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Biomedical subjects

C S Landefeld

Publications and source records attributed to C S Landefeld.

At least 73 records · Page 4Linked to original sources
PubMed1993

Do older Medicare patients cost hospitals more? Evidence from an academic medical center.

BACKGROUND: It is uncertain, under prospective payment, if hospitals face financial disincentives to treat older Medicare patients. Therefore, we studied associations between age and hospital charges and length of stay for Medicare patients and the impact on hospital reimbursement of Medicare's decision in October 1987 to eliminate older age (> or = 70 years) as a criterion for stratifying diagnosis-related groups (DRGs). METHODS: The 23,179 medical and surgical admissions to one academic medical center in 1985 through 1989 who were aged 65 years or more were studied using a retrospective cohort design. Clinical and financial data were obtained from hospital databases; charges and length of stay for each patient were adjusted for DRG weight, the measure used to determine reimbursement. Admission severity of illness was measured for 11,060 patients using the Nursing Severity Index, a previously validated method. RESULTS: Compared with patients aged 65 to 69 years, DRG-adjusted charges were 1%, 5%, 5%, and 6% higher and DRG-adjusted length of stay was 4%, 11%, 16%, and 18% greater for patients aged 70 to 74 years, 75 to 79 years, 80 to 84 years and 85 years or more, respectively. In multivariate analyses, these estimates were similar, even after controlling for sex, race, socioeconomic status, and other variables associated with charges and length of stay. However, further controlling for severity of illness revealed that nearly all of the differences in charges and a large proportion of the differences in length of stay in older patients could be explained by their higher severity of illness. In separate stratified analyses, the association with age was stronger and more consistent in patients admitted after October 1987 and in medical patients. CONCLUSIONS: These findings suggest that currently hospitals may face financial disincentives to care for older Medicare patients and that the equitability of DRG-based hospital payments, with respect to age, may have been adversely affected by Medicare's decision to eliminate older age (> or = 70 years) as a criterion for classifying DRGs. The inclusion of patient age in prospective payment formulas may make hospital reimbursement more equitable.

Academic Medical Centers↗
PubMed1993

Rashes in immunocompromised cancer patients. The diagnostic yield of skin biopsy and its effects on therapy.

BACKGROUND AND DESIGN: Rashes in immunocompromised cancer patients can be important, and skin biopsies are often recommended for their evaluation. The objectives of this study were to determine how often skin biopsy in these patients is performed and how often it alters diagnosis and therapy. Records of all immunocompromised adults with cancer and acute rash seen by dermatology consultants on a hematology-oncology ward of a university hospital for 39 months were reviewed to determine patients' course and outcome (190 episodes of rash in 123 patients). RESULTS: Skin biopsies were performed on 108 rashes (57%); 82 rashes (43%) were evaluated without biopsy. Among the 108 patients who underwent a biopsy of their rashes, the biopsy findings supported the prebiopsy diagnosis in 51% (95% confidence interval [CI], 42% to 60%), altered it in 44% (95% CI, 35% to 53%), and did not contribute to the final diagnosis in 6% (95% CI, 2% to 12%). Fifteen of 108 biopsies (14%) (95% CI, 7% to 21%) changed systemic therapy. Most treatment changes were for cutaneous reactions to drugs; biopsy never resulted in the diagnosis of untreated systemic infection. Biopsy findings that altered diagnoses were not more likely to change therapy. Among the 82 rashes in which biopsies were not performed, review of the chart revealed no adverse sequelae (0%) (95% CI, 0% to 5%), which would have made a biopsy advisable. CONCLUSIONS: Skin biopsy findings often changed dermatologic diagnoses in immunocompromised cancer patients, but treatment changes based on biopsy results were much less common, and altered diagnoses in patients who underwent biopsy often did not change therapy. Untreated systemic infection was never diagnosed by means of a skin biopsy. Skin biopsies of these rashes may not be mandatory for either diagnostic or therapeutic reasons.

Adolescent↗
PubMed1993

Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention.

OBJECTIVE: To review (1) the clinical epidemiology of bleeding during anticoagulant therapy with heparin or warfarin, (2) data useful in estimating the risk for bleeding in individual patients, and (3) the efficacy of methods for its prevention. METHODS: Relevant literature was identified by a computerized search of the Medline database and by review of the bibliographies of original and review articles. Studies were classified according to their design. Estimates of the risk for bleeding during anticoagulant therapy, compared with the risk without therapy, were obtained from randomized trials. Estimates of the frequency of bleeding during the course of anticoagulant therapy and information about risk factors for bleeding were obtained primarily from longitudinal studies of inception cohorts of patients followed from the start of therapy. MAIN RESULTS: The average daily frequencies of fatal, major, and major or minor bleeding during heparin therapy were 0.05%, 0.8%, and 2.0%, respectively; these frequencies are approximately twice those expected without heparin therapy. The average annual frequencies of fatal, major, and major or minor bleeding during warfarin therapy were 0.6%, 3.0%, and 9.6%, respectively; these frequencies are approximately five times those expected without warfarin therapy. The risk for anticoagulant-related bleeding is highest at the start of therapy: during warfarin therapy, the risk for major bleeding during the first month of therapy is approximately 10 times the risk after the first year of therapy. An individual patient's risk for major anticoagulant-related bleeding can be estimated on the basis of specific risk factors such as the intensity of the anticoagulant effect achieved and the presence of serious comorbid diseases, especially cerebrovascular, kidney, heart, and liver disease; older age and concurrent medicines may also be independent risk factors. Major bleeding most often affects the gastrointestinal tract, soft tissues, and urinary tract. Diagnostic evaluation of gastrointestinal bleeding and gross hematuria leads to identification of previously unknown lesions in approximately one-third of cases, even when the prothrombin time is elevated. Intracranial bleeding is rare, but it is frequently fatal. The frequency of bleeding during warfarin therapy is reduced by less intense therapy achieving a prothrombin time with an International Normalized Ratio of 2.0 to 3.0, which is efficacious for most indications. CONCLUSION: Anticoagulant-related bleeding is common and often serious. The risk for bleeding can be estimated in an individual patient, giving the primary physician a quantitative basis for weighing the risks and benefits of therapy and for optimizing patient management. The frequency of anticoagulant-related bleeding is reduced by less intense warfarin therapy. Future studies should evaluate new approaches to management that may further reduce complications while maintaining efficacy.

Anticoagulants↗
PubMed1992

Guideline-based consultation to prevent anticoagulant-related bleeding. A randomized, controlled trial in a teaching hospital.

OBJECTIVE: To test the efficacy of consultation designed to prevent anticoagulant-related bleeding. DESIGN: Randomized, controlled trial. SETTING: A large teaching hospital. PATIENTS: A total of 101 patients at increased (greater than 15%) risk for major, in-hospital bleeding while starting long-term anticoagulant therapy who were identified using a validated prediction rule. INTERVENTIONS: Fifty-five patients received usual care under the direction of the attending physician who had initiated anticoagulant therapy. Forty-six patients received guideline-based consultation in addition to usual care. Guideline-based consultation included individualized review of the risks and benefits of anticoagulant therapy and, on the basis of current practice guidelines, recommendations for daily management. MEASUREMENTS: The main outcome was in-hospital bleeding, which was classified using a reliable, explicit index. RESULTS: Major or minor bleeding occurred in 17 of 55 patients (31%) receiving usual care alone, compared with 6 of 46 patients (13%) receiving consultation in addition to usual care (P = 0.03). The protective efficacy of consultation was 58% (95% CI, 3% to 82%). Consultation was associated with similar reductions in the frequencies of major bleeding (from 13% to 4%) and minor bleeding (from 18% to 9%). Consultative recommendations had an 84% compliance rate and directly affected anticoagulant management: In the consult group, nonsteroidal anti-inflammatory agents were stopped in six patients (13%), and therapeutic ranges were achieved more often for activated partial thromboplastin times (52% compared with 45% in the usual care group, P = 0.08) and for prothrombin times (47% compared with 27% in the usual care group, P less than 0.001). Nearly all housestaff and attending physicians (91%) for patients receiving consultation also reported that consultation improved housestaff learning. The consult group had a somewhat lower rate of thromboembolism in the 90 days after discharge (5% compared with 17%, P = 0.06). Death rates and mean lengths of stay were similar in the two groups. CONCLUSION: Guideline-based consultation was associated with reduction in the frequency of anticoagulant-related bleeding in patients at increased risk for major in-hospital bleeding.

Aged↗
PubMed1992

The Cleveland Veterans Affairs Medical Center firm system.

Hospital-based "firms" provide a means for combatting the fragmentation experienced by both patients and caregivers in the modern teaching hospital environment. A "firm" is an academic group practice that includes attending physicians, physician trainees, nurses, other staff, and patients. Each person's relationship with a firm lasts throughout his or her association with a particular institution. This article describes the firm system that was recently implemented on the Medical Service of the Cleveland VAMC. This system incorporates both inpatient and outpatient general medical services and provides for unbiased assignment of patients, physicians, and nurses.

Adult↗
PubMed1992

Development and validation of the Nursing Severity Index. A new method for measuring severity of illness using nursing diagnoses. Nurses of University Hospitals of Cleveland.

The purpose of this study was to develop and validate the Nursing Severity Index, a new method used to measure the admission severity of illness of hospital patients using nursing diagnoses, which categorize biologic, functional, cognitive, and psychosocial abnormalities. This retrospective cohort study with independent development and testing phases was conducted at a U.S. academic medical center. In the development phase, data regarding 14,183 adult medical-surgical patients admitted to the medical center in 1985 and 1986 was used. In the testing phase, data regarding 7,302 patients admitted in 1987 and 1988 was used. Primary nurses prospectively recorded the presence or absence of 61 nursing diagnoses on admission. Demographic and clinical data were obtained from hospital data bases. In the development phase, the number of admission nursing diagnoses was highly related (P < 0.001) to in-hospital mortality. Using multiple logistic regression, 34 nursing diagnoses were identified as independent predictors of mortality; the Nursing Severity Index equals the number of these 34 diagnoses. In the testing phase of 7,302 patients, the Nursing Severity Index was related (P < 0.001) to mortality rates, which were 0.5%, 1%, 2%, 6%, 13%, 22%, and 31% in seven hierarchical strata defined by the Index. The Index was as accurate in predicting mortality as MedisGroups (receiver-operating-characteristic curve areas, 0.814 +/- 0.016 vs. 0.845 +/- 0.015, respectively, P = 0.12). Furthermore, the Nursing Severity Index and MedisGroups together (receiver operating characteristic curve area 0.880 +/- 0.014), were more accurate (P < 0.01) than either measure alone. The Nursing Severity Index assesses multiple dimensions of illness, can be easily measured during routine patient care, accurately predicts the risk of in-hospital death, and has similar prognostic accuracy as MedisGroups. Its usefulness in outcomes assessment, quality assurance, and case management merits further study.

Academic Medical Centers↗
PubMed1991

Doctors, drug companies and gifts.

This paper by Chren and Landefeld was originally presented at the Miriam Hospital on March 21, 1991, as the 1991 Lichtman Oration, an annual meeting devoted to ethical problems in medicine honoring Herbert C. Lichtman, MD, former physician-in-chief at the hospital. Because of the importance of this paper, and its controversial character, the Journal has asked a number of practicing physicians and other concerned persons to offer their opinions on this paper. These commentaries will then be published in a subsequent issue of the Journal, along with reactions by our readers.

Drug Industry↗
PubMed1990

A bleeding risk index for estimating the probability of major bleeding in hospitalized patients starting anticoagulant therapy.

PURPOSE: To construct and test prospectively a bleeding risk index for estimating the probability of major bleeding in hospitalized patients starting long-term anticoagulant therapy. PATIENTS AND METHODS: In an inception cohort of 617 patients starting long-term anticoagulant therapy in one hospital, data were gathered retrospectively and bleeding was classified using reliable explicit criteria. We constructed a bleeding risk index by identifying and weighting independent predictors of major bleeding using a multivariate proportional-hazards model. The bleeding risk index was tested in 394 other patients prospectively identified in a second hospital. The index was compared to physicians' predictions. RESULTS: Major bleeding developed before discharge in 61 of all 1,011 patients (6%). The bleeding risk index included four independent risk factors for major in-hospital bleeding: the number of specific comorbid conditions; heparin use in patients aged 60 years or older; maximal prothrombin or partial thromboplastin time 2.0 or more times control; liver dysfunction worsening during therapy. In the testing group, the index predicted major bleeding, which occurred in 3% of 235 low-risk patients, 16% of 96 middle-risk patients, and 19% of 63 high-risk patients (p less than 0.001). The bleeding risk index performed as well as physicians' predictions, and integration of the bleeding risk index with physicians' predictions led to a classification system that was more sensitive (p = 0.03) than physicians' predictions alone. In 86% of patients with a high risk of major bleeding, we identified specific ways of improving therapy, e.g., avoiding overanticoagulation and nonsteroidal anti-inflammatory agents. CONCLUSION: The bleeding risk index provides valid estimates of the probability of major bleeding in hospitalized patients starting long-term anticoagulant therapy and complements physicians' predictions. The possibility that bleeding can be prevented in high-risk patients warrants prospective evaluation.

Aged↗
PubMed1990

Failure to limit quantities of benzodiazepine hypnotic drugs for outpatients: placing the elderly at risk.

PURPOSE: The long-term use of benzodiazepine hypnotics by the elderly is associated with serious side effects, and prescriptions of large quantities of these agents allow such use. Therefore, we determined the quantities of these agents prescribed to outpatients in our Veterans Administration teaching hospital, and the relationship of patient age to total number of doses prescribed per prescription. PATIENTS AND METHODS: Pharmacy and patient records related to 655 consecutive prescriptions for triazolam (Halcion) and flurazepam (Dalmane) were reviewed. Only 266 (41%) of the prescriptions were for 30 or fewer doses, while 178 (27%) were written for 180 or more doses. RESULTS: Thirty-six percent of prescriptions for patients aged 65 years or older were for 180 or more doses, compared with 24% for those aged 45 to 64 years old, and 16% of the prescriptions for patients less than 45 years old (p less than 0.0001). In a multivariate analysis controlling for six other factors related to the total number of doses prescribed, patients aged 65 years or older were still more likely to receive a prescription for 180 or more doses (relative risk 1.9, 95% confidence interval 1.3, 2.8). CONCLUSION: We conclude that inappropriately large quantities of benzodiazepine hypnotics were commonly prescribed, and that patients aged 65 years or older were at greatest risk for receiving such prescriptions.

Age Factors↗
PubMed1990

Clinical findings associated with acute proximal deep vein thrombosis: a basis for quantifying clinical judgment.

PURPOSE: To identify clinical findings useful in estimating the probability of acute proximal deep vein thrombosis (DVT). PATIENTS AND METHODS: The records of 355 symptomatic patients who underwent ascending venography were reviewed. Data on 76 clinical items were collected using standardized forms. Venograms were interpreted according to standard criteria and interobserver agreement was evaluated in a sample of 119 venograms. Independent clinical correlates of proximal DVT were identified using multivariate discriminant analysis in 236 randomly chosen patients; they were tested in the remaining 119 patients. RESULTS: Acute proximal DVT was shown by venogram in 96 patients (27%). Five independent clinical correlates of proximal DVT--swelling above the knee of the affected leg, swelling below the knee, recent immobility, cancer, fever--predicted proximal DVT in the testing group; in patients with none, one, or two or more of these clinical findings, proximal DVT was present in 5%, 15%, and 42%, respectively. If venography had been performed only in patients with one or more of the five factors, 97% of cases of proximal DVT would have been diagnosed and venography would have been avoided in 26% of patients with normal test results. CONCLUSION: These data provide a quantitative basis for estimating the probability of proximal DVT on the basis of clinical findings in symptomatic patients. How these findings can best be integrated with noninvasive testing and venography into diagnostic strategies for DVT remains to be determined.

Adult↗
PubMed1990

The relation of chlamydial infection of the cervix to time elapsed from the onset of menses.

To investigate the relation of chlamydial infection of the cervix to time elapsed from the onset of menses, we prospectively studied 338 women receiving routine gynecologic care in two clinical sites in which the prevalence of chlamydial infection was 3 and 6%. Eleven (13%) of 86 women evaluated in the fourth or fifth week after the onset of menses (days 22-35) had chlamydial infection compared to 4 (1.6%) of 252 women seen in the first 3 weeks (days 1-21) (p less than 0.001). For women seen in the fourth or fifth week, the relative risk of chlamydial infection was 8.1 (95% CI, 3.1-20.6). Controlling for known risk factors for chlamydial infection with multiple logistic regression analysis, the relative risk was sustained (RR 10.8; 95% CI, 3.1-37.4). We conclude that time elapsed from the onset of menses is an important independent risk factor for chlamydial infection of the cervix that may lead to more effective and efficient screening strategies.

Adult↗
PubMed1990

Outcomes in SUPPORT.

Explore the source record for details and available documents.

Activities of Daily Living↗
PubMed1989

'Brain death' and organ retrieval. A cross-sectional survey of knowledge and concepts among health professionals.

A sample of 195 physicians and nurses likely to be involved in organ procurement for transplantation was interviewed about knowledge, personal concepts, and attitudes concerning "brain death" and organ donation. Only 68 respondents (35%) correctly identified the legal and medical criteria for determining death. Personal concepts of death varied widely. Most respondents (58%) did not use a coherent concept of death consistently; others (19%) had a concept of death that was logically consistent with changing the whole-brain standard to classify anencephalics and patients in a persistent vegetative state as dead. The findings demonstrate confusion about correct criteria for determining death and differences in concepts of death that might prove troublesome to the transplantation enterprise. We conclude that health professionals should do more to resolve the clinical and conceptual issues in the definition and determination of death before policies concerning organ retrieval are changed.

Attitude of Health Personnel↗
PubMed1989

The bleeding severity index: validation and comparison to other methods for classifying bleeding complications of medical therapy.

Reports of bleeding complications of medical therapy should be based on valid methods of classification, but the reproducibility of existing methods has not been tested. Therefore, we prospectively studied three methods to classify the severity of bleeding: a purely subjective implicit method, a previously published explicit method using brief criteria, and the bleeding severity index, which is a new explicit method using detailed criteria about the amount, rate, and consequences of bleeding. Three physicians independently reviewed abstracts of 168 patients treated with anticoagulants. The proportion of cases classified as major bleeding varied widely when the implicit method was used (2, 14 and 39%), less when the old explicit method was used (28, 40 and 47%), and not at all when the new bleeding severity index was used (20, 20 and 20%). Intraobserver agreement was excellent for both explicit methods (kappa greater than or equal to 0.95). However, interobserver agreement was better for the bleeding severity index (kappa = 0.87) than for the old explicit method (kappa = 0.69) or the implicit method (kappa = 0.39). We conclude that the classification of bleeding complications of medical therapy depends on the method used. In comparison to older methods, the bleeding severity index is highly reproducible and should be tested more widely to determine whether it can be applied to the burgeoning clinical research in anticoagulation and thrombolysis.

Anticoagulants↗
PubMed1989

Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy.

PURPOSE: To determine the incidence of major bleeding in outpatients treated with warfarin and to identify predictive factors known at the start of therapy. PATIENTS AND METHODS: The records of 565 patients starting outpatient therapy with warfarin upon discharge from a university hospital were reviewed. Follow-up information was obtained for 562 patients (99.5%). Bleeding was classified as major or minor using explicit criteria. The cumulative incidence of bleeding was estimated by means of survival analysis. Independent risk factors for major bleeding were identified using Cox regression analysis in 375 randomly chosen patients; they were tested in the remaining 187 patients. RESULTS: Major bleeding occurred in 65 patients (12%) and was fatal in 10 patients (2%). The cumulative incidences of major bleeding at one, 12, and 48 months were 3%, 11%, and 22%, respectively. The monthly risk of major bleeding decreased over time, from 3% during the first month of outpatient therapy to 0.3% per month after the first year of therapy. Five independent risk factors for major bleeding--age 65 years or greater, history of stroke, history of gastrointestinal bleeding, a serious comorbid condition (recent myocardial infarction, renal insufficiency, or severe anemia), atrial fibrillation--predicted major bleeding in the testing group; the cumulative incidence of major bleeding at 48 months was 2% in 57 low-risk patients, 17% in 110 middle-risk patients, and 63% in 20 high-risk patients. CONCLUSION: These findings provide a quantitative basis for evaluating the risk of major bleeding in individual patients at the start of outpatient therapy with warfarin. Whether the risk of bleeding can be reduced in high-risk patients without reducing the benefit of therapy remains to be determined.

Adolescent↗
PubMed1989

Bleeding in outpatients treated with warfarin: relation to the prothrombin time and important remediable lesions.

PURPOSE: To determine the relation of bleeding to prothrombin times and important remediable lesions in outpatients treated with warfarin. PATIENTS AND METHODS: An inception cohort of 565 patients starting outpatient therapy with warfarin on discharge from a university hospital was assembled. Detailed records of outpatient prothrombin times were obtained for 103 of 130 case subjects with major or minor bleeding and for 117 control patients without bleeding. A nested case-control design was used to evaluate the association of bleeding with temporally related prothrombin times; odds ratios were estimated using multivariate logistic regression analysis to control for known predictors of major bleeding. The relation of bleeding to important remediable lesions was determined in all 130 cases of bleeding. RESULTS: For each 1.0 increase in the prothrombin time-to-control ratio, the odds ratio for major bleeding during the week after a prothrombin time measurement increased 80%; the odds ratio for minor bleeding increased 50%. These odds ratios were lower during the first month of therapy and higher thereafter. Bleeding was related to important remediable lesions in 49 of 130 cases (38%), but these lesions were unknown before bleeding in only 22 cases (17%). The mean prothrombin time rose sharply at the time of bleeding in patients without important remediable lesions, but not in patients with lesions. New, previously unknown lesions (including nine malignancies) were discovered in 20 of 59 case subjects (34%) with gastrointestinal bleeding or hematuria, but in only two of 71 case subjects (3%) with other bleeding (p less than 0.001). CONCLUSION: Our results provide a valid quantitative basis for estimating the odds of bleeding in relation to the prothrombin time and the yield of diagnostic evaluation in patients with bleeding.

Aged↗