Thiazolidinediones and Cardiovascular Outcomes in Older Patients With Diabetes
Cardiovascular disease is an important cause of morbidity and mortality among persons with type 2 diabetes mellitus. The thiazolidinediones (TZDs) rosiglitazone and pioglitazone are oral hypoglycemic agents that have been shown to improve glycemic control and may act to slow the progression of beta cell failure. While improved glycemic control has been linked to better clinical outcomes in diabetes and TZDs have been suggested as having potential cardiovascular benefits, recent concerns have arisen regarding adverse cardiac effects of these drugs. TZDs, used to treat type 2 diabetes, are associated with an excess risk of congestive heart failure, and possibly acute myocardial infarction. However, the association between TZD use and cardiovascular events has not been adequately evaluated on a population level.

The researchers’ objective in this study was to explore the association between TZD therapy and congestive heart failure, acute myocardial infarction, and mortality as compared to treatment with other oral hypoglycemic agents. A nested case-control analysis of a retrospective cohort study was conducted using healthcare databases in Ontario, and included diabetes patients age 66 years or older treated with at least one oral hypoglycemic agent between 2002 and 2005 (N=159,026) and followed them up until March 31, 2006. The primary outcome consisted of an emergency department visit or hospitalization for congestive heart failure; secondary outcomes were an emergency department visit or hospitalization for acute myocardial infarction and all-cause mortality. The risks of these events were compared between persons treated with TZDs (rosiglitazone and pioglitazone) and other oral hypoglycemic agent combinations, after matching and adjusting for prognostic factors. During a median follow-up of 3.8 years, 12,491 patients (7.9%) had a hospital visit for congestive heart failure, 12,578 (7.9%) had a visit for acute myocardial infarction, and 30,265 (19%) died. Current treatment with TZD monotherapy was associated with a significantly increased risk of congestive heart failure (78 cases; adjusted rate ratio [RR], 1.60; 95% confidence interval [CI], 1.21-2.10; P<.001), acute myocardial infarction (65 cases; RR, 1.40; 95% CI, 1.05-1.86; P=.02), and death (102 cases; RR, 1.29; 95% CI, 1.02-1.62; P=.03) compared with other oral hypoglycemic agent combination therapies (3478 congestive heart failure cases, 3695 acute myocardial infarction cases, and 5529 deaths). The increased risk of congestive heart failure, acute myocardial infarction, and mortality associated with TZD use appeared limited to rosiglitazone.

The authors concluded that in this population-based study of older patients with diabetes, TZD treatment, primarily with rosiglitazone, was associated with an increased risk of congestive heart failure, acute myocardial infarction, and mortality when compared with other combination oral hypoglycemic agent treatments.

JAMA 2007;298(22):2634-2643
Lorraine L. Lipscombe, MD, MSc, Tara Gomes, MHSc, Linda E. Lévesque, BScPhm, MSc, Janet E. Hux, MD, MSc, David N. Juurlink, BPhm, MD, PhD, David A. Alter, MD, PhD

High-Trauma Fractures and Low Bone Mineral Density in Older Women and Men
Approximately 1.5 million osteoporotic fractures occur each year in the United States.! As the population ages, the number of fractures is projected to increase almost 4-fold by 2050 if effective prevention strategies are not implemented. The criteria used to define osteoporotic fractures warrant further investigation. By the current definition, fractures are recognized as osteoporotic if they are associated with low bone mineral density (BMD) and if they increase the risk of subsequent fracture. It remains unclear whether degree of trauma should be included in the definition of osteoporotic fractures. Most low-trauma fractures (eg, those resulting from falls from standing height or less) are considered osteoporotic because they are related to low BMD. It is widely believed that fractures resulting from high trauma are not osteoporotic; however, this assumption has not been studied prospectively.

The researchers’ objective in this study was to examine the association between bone mineral density (BMD) and high-trauma fracture and between high-trauma fracture and subsequent fracture in older women and men. Two prospective U.S. cohort studies were conducted in community-dwelling adults age 65 years or older from geographically diverse sites. The Study of Osteoporotic Fractures followed up 8022 women for 9.1 years (1988-2006). The Osteoporotic Fractures in Men Study followed up 5995 men for 5.1 years (2000-2007). Hip and spine BMD were assessed by dual-energy xray absorptiometry. Incident nonspine fractures were confirmed by radiographic report. Fractures were classified, without knowledge of BMD, as high trauma (due to motor vehicle crashes and falls from greater than standing height) or as low trauma (due to falls from standing height and less severe trauma). Results showed that, overall, 264 women and 94 men sustained an initial high-trauma fracture and 3211 women and 346 men sustained an initial low-trauma fracture. For women, each 1-SD reduction in total hip BMD was similarly associated with an increased risk of high-trauma fracture (multivariate relative hazard [RH], 1.45; 95% confidence interval [CI], 1.23-1.72) and low-trauma fracture (RH, 1.49; 95% CI, 1.42-1.57). Results were consistent in men (high trauma fracture RH, 1.54; 95% CI,1.20-1.96; low-trauma fracture RH, 1.69; 95% CI 1.49-1.91). Risk of subsequent fracture was 34% (95% CI, 7%-67%) greater among women with an initial high-trauma fracture and 31% (95% CI, 20%-43%) greater among women with an initial low-trauma fracture, as compared with women having no high- or low-trauma fracture, respectively. Risk of subsequent fracture was not modeled for men.

The authors concluded that, similar to low-trauma nonspine fractures, high-trauma nonspine fractures are associated with low BMD and increased risk of subsequent fracture in older adults. High-trauma nonspine fractures should be included as outcomes in osteoporotic trials and observational studies.

JAMA 2007;298(20):2381-2388.
Dawn C. Mackey, MSc, Li-Yung Lui, MA, MS, Peggy M. Cawthon, PhD, Douglas C. Bauer, MD, Michael C. Nevitt, PhD, Jane A. Cauley, DrPH, Teresa A. Hillier, MD, MS, Cora E. Lewis, MD, Elizabeth Barrett-Connor, MD, Steven R. Cummings, MD, for the Study of Osteoporotic Fractures (SOF) and Osteoporotic Fractures in Men Study (MrOS) Research Groups

Geriatric Care Management for Low-Income Seniors A Randomized Controlled Trial
Low-income older persons represent a diverse and complex group of older adults who frequently have socioeconomic stressors, low health literacy, chronic medical conditions, and limited access to healthcare. In addition, this group accounts for a disproportionate share of health care expenditures including high rates of acute care utilization. Older adults in general, and especially the poor, often do not receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care was developed specifically to improve the quality of care for low income seniors. The GRACE model builds on lessons learned from prior efforts to improve the care of older adults through multidimensional assessment. Prior reviews of this literature suggest that time-limited and sitespecific geriatric consultation has limited impact on the process and outcomes of care.

The objective of this study was to test the effectiveness of a geriatric care management model on improving the quality of care for low-income seniors in primary care.

A controlled clinical trial was conducted of 951 adults age 65 years or over with an annual income less than 200% of the federal poverty level, whose primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers. Patients received two years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. Main outcome measures were the Medical Outcomes 36-Item Short Form (SF-36) scales and summary measures; instrumental and basic activities of daily living (ADLs); and emergency department (ED) visits not resulting in hospitalization and hospitalizations. Intention-to-treat analysis revealed significant improvements for intervention patients compared with usual care at 24 months in 4 of 8 SF-36 scales: general health (0.2 vs -2.3, P=.045), vitality (2.6 vs -2.6, P<.001), social functioning (3.0 vs -2.3, P=.008), and mental health (3.6 vs -0.3, P=.001); and in the Mental Component Summary (2.1 vs -0.3, P<.001). No group differences were found for ADLs or death. The cumulative 2-year ED visit rate per 1000 was lower in the intervention group (1445 [n=474] vs 1748 [n=477], P=.03), but hospital admission rates per 1000 were not significantly different between groups (700 [n=474] vs 740 [n=477], P=.66). In a predefined group at high risk of hospitalization (comprising 112 intervention and 114 usual-care patients), ED visit and hospital admission rates were lower for intervention patients in the second year (848 [n=106] vs 1314 [n=105]; P=.03 and 396 [n=106] vs 705 [n=105]; P=.03, respectively).

The authors concluded that integrated and home-based geriatric care management resulted in improved quality of care and reduced acute care utilization among a high-risk group. Improvements in health-related quality of life were mixed, and physical function outcomes did not differ between groups. Future studies are needed to determine whether more specific targeting will improve the program's effectiveness and whether reductions in acute care utilization will offset program costs.

JAMA 2007;298(22):2623-2633.
Steven R. Counsell, MD, Christopher M. Callahan, MD, Daniel O. Dark, PhD, Wanzhu Tu, PhD, Amna B. Buttar, MD, MS, Timothy E. Stump, MS, Gretchen D. Ricketts, BSW