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In This Issue of Archives of Internal Medicine |

In This Issue of Archives of Internal Medicine FREE

Arch Intern Med. 2012;172(8):606. doi:10.1001/archinternmed.2011.937.
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Recent events have increased the instability of health insurance, with health care reform expanding insurance coverage and the economic recession increasing the uninsured population. This analysis of 159 934 US adults from the National Health Interview Survey found that while uninsured adults had similar emergency department (ED) use rates as insured adults, those with recent changes in insurance status had over 30% higher ED use than those with insurance stability. Consistency, in addition to the provision and type of health insurance, may improve access to primary care services and reduce patient reliance on ED services.

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In this retrospective mortality study, Wong et al characterize the patterns and determinants of health care utilization at the end of life among 99 329 Medicare beneficiaries 65 years or older receiving long-term dialysis. The authors found that older dialysis patients experience very high rates of hospitalization, intensive care unit admission, and use of invasive procedures (including mechanical ventilation, cardiopulmonary resuscitation, and feeding tube placement) during the final month of life that exceed rates reported for other Medicare beneficiaries with severe chronic illness. Patterns of health care utilization at the end of life in this population also appeared to vary more by regional health care patterns than by individual patient characteristics.

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Agarwal et al performed a meta-analysis of large contemporary randomized control trials to estimate the absolute safety and efficacy rates associated with warfarin use in patients with atrial fibrillation. The authors observed that the current use of warfarin as a stroke prevention agent in these patients is associated with a low rate of residual stroke or systemic embolism, estimated to be 1.66% per year. Compared with prior meta-analysis, there has been a significant improvement in the proportion of time spent in therapeutic anticoagulation, with a resultant decline in observed stroke rates. Female patients, elderly patients, patients with a history of stroke, and patients with no prior exposure to vitamin K antagonists were at a significantly higher risk of thromboembolic events.

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Use of antipsychotics (APs) is associated with an increased risk of ischemic stroke and possibly other thrombotic events in demented elderly patients. Pariente et al used data from the Quebec administrative health care databases (RAMQ) to estimate the risk of myocardial infarction (MI) associated with the use of APs among 37 138 community-dwelling elderly patients with dementia treated with cholinesterase inhibitors. Within 1 year of initiating AP treatment, 1.6% of elderly patients had an incident MI. A survival analysis and a self-controlled case-series analysis were conducted, and both showed a modest and time-limited increase in the risk of MI, especially during the first month of treatment. Since AP use is frequent in this population (almost 30%), such risk may have a major public health impact.

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One-year MI–free survival and incidence of MI among community-dwelling older patients with treated dementia in the exposed subcohort (incident users of antipsychotic agents) vs the unexposed subcohort (nonusers).

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