A report in the July 29 issue of Circulation, the journal of the American Heart Association (AHA; Dallas, Texas), says that prevention and education efforts must be pursued to curb the growing trend of hospitalizations for atrial fibrillation (AF) in the U.S. The "substantial" increase in such hospitalizations will be a "staggering burden" on both the U.S. healthcare system and patients' quality of life, said senior author George Mensah, MD, chief of the cardiovascular health programs at the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia).

According to the report, the number of hospitalizations among people age 35 and older in which AF was listed as the first diagnosis increased 144% between 1985 and 1999. Even more startling than that statistic, which in real numbers was an increase from 154,086 AF-attributed hospitalizations in the former year to 376,487 in the latter, was a finding that the total number of hospitalizations in which atrial fibrillation was listed as a diagnosis jumped 190% from 787,750 to almost 2.3 million over the same 15-year period. And Mensah noted that current predictions are for AF-related hospitalizations to climb to more than 3.3 million by 2025. He said that some AF hospitalizations are for procedures used to convert AF to normal rhythm, accounting for a small percentage of the increased hospitalizations.

The Circulation report noted that the risk for AF increases with age, so hospitalization rates rise with the aging population. Searching the National Hospital Discharge Survey to identify AF-associated hospitalizations that occurred in people age 35 or older, Mensah and colleagues at the CDC found that more than half of such hospitalizations occurred in people aged 75 or older. He said that is especially significant because in addition to an increased number of AF hospitalizations, there was also a dramatic increase in the number of discharges to nursing homes.

"The adverse trend in hospitalization for AF in the context of an aging population and associated prevalence of congestive heart failure presages a staggering burden on the Medicare system and the quality of life for affected persons," the authors noted. Mensah said, "The real message here is about prevention. We need to concentrate our efforts on measures that will reduce these hospitalizations and the need for long- term care for these patients."

With AF being associated with high blood pressure, stroke, ischemic heart disease, diabetes and congestive heart failure, he said prevention efforts should target those conditions. "There is a need for more aggressive attention to addressing risk factors in women especially a focus on high blood pressure because we found that women are hospitalized more than men and because women live longer than men," Mensah added. He also noted that compliance with instructions on the use of medications to control heart rhythm and heart rate among AF patients could help reduce hospitalizations and complications.

Heart disease research lacking in women

What's good for men isn't necessarily good for women, especially when it comes to research involving coronary heart disease. But then the research on coronary disease in women hardly parallels that which is done in men. Even though more than 250,000 women die each year from coronary heart disease (CHD), a majority of the research to diagnose and treat the disease in the past 20 years has entirely excluded women or included limited numbers of women, and, as a result, the tests and therapies used to treat CHD are based on studies conducted on men, even when the therapies are used in women.

Those findings were released last month based on evidence reviews conducted for the Agency for Healthcare Research and Quality (AHRQ; Rockville, Maryland) and the National Institutes of Health's (NIH; Bethesda, Maryland) Office of Research on Women's Health, both agencies of the U.S. Department of Health and Human Services. The evidence reviews were conducted by the University of California San Francisco/Stanford Evidence-based Practice Center (San Francisco, California). The reports are titled, "Results of Systematic Review of Research on Diagnosis and Treatment of Coronary Heart Disease in Women" and "Diagnosis and Treatment of Coronary Heart Disease in Women: Systematic Reviews of Evidence on Selected Topics."

Perhaps more troubling for women is that, even when included in studies, the published research often doesn't provide findings specific to them, according to the study. Researchers found that only 20% of published articles reviewed for the project included separate clinical findings for women. Funding agencies may stipulate that women and minorities be included, but the data are not clear in the published findings, the researchers also found.

Among the findings:

Fair or good evidence suggests the use of diagnostic tests and treatments may differ by gender; men are more likely than women to undergo diagnostic testing and treatment for CHD, but women are more likely to be treated for hypertension.

Fair or good evidence suggests that beta-blockers, aspirin, and angiontensin-converting enzyme inhibitors (ACE inhibitors) reduce risk for CHD events.

Good evidence suggests that treatment of hypertension lowers the risk for CHD events in women, and that these benefits may be greater in African-American women.

Fair evidence suggests that smoking cessation after heart attack lowers the risk for CHD in women.

Fair evidence suggests that women who receive glycoprotein Iib/IIIa inhibitor drugs during coronary procedures seem to benefit from this treatment, but good evidence suggests that use of glycoprotein Iib/IIIa inhibitor drugs in women with acute coronary syndromes may be associated with an increased risk of death. This was the only treatment studied where there was evidence that the outcomes may be different between men and women. Men treated with glcoprotein Iib/IIIa inhibitor drugs during acute coronary syndromes appeared to benefit.

Clot-busting drugs denied many

A clinical analysis of 60,770 U.S. patients who arrived at hospital emergency rooms with heart attack symptoms indicated that three out of four did not receive a class of clot-inhibiting drug proven in clinical trials to reduce mortality, or myocardial infarction. As far back as September 2000, the American Heart Association (AHA; Dallas, Texas) and the American College of Cardiology (ACC; Bethesda, Maryland) recommended that these drugs glycoprotein (GP) inhibitors be given to high-risk heart patients.

The July 2 issue of the Journal of the American College of Cardiology (JACC), carried an article whose first author is cardiovascular researcher Eric Peterson at Duke University (Durham, North Carolina). Peterson cited three findings in particular: "First, the national guidelines are not necessarily being followed as a guide to certain therapies in this case the glycoprotein inhibitors. Only 25% of patients had been treated by the guidelines. Some are less likely to receive therapy than others, particularly women, the elderly, the uninsured and whites." In addition, he said, patients who are at higher risk, and stand the most to benefit, are less likely to be treated.

Secondly, Peterson said, "we have a professional need to get better at the newer therapies in a quicker fashion so there isn't a delay between discovery and actual utilization in practice." And thirdly, "we were able to demonstrate in real-life patients the beneficial effects of the recommended glycoprotein drugs compared with those enrolled in clinical trials."

He added, "when a person has a heart attack, these drugs prevent furthering of the attack, and help dissolve the clot." He summed up the outcome of the 60,000-plus patients: "This class of drugs, the GPs, reduced those patients' likelihood of dying from myocardial infarction in a heart attack by 12%. And those receiving the therapy had a significantly lower mortality rate of 3.3% compared to 9.6% of those who didn't."

Disagreement on med-tech economics

What is unique to the healthcare industry so that new technologies and healthcare innovations seem not to result in greater efficiency and lower production costs? That's the question lawmakers attempted to answer last month during a hearing of the Joint Economic Committee, which includes members from both legislative chambers. "In most sectors of the economy the introduction of new technologies and other innovations often result in greater efficiencies and lower production costs," said Sen. Bob Bennett (R-Utah) in his opening remarks to members of the committee. "In healthcare," he said, "the opposite appears to be true." Bennett, chair of the committee, convened the hearing to discuss "Technology, Innovation and the Costs of Healthcare."

In written testimony presented to the committee, the Advanced Medical Technology Association (AdvaMed; Washington) argued the contrary view, that medical technology does benefit the economy but that those benefits are not always short-term or obvious. It offered the view that medical technology produces enormous long-term benefits for patients, the healthcare system and the overall economy. Rapid medical technology innovation fueled by record investments in research and development is the reason for the benefits, AdvaMed said. "Medical technology is one of the key reasons healthcare in the U.S. is the best in the world. Medical technology is transforming healthcare in a variety of ways, and the results are measurable and impressive. In addition to the benefits to patients, these innovations improve productivity and health system efficiency," the organization said.

The hearing comes on the heels of a study released a day before that found that uninsured Americans have less access to medical technologies and that this may be a cause for increased costs. The study, published in the July 8 issue of Health Affairs, concluded that medical technology advances aren't reaching the millions of uninsured in America, an access gap the researchers estimate is costing the nation $1.1 billion a year. The "Uninsured and the Benefits of Medical Progress" report stated that medical technology offers positive net benefits for several conditions, especially heart disease, cataracts and depression.

Researchers compared the use of high-tech treatments for heart attack, cataracts and depression among insured and uninsured patients aged 55-64. In each case, the uninsured group received the high-tech treatments at lower rates compared with the insured group. The discrepancy amounts to an estimated annual loss of $350 in excess morbidity and mortality costs per uninsured person in this age group, the researchers found. The study was funded by the Commonwealth Fund's (New York) Task Force on the Future of Health Insurance.

Historically, cost inputs for medical technology have been measured through increases in healthcare spending, AdvaMed noted. The trend in recent years, however, is that researchers are measuring the benefits of the health and economic outputs from the expenditures, the organization added. "Medical technology holds the potential to help the U.S. and the world cope with increasing healthcare demands by patients and an aging population. Innovation is enabling patients to live longer and healthier lives, require less medical care and allowing our healthcare system to get more for every dollar spent," according to AdvaMed. It pointed to two studies that demonstrate the value of medical technology. It concluded that society received up to $2 of benefits for every dollar spent on healthcare in the 1980s, the last decade with complete data that exist. The second study found that medical technology is helping to dramatically reduce disability levels in the U.S., which improves quality of life, increases productivity, and reduces healthcare costs, the association said.

Federal and state obstacles to innovation still exist, the association said, and steps should be taken to eliminate barriers to patient access. Fully funding FDA to reduce product review times, as well as streamlining Medicare coverage, coding, and payment processes lasting 15 months to five years to make new technologies available to patients are a few needed steps, AdvaMed said.