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OBJECTIVE:The Acute Physiology and Chronic Health Evaluation II (APACHE II) was developed to predict intensive-care unit (ICU) resource utilization. This study tested APACHE II's ability to predict long-term survival of patients with chronic obstructive pulmonary disease (COPD) admitted to general medical floors. DESIGN:We performed a retrospective cohort study of patients admitted for COPD exacerbation outside the ICU. APACHE II scores were calculated by chart review. Mortality was determined by the Social Security Death Index. We tested the association between APACHE II scores and long-term mortality with Cox regression and logistic regression. PATIENTS:The analysis included 92 patients admitted for COPD exacerbation in two Burlington, Vermont hospitals between January 1995 and June 1996. In addition to ICU resource utilization, the APACHE II has been used to predict long-term survival. The APACHE II score is strongly associated with long-term survival in general cohorts of ICU patients. 5,6 It is less predictive of long-term survival with selected cohorts of ICU patients such as in-hospital survivors of cardiopulmonary arrest and patients with Pneumocystis carinii infection. MEASUREMENTS AND MAIN RESULTS: 7,8The APACHE II has rarely been studied outside the ICU. Rubin et al. found a monotonic inverse relationship between APACHE II score and 30-day survival in patients receiving a transjugular intrahepatic portosystemic shunt. El-Shahawy et al. found that APACHE II score was correlated with mortality in 222 patients with acute tubular necrosis.10 Extending the APACHE II outside the ICU may be useful in predicting long-term survival. Patients with chronic obstructive pulmonary disease (COPD) exacerbation represent a spectrum of disease with a wide range of acuity. We suspect the pathophysiology of COPD exacerbation in patients admitted to the general medical floor is similar to the disease process in patients admitted to the ICU. Many of the components of APACHE II (i.e., age, oxygenation, anemia, renal insufficiency, and immunosuppression) appear to be related to mortality. This makes COPD exacerbation a good candidate disease for extending the APACHE II outside the ICU.The APACHE II has been used to predict inpatient and long-term survival in COPD patients admitted to the ICU. 11,12 Afessa et al. studied 180 patients admitted to an ICU for COPD exacerbation requiring intubation.11 APACHE II score was independently associated with hospital outcome. Breen et al. studied 74 patients admitted to the ICU for COPD exacerbation and found the partial presence of carbon dioxide (pCO 2 ) and APACHE II scores were independently associated with inpatient mortality. 12 They found no significant predictors of long-term survival.

Clinicians with samples in their clinics were less likely to prescribe preferred medications for hypertension and depression.

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OBJECTIVE -This study analyzed lipid results from a large community-based population of patients with diabetes to assess the feasibility of attaining the standard and new optional LDLbased lipid goals using currently available lipid-lowering medications.RESEARCH DESIGN AND METHODS -Ambulatory patients with diabetes who were interviewed as part of the Vermont Diabetes Information System trial with a reported LDL were analyzed. Patients were categorized into high-risk and very-high-risk cardiovascular status. For patients not at the LDL goal, the required changes in therapy to achieve the goal were assessed.RESULTS -Of the entire cohort, 49.4% (321 of 650) had LDL Ͻ100 mg/dl. According to the National Cholesterol Education Program, 29.4% (191 of 650) of patients were very high risk and have an optional LDL goal of Ͻ70 mg/dl. Only 15.7% (30 of 191) of very-high-risk patients had an LDL Ͻ70 mg/dl. Based on our analysis of high-risk patients, 17 of 459 (3.7%) would require more than two lipid-lowering drugs to achieve an LDL Ͻ100 mg/dl. In the very-high-risk group, we estimate that 26.2% (50 of 191) of patients will not reach LDL Ͻ70 mg/dl with two lipidlowering medications.CONCLUSIONS -In many patients with diabetes and cardiovascular disease, it will be difficult to attain an LDL goal of Ͻ70 mg/dl. Approximately 25% of patients will require more than two lipid-lowering drugs at maximal doses to attain this goal, assuming 100% tolerance of lipid-lowering medications. Recently, the NCEP released a report providing updated recommendations, which includes an "optional" LDL goal of Ͻ70 mg/dl for patients who are at "very high risk" for cardiovascular heart disease (2). Very high risk is defined as patients with established CVD plus one or more of the following: patients with multiple risk factors (including diabetes), severe and poorly controlled risk factors, multiple risk factors of the metabolic syndrome, and acute coronary syndromes. Diabetes CareTo effectively manage hypercholesterolemia, many patients require lipidlowering medications. Potent lipidlowering medications are available, including hydroxymethylglutaryl-CoA reductase inhibitors (i.e., statins), ezetimibe, fibrates, niacin, and bile acid sequestrants. Based on the updated report, statins should be prescribed using at least "standard" doses of LDL-lowering drugs, defined as doses that are expected to provide a 30 -40% reduction in LDL levels (2).Despite available therapies and increased attention to hypercholesterolemia, many patients fail to achieve LDL goals (3-4). Data from the third U.S. National Health and Nutrition Examination Survey (NHANES; 1988-1994 showed only 42% of patients with diabetes achieved an LDL Ͻ130 mg/dl (5). More recent data demonstrated only 22.5% of patients with diabetes in a managed care sample achieved an LDL Ͻ100 mg/dl (6). Further, data from 1996 to 1998 showed patients with diabetes were 26% less likely to have a lipid profile than patients without diabetes (7). Many patients with diabetes will meet the criteria for very hig...