Mary Beth Hamel

Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States

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Publications (92)1116.09 Total impact

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    ABSTRACT: Patients with obesity face widespread social bias, but the importance of this social stigma to patients relative to other quality of life (QOL) factors is unclear.
    Journal of General Internal Medicine 10/2014; · 3.42 Impact Factor
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    ABSTRACT: IMPORTANCE Guidelines recommend that women 75 years and older should be informed of the benefits and risks of mammography before being screened. However, few are adequately informed. OBJECTIVES To develop and evaluate a mammography screening decision aid (DA) for women 75 years and older. DESIGN We designed the DA using international standards. Between July 14, 2010, and April 10, 2012, participants completed a pretest survey and read the DA before an appointment with their primary care physician. They completed a posttest survey after their appointment. Medical records were reviewed for follow-up information. SETTING AND PARTICIPANTS Boston, Massachusetts, academic primary care practice. Eligible women were aged 75 to 89 years, English speaking, had not had a mammogram in 9 months but had been screened within the past 3 years, and did not have a history of dementia or invasive or noninvasive breast cancer. Of 84 women approached, 27 declined to participate, 12 were unable to complete the study for logistical reasons, and 45 participated. INTERVENTIONS The DA includes information on breast cancer risk, life expectancy, competing mortality risks, possible outcomes of screening, and a values clarification exercise. MAIN OUTCOMES AND MEASURES Knowledge of the benefits and risks of screening, decisional conflict, and screening intentions; documentation in the medical record of a discussion of the risks and benefits of mammography with a primary care physician within 6 months; and the receipt of screening within 15 months. We used the Wilcoxon signed rank test and McNemar test to compare pretest-posttest information. RESULTS The median age of participants was 79 years, 69% (31 of 45) were of non-Hispanic white race/ethnicity, and 60% (27 of 45) had attended at least some college. Comparison of posttest results with pretest results demonstrated 2 findings. First, knowledge of the benefits and risks of screening improved (P < .001). Second, fewer participants intended to be screened (56% [25 of 45] afterward compared with 82% [37 of 45] before, P = .03). Decisional conflict declined but not significantly (P = .10). In the following 6 months, 53% (24 of 45) of participants had a primary care physician note that documented the discussion of the risks and benefits of screening compared with 11% (5 of 45) in the previous 5 years (P < .001). While 84% (36 of 43) had been screened within 2 years of participating, 60% (26 of 43) were screened within 15 months after participating (≥2 years since their last mammogram) (P = .01). Overall, 93% (42 of 45) found the DA helpful. CONCLUSIONS AND RELEVANCE A DA may improve older women's decision making about mammography screening.
    JAMA Internal Medicine 12/2013; 174(3). · 13.25 Impact Factor
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    ABSTRACT: CONTEXT: Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported. OBJECTIVES: To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia. METHODS: NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALDs) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months. RESULTS: Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALDs. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALDs. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355). CONCLUSION: Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.
    Journal of pain and symptom management 04/2013; · 2.42 Impact Factor
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    ABSTRACT: IMPORTANCE Weight loss surgery (WLS) has been shown to produce long-term weight loss but is not risk free or universally effective. The weight loss expectations and willingness to undergo perioperative risk among patients seeking WLS remain unknown. OBJECTIVES To examine the expectations and motivations of WLS patients and the mortality risks they are willing to undertake and to explore the demographic characteristics, clinical factors, and patient perceptions associated with high weight loss expectations and willingness to assume high surgical risk. DESIGN We interviewed patients seeking WLS and conducted multivariable analyses to examine the characteristics associated with high weight loss expectations and the acceptance of mortality risks of 10% or higher. SETTING Two WLS centers in Boston. PARTICIPANTS Six hundred fifty-four patients. MAIN OUTCOME MEASURES Disappointment with a sustained weight loss of 20% and willingness to accept a mortality risk of 10% or higher with WLS. RESULTS On average, patients expected to lose as much as 38% of their weight after WLS and expressed disappointment if they did not lose at least 26%. Most patients (84.8%) accepted some risk of dying to undergo WLS, but only 57.5% were willing to undergo a hypothetical treatment that produced a 20% weight loss. The mean acceptable mortality risk to undergo WLS was 6.7%, but the median risk was only 0.1%; 19.5% of all patients were willing to accept a risk of at least 10%. Women were more likely than men to be disappointed with a 20% weight loss but were less likely to accept high mortality risk. After initial adjustment, white patients appeared more likely than African American patients to have high weight loss expectations and to be willing to accept high risk. Patients with lower quality-of-life scores and those who perceived needing to lose more than 10% and 20% of weight to achieve "any" health benefits were more likely to have unrealistic weight loss expectations. Low quality-of-life scores were also associated with willingness to accept high risk. CONCLUSIONS AND RELEVANCE Most patients seeking WLS have high weight loss expectations and believe they need to lose substantial weight to derive any health benefits. Educational efforts may be necessary to align expectations with clinical reality.
    JAMA surgery. 03/2013; 148(3):264-71.
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    ABSTRACT: BACKGROUND: Obesity is a stigmatizing condition associated with adverse psychosocial consequences. The relative importance of weight stigma in reducing health utility or the value a person places on their current health state is unknown. METHODS: We conducted a telephone survey of patients with obesity. All were seeking weight loss surgery at two bariatric centers (70 % response rate). We assessed patients' health utility (preference-based quality life measure) via a series of standard gamble scenarios assessing patients' willingness to risk death to lose various amounts of weight or achieve perfect health (range 0 to 1; 0 = death and 1 = most valued health/weight state). Multivariable models assessed associations among quality of life domains from the Short-form 36 (SF-36) and Impact of Weight on Quality of Life-lite (IWQOL-lite) and patients' health utility. RESULTS: Our study sample (n = 574) had a mean body mass index of 46.5 kg/m(2) and a mean health utility of 0.87, reflecting the group's average willingness to accept a 13 % risk of death to achieve their most desired health/weight state; utilities were highly variable, however, with 10 % reporting a utility of 1.00 and 27 % reporting a utility lower than 0.90. Among the IWQOL-lite subscales, Public Distress and Work Life were the only two subscales significantly associated with patients' utility after adjustment for sociodemographic factors. Among the SF-36 subscales, Role Physical, Physical Functioning, and Role Emotional were significantly associated with patients' utility. When the leading subscales on both IWQOL-lite and SF-36 were considered together, Role Physical, Public Distress, and to a lesser degree Role Emotional remained independently associated with patients' health utility. CONCLUSION: Patients seeking weight loss surgery report health utilities similar to those reported for people living with diabetes or with laryngeal cancer; however, utility values varied widely with more than a quarter of patients willing to accept more than a 10 % risk of death to achieve their most valued health/weight state. Interference with role functioning due to physical limitations and obesity-related social stigma were strong determinants of reduced health utility.
    Journal of General Internal Medicine 09/2012; · 3.42 Impact Factor
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    ABSTRACT: Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, hospitalization) of questionable clinical benefit. To facilitate cost-effectiveness analyses of these interventions, utility-based measures are needed in order to estimate quality-adjusted outcomes. Nursing home residents with advanced dementia in 22 facilities were followed for 18 months (N=319). Validated health status measures ascertained from nurses at baseline, quarterly, and death (N=1702 assessments) were mapped to the Health Utilities Index Mark 2 [range, 1 (perfect health) to 0 (death); scores below 0 indicate states worse than death]. To assess validity, utility scores were compared between residents who did and did not receive burdensome interventions (parenteral therapy, percutaneous endoscopic gastrostomy tubes, and hospital transfers), residents with and without pneumonia, and residents who did and did not die at the last assessment. Mean (±SD) Health Utilities Index Mark 2 utility score for the cohort was 0.165±0.060 (range, -0.005 to 0.215). Residents spent an average of 15.5% of their days with utilities <0.10. Lower utility scores were found among residents who received burdensome interventions (0.152±0.067 vs. 0.171±0.056; P=0.0003); had pneumonia (0.147±0.066 vs. 0.170±0.057; P=0.003); and were dying (0.163±0.057 vs. 0.180±0.055; P=0.006). It is feasible to map health status measures to utility-based measures for advanced dementia. This work will facilitate future cost-effectiveness analyses aimed at quantifying the cost of interventions relative to quality-based outcomes for patients with this condition.
    Medical care 05/2012; 50(5):446-51. · 2.94 Impact Factor
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    ABSTRACT: Most elderly patients do not receive recommended preventive care, acute care, and care for chronic conditions. We conducted a controlled trial to assess the effectiveness of electronic medical record (EMR) reminders, with or without panel management, on health care proxy designation, osteoporosis screening, and influenza and pneumococcal vaccinations in patients older than 65 years. Physicians were assigned to 1 of the following 3 arms: EMR reminder, EMR reminder plus panel manager, or control. We assessed completion of recommended practices during a 1-year period. Among patients who had not already received the recommended care, health care proxy was designated in 6.5% of patients in the control arm, 8.8% of the EMR reminder arm, and 19.7% of the EMR reminder plus panel manager arm (P=.002). Bone density screening was completed in 17.7% of patients in the control arm, 19.7% of the EMR reminder arm, and 30.5% of the EMR reminder plus panel manager arm (P=.02). Pneumococcal vaccine was given to 13.1% of patients in the control arm, 19.5% of the EMR reminder arm, and 25.6% of the EMR reminder plus panel manager arm (P=.02). Influenza vaccine was given to 46.8% of patients in the control arm, 56.5% of the EMR reminder arm, and 59.7% of the EMR reminder plus panel manager arm (P=.002). Results were similar when adjusted for individual physician performance in the preceding year, patient age, patient sex, years cared for by the practice, and number of visits. Electronic medical record reminders alone facilitated improvement in vaccination rates and, when augmented by panel management, facilitated further improvement in vaccination rates and boosted the rates of health care proxy designation and bone density screening. Identifier: NCT01313169.
    Archives of internal medicine 09/2011; 171(17):1552-8. · 11.46 Impact Factor
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    ABSTRACT: Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, tube feeding) that may be of limited clinical benefit. To our knowledge, Medicare expenditures have not been extensively described in this population. Nursing home residents with advanced dementia in 22 facilities (N = 323) were followed up for 18 months. Clinical and health services use data were collected every 90 days. Medicare expenditures were described. Multivariate analysis was used to identify factors associated with total 90-day expenditures for (1) all Medicare services and (2) all Medicare services excluding hospice. Over an 18-month period, total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12,000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%). Among decedents (n = 177), mean Medicare expenditures increased by 65% in each of the last 4 quarters before death owing to an increase in both acute care and hospice. After multivariable adjustment, not living in a special care dementia unit was a modifiable factor associated with higher total expenditures for all Medicare services. Lack of a do-not-hospitalize order, tube feeding, and not living in a special care unit were associated with higher nonhospice Medicare expenditures. Medicare expenditures among nursing home residents with advanced dementia vary substantially. Hospitalizations and hospice account for most spending. Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life.
    Archives of internal medicine 05/2011; 171(9):824-30. · 11.46 Impact Factor
  • James H Ware, Mary Beth Hamel
    New England Journal of Medicine 05/2011; 364(18):1685-7. · 54.42 Impact Factor
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    ABSTRACT: Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well described. We followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months in 22 nursing homes. Data were collected to characterize the residents' survival, clinical complications, symptoms, and treatments and to determine the proxies' understanding of the residents' prognosis and the clinical complications expected in patients with advanced dementia. Over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last 3 months of life, 40.7% of residents underwent at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding). Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding (adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37). Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among such patients. Patients with health care proxies who have an understanding of the prognosis and clinical course are likely to receive less aggressive care near the end of life.
    New England Journal of Medicine 10/2009; 361(16):1529-38. · 54.42 Impact Factor
  • Marissa B Wilck, Mary Beth Hamel, Lindsey R Baden
    New England Journal of Medicine 07/2009; 360(23):e30. · 54.42 Impact Factor
  • New England Journal of Medicine 04/2009; 360(11):1141-3. · 54.42 Impact Factor
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    ABSTRACT: To exfamine patient perceptions of physician discussions and recommendations about total joint arthroplasty (TJA). Prospective cohort study. One large academic medical center and four community affiliates in Boston. One hundred seventy-four patients aged 65 and older with severe osteoarthritis of the hip or knee for at least 6 months not controlled with medications. Patient perceptions of primary care physicians' (PCPs) and orthopedists' communication about TJA were assessed at baseline for all patients and at 12 months for those who did not undergo surgery. Of the 174 patients, 49 were aged 80 and older, 82% were non-Hispanic white, and 69% had knee osteoarthritis. Eighty-seven percent of individuals with baseline interviews and a PCP (142/163) reported that they had discussed their hip or knee arthritis with their PCP at baseline, and 26% (42/163) reported that their PCP discussed TJA as a treatment option. Of the 128 patients who saw an orthopedist, 65% reported that their orthopedist recommended TJA. Only 29% (51/174) of patients underwent TJA. Those who reported discussing TJA with their PCP at baseline were more likely to undergo TJA (P<.01). Thirty-six percent (44/123) of the patients who did not undergo TJA reported that their PCP discussed surgery as a treatment option at baseline or at 12month follow-up. Patients with severe osteoarthritis of their hip or knee who report discussing TJA as a treatment option with their PCP are more likely to undergo TJA within the next year, but few older adults report having these discussions. Improvement is needed in communication between PCPs and patients about TJA.
    Journal of the American Geriatrics Society 12/2008; 57(1):82-8. · 4.22 Impact Factor
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    Mary Beth Hamel, Maria Toth, Anna Legedza, Max P Rosen
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    ABSTRACT: Osteoarthritis (OA) of the hip and knee is a common cause of pain and disability in elderly patients. Joint replacement surgery can alleviate pain and restore function but is associated with risks and discomfort. We conducted a prospective cohort study to examine decision making and clinical outcomes for elderly patients (age >or=65 years) with severe OA of the hip or knee with symptoms inadequately controlled with conservative treatments. Osteoarthritis symptoms and functional status were assessed at baseline and at 12 months. Postoperative symptoms and function were assessed 6 weeks, 6 months, and 12 months after surgery. For the 174 patients studied (mean age, 75 years; 76% were female, 17% were nonwhite, 69% had knee OA, and 31% had hip OA), the mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 56 on a 100-point scale. During a 12-month follow-up, 29% had joint replacement surgery. Of patients who had surgery, no patients died, 17% had postoperative complications, and 38% had postoperative pain lasting more than 4 weeks. The median time to recovery of independence in walking was 12 days and to ability to perform household chores was 49 days, with similar times for patients 65 to 74 years old and those 75 years or older. At 12 months, WOMAC scores improved by 24 points in the patients who had surgery and 0.5 point in the patients who did not have surgery (P < .001); improvements were 19 and 0.3 points in patients 75 or older (P < .001). Among patients who did not have surgery, 45% reported that surgery was not offered as a potential treatment option. Elderly patients who had hip or knee replacements for severe OA took several weeks to recover but experienced excellent long-term outcomes. Physicians often do not discuss joint replacement surgery with elderly patients who might benefit.
    Archives of internal medicine 07/2008; 168(13):1430-40. · 11.46 Impact Factor
  • Autumn Klein, Caren G Solomon, Mary Beth Hamel
    New England Journal of Medicine 06/2008; 358(20):e23. · 54.42 Impact Factor
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    ABSTRACT: To study whether obese individuals, who are at higher risk for diabetes and disparities in care than nonobese individuals, are more likely to have undiagnosed diabetes. We performed an analysis of 5,514 adult participants in the 1999-2004 National Health and Nutrition Examination Survey. Participants were interviewed about sociodemographic and medical data, including whether they had been diagnosed with diabetes, and were examined for height, weight, and fasting plasma glucose level >or=126 mg/dl or by previous physician diagnosis. After categorizing participants into normal weight, overweight, and obese according to BMI, the prevalence and diagnosis of diabetes across BMI categories was compared using chi(2). Of the 9.8% (weighted sample) of participants who had diabetes, based on fasting glucose levels and self-reported diagnosis, 28.1% were undiagnosed, translating to an estimated 5.2 million people in the U.S. population. The proportion undiagnosed was not significantly different among normal-weight (22.2%), overweight (32.5%), or obese adults (27.4%). Nevertheless, obese adults comprise more than half of the undiagnosed diabetes cases (2.7 million). Relative to normal-weight adults, the adjusted odds ratio (OR) for having undiagnosed diabetes was 1.50 (0.73-3.08) in overweight and 1.37 (0.72-2.63) in obese adults. Despite a higher underlying risk of diabetes and widespread clinical recognition of this higher risk, obesity does not increase the likelihood that an individual's diabetes will be diagnosed.
    Diabetes care 06/2008; 31(9):1813-5. · 7.74 Impact Factor
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    Christina C Wee, Roger B Davis, Mary Beth Hamel
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    ABSTRACT: To assess how well the SF-36, a well-validated generic quality of life (QOL) instrument, compares with its shorter adaptation, the SF-12, in capturing differences in QOL among patients with and without obesity. We compared the correlation between the physical (PCS) and mental (MCS) component summary measures of the SF-12 and SF-36 among 356 primary care patients using Pearson coefficients (r) and conducted linear regression models to see how these summary measures captures the variation across BMI. We used model R2 to assess qualitatively how well each measure explained the variation across BMI. Correlations between SF-12 and SF-36 were higher for the PCS in obese (r = 0.89) compared to overweight (r = 0.73) and normal weight patients (r = 0.75), p < 0.001, but were similar for the MCS across BMI. Compared to normal weight patients, obese patients scored 8.8 points lower on the PCS-12 and 5.7 points lower on the PCS-36 after adjustment for age, sex, and race; the model R2 was higher with PCS-12 (R2 = 0.22) than with PCS-36 (R2 = 0.16). BMI was not significantly associated with either the MCS-12 or MCS-36. The SF-12 correlated highly with SF-36 in obese and non-obese patients and appeared to be a better measure of differences in QOL associated with BMI.
    Health and Quality of Life Outcomes 02/2008; 6:11. · 2.10 Impact Factor
  • Alexie Cintron, Russell Phillips, Mary Beth Hamel
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    ABSTRACT: To examine the effect of patient-directed electronic messages on health care proxy (HCP) use. Design: Randomized control trial using an electronic message intervention to encourage patients to complete an HCP document. General medical practice at a large tertiary care teaching institution. Participants: Nine hundred twelve patients aged older than 50. We reviewed online medical records (OMRs) to assess for discussion and documentation of HCPs and to collect information on patient characteristics. We surveyed participants to determine knowledge, discussion, and completion of HCPs. Four hundred thirty participants were randomized to the intervention group and 482 to the control group. Only 1 HCP discussion (intervention group) and only 10 new HCPs (4 in intervention group versus 6 in control group, p = 0.649) were documented in the OMR. Among the 444 survey responders, 205 (46%) reported having an HCP, but only 74 (36%) of these had discussed the HCP with their doctors and only 9 (4%) had a documented HCP in the OMR. Patients in the intervention group were more likely to report knowledge of HCPs (adjusted risk ratio [RR] 1.07; 95% confidence interval [CI], 1.01-1.14) and having a plan to complete one in the future (adjusted RR 1.19; 95% CI, 1.05-1.36). This patient-directed intervention did not increase patient completion of an HCP but was associated with greater knowledge of an HCP and planning to complete one.
    Journal of Palliative Medicine 01/2007; 9(6):1320-8. · 2.06 Impact Factor
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    New England Journal of Medicine 08/2006; 355(3):310-2. · 54.42 Impact Factor
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    Erik Charlson, Anna T R Legedza, Mary Beth Hamel
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    ABSTRACT: Aortic stenosis (AS) remains the most common valvular disease of the elderly in the United States. Though valve replacement has proven effective among older adults, decision-making regarding surgery is difficult for these patients and their physicians. Herein, the clinical outcomes and decision-making process for elderly patients with severe symptomatic AS was assessed. A retrospective cohort study of patients aged > or = 60 years with severe AS was conducted at two large urban teaching hospitals. Severe AS was defined by a mean valve gradient > or = 50 mmHg or valve area < 0.8 cm2 by echocardiogram, and associated symptoms (angina, congestive heart failure, dyspnea, fatigue, or exercise intolerance). Demographic and clinical data and information about decision-making were obtained from inpatient and outpatient medical records. Of the 124 patients studied, 49 (39.5%) had aortic valve replacement (AVR) surgery. In a logistic regression analysis adjusting for gender, comorbidity and baseline functional status, those patients aged < 80 years were significantly more likely to have surgery than older patients. Surgery was associated with a large reduction in mortality in all age groups. At one-year follow up, 87.8% of all patients (87.5% of those aged > or = 80 years) who had undergone surgery were alive, while only 54.7% (49.1% of those aged > or = 80 years) who did not receive surgery were alive. Postoperative complications were similar among older and younger elderly patients. Comorbidity and age were the most common reasons for not offering elderly patients valve replacement. The results of the present study showed that AVR surgery improves the survival of elderly patients with severe AS, and patients aged > 80 years experience benefits similar to younger patients. Nevertheless, these findings suggest that surgery may not always be offered to elderly patients who might benefit from it.
    The Journal of heart valve disease 05/2006; 15(3):312-21. · 0.73 Impact Factor

Publication Stats

4k Citations
1,116.09 Total Impact Points


  • 1995–2013
    • Beth Israel Deaconess Medical Center
      • • Department of Medicine
      • • Division of General Medicine and Primary Care
      Boston, Massachusetts, United States
  • 2011–2012
    • Columbia University
      • Department of Biostatistics
      New York City, NY, United States
  • 2006–2011
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2009
    • Hebrew SeniorLife
      Cambridge, Massachusetts, United States
  • 2007
    • Icahn School of Medicine at Mount Sinai
      Manhattan, New York, United States
  • 2004
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2003
    • Medical College of Wisconsin
      • Center for Patient Care and Outcomes Research
      Milwaukee, WI, United States
  • 2002
    • University of Hawaiʻi at Mānoa
      • Department of Geriatric Medicine
      Honolulu, HI, United States
  • 2001
    • University of California, San Francisco
      • Division of Hospital Medicine
      San Francisco, CA, United States
  • 2000
    • George Washington University
      • Department of Medicine
      Washington, Washington, D.C., United States
    • Case Western Reserve University School of Medicine
      Cleveland, Ohio, United States
  • 1998
    • Yale University
      • School of Medicine
      New Haven, CT, United States