) risk factor in the development of AF. So the question remains whether AF is the cause of dementia or other co-morbidities such as OSA that frequently co-exist in the AF population."

"Look for AF in patients with dementia and also caution patients with AF of the possibility of developing this condition in the future," Dr. Dixit advised. "Since catheter ablation therapy has been shown to have better outcomes for long-term control of AF than drugs, physicians should discuss this with patients and consider referring them to cardiac electrophysiologists early in the course of the disease."

Dr. T. Jared Bunch, director of heart rhythm services for Intermountain Healthcare, Murray, Utah, said by email, "It is great to see another confirmatory study that found essentially the same thing we did 5 years ago. These data in aggregate make the likelihood of the association much more compelling."

"What is interesting in our subsequent work is the patients more sensitive to poor warfarin management (low times in therapeutic range) were at the highest relative risk of dementia compared to older patients," Dr. Bunch explained. "Now we all need to start to unravel the mechanisms behind it and find avenues of preventative treatment. The choice and manner of anticoagulant treatment is one and allowing faster heart rates is another."

Dr. Shih-An Chen and Dr. Tzu-Fan Chao from Taipei Veterans General Hospital, Taipei, Taiwan, who recently reported on the independent association between AF and dementia, struck a more cautious note.

"Only when a lower risk of dementia can be achieved by AF ablation in the prospective and randomized trial can we conclude that AF is the direct cause of dementia," they said in a joint email. "It should also be noted that the development of dementia is multifactorial, and AF only represents one of them."