Search PubMed⌕ Search

Biomedical subjects

N V Dawson

Publications and source records attributed to N V Dawson.

At least 37 records · Page 2Linked to original sources
PubMed1998

Outcomes of acute exacerbation of severe congestive heart failure: quality of life, resource use, and survival. SUPPORT Investigators. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Congestive heart failure (CHF) is a common disease with high health care costs and high mortality rates. Knowledge of the health-related quality of life outcomes of CHF may guide decision making and be useful in assessing new therapies for this population. METHODS: A prospective cohort study was conducted involving 1390 adult patients hospitalized with an acute exacerbation of severe CHF (New York Heart Association class III-IV). Demographic data and health-related quality of life were determined by interview; physiologic status and cost and intensity of care were determined from hospital charts. RESULTS: The median (25th, 75th percentiles) age of patients was 68.0 (58.2, 76.9) years; 61.7% were male. Survival was 93.4% at discharge from the index hospitalization, 72.9% at 180 days, and 61.5% at 1 year. Of patients interviewed at 180 days, the median health rating on a scale of 0 to 100 (0 indicates death; 100, excellent health) was 60 (interquartile range, 50-80), and 59.7% were independent in their activities of daily living. Overall quality of life was reported to be good, very good, or excellent in 58.2% at 180 days. Patients with worse functional capacity were more likely to die. Health perceptions among the patients with available interview data improved at 60 and 180 days after acute exacerbation of severe CHF. CONCLUSIONS: Patients hospitalized for acute exacerbation of severe CHF have a generally poor 6-month survival, but survivors retain relatively good functional status and have good health perceptions. Furthermore, health perceptions improve after the acute exacerbation.

Acute Disease↗
PubMed1998

Depressed mood and survival in seriously ill hospitalized adults. The SUPPORT Investigators.

OBJECTIVES: To assess the relationship among depressed mood, physical functioning, and severity of illness and to determine the relationship between depressed mood and survival time, controlling for severity of illness, baseline functioning, and characteristics of patients. METHODS: Prospective cohort study of data for 3529 seriously ill hospitalized adults who received care at 5 tertiary care teaching hospitals and who completed a depressed mood assessment 7 to 11 days after admission to the study. The Profile of Mood States depression subscale was used to assess depressed mood. A stratified Cox proportional hazards model was used to assess the independent effect of depressed mood on survival time, adjusting for demographic characteristics of patients and health status. RESULTS: Greater magnitudes of depressed mood were associated with worse levels of physical functioning (r = 0.151; P < .001) and more severity of illness. Depressed mood was associated with reduced survival time after adjusting for patient demographics and health status (hazards ratio, 1.134; 95% confidence interval, 1.071-1.200; P < or = .001). CONCLUSION: Seriously ill patients should be assessed for the presence of depressed mood even if they have not been given a diagnosis of depression. Further study is needed to determine whether interventions aimed at relieving depressed mood may improve prognosis.

Affect↗
PubMed1998

Health values of hospitalized patients 80 years or older. HELP Investigators. Hospitalized Elderly Longitudinal Project.

CONTEXT: Health values (utilities or preferences for health states) are often incorporated into clinical decisions and health care policy when issues of quality vs length of life arise, but little is known about health values of the very old. OBJECTIVE: To assess health values of older hospitalized patients, compare their values with those of their surrogate decision makers, investigate possible determinants of health values, and determine whether health values change over time. DESIGN: A prospective, longitudinal, multicenter cohort study. SETTING: Four academic medical centers. PARTICIPANTS: Four hundred fourteen hospitalized patients aged 80 years or older and their surrogate decision makers who were interviewed and understood the task. MAIN OUTCOME MEASURES: Time-trade-off utilities, reflecting preferences for current health relative to a shorter but healthy life. RESULTS: On average, patients equated living 1 year in their current state of health with living 9.7 months in excellent health (mean [SD] utility, 0.81 [0.28]). Although only 126 patients (30.7%) rated their current quality of life as excellent or very good, 284 (68.6%) were willing to give up at most 1 month of 12 in exchange for excellent health (utility > or =0.92). At the other extreme, 25 (6.0%) were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility < or =0.04). Patients were willing to trade significantly less time for a healthy life than their surrogates assumed they would (mean difference, 0.05; P=.007); 61 surrogates (20.3%) underestimated the patient's time-trade-off score by 0.25 (3 months of 12) or more. Patients willing to trade less time for better health were more likely to want resuscitation and other measures to extend life. Time-trade-off score correlated only modestly with quality-of-life rating (r=0.28) and inversely with depression score (r=-0.27), but there were few other clinical or demographic predictors of health values. When patients who survived were asked the time-trade-off question again at 1 year, they were willing to trade less time for better health than at baseline (mean difference, 0.04; P=.04). CONCLUSION: Very old hospitalized patients who could be interviewed were able, in most cases, to have their health values assessed using the time-trade-off technique. Most patients were unwilling to trade much time for excellent health, but preferences varied greatly. Because proxies and multivariable analyses cannot gauge health values of elderly hospitalized patients accurately, health values of the very old should be elicited directly from the patient.

Advance Directives↗
PubMed1998

Physician experience caring for dying patients and its relationship to patient outcomes.

BACKGROUND: The quality of end-of-life care has become important to care systems and the public. No research has assessed how physician factors affect patient and family experience. OBJECTIVE: The objective of this study was to examine whether physicians' experience with dying is associated with differences in their patients' experiences while dying. METHODS: This was a prospective cohort study. Data were obtained from five geographically diverse teaching hospitals. The survey population was composed of 765 attending physicians who had at least one patient enrolled in a study of those with a high risk of dying. The patients were 8203 hospitalized adults who were at least 80 years of age or had one of nine serious illnesses. The physician survey provided information about physician characteristics. Physician experience with death was stratified into five groups according to self-reported rate of dying patients in the physician's practice. Patient outcomes included pain, anxiety, depression, satisfaction with pain relief, presence and timing of do-not-resuscitate orders, concordance with their physicians about cardiopulmonary resuscitation, and hospital resource use. RESULTS: Oncologists and pulmonologists or critical care physicians had more frequent contact with death. Physician characteristics other than specialty were not associated with death experience. Compared with the physician group having no experience with death, the adjusted odds ratios for accord on resuscitation preferences were 1.38 (95% confidence interval [CI], 0.96 to 1.98), 1.47 (95% CI, 1.03 to 2.11), 1.58 (95% CI, 1.10 to 2.26), and 1.64 (95% CI, 1.09 to 2.46) for the other four physician groups with progressively increasing experience. Other outcomes for patients were not associated with increasing physician experience. CONCLUSION: Most physicians have little experience with dying, and physicians' experience with death has little effect on patient outcomes. The concentration of experience in a small segment of physicians offers opportunities for targeting improvements in the care of dying patients, including physician education.

Journal Article↗
PubMed1997

A prognostic model for patients with end-stage liver disease.

BACKGROUND & AIMS: Survival of patients with end-stage liver disease is variable and difficult to predict. A two-phase prospective cohort study was conducted at five teaching hospitals to develop and evaluate a model for prediction of death. METHODS: Five hundred thirty-eight hospitalized patients with a history of chronic liver disease and two or more signs of decompensation were studied. RESULTS: The cumulative incidence of death was 30% at 30 days and 50% at 6 months. In 295 patients in phase I, time till death was independently associated (P < 0.01) with five factors measured on study day 3: renal insufficiency, cognitive dysfunction, ventilatory insufficiency, age > or = 65 years, and prothrombin time > or = 16 seconds. These risk factors stratified 243 patients in phase II into three groups with cumulative incidences of death at 30 days of 12%, 40%, and 74%, respectively. Integration of the prognostic model with physicians' predictions led to improved estimates of the probability of death. Although performance of liver transplantation after study entry was independently associated with enhanced survival, the intensity of other acute therapies was not. CONCLUSIONS: Five risk factors were associated with the risk of death in patients with end-stage liver disease and provided a quantitative basis to complement physicians' prognostic estimates.

Adult↗
PubMed1996

The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators.

OBJECTIVE: To examine the association between the use of right heart catheterization (RHC) during the first 24 hours of care in the intensive care unit (ICU) and subsequent survival, length of stay, intensity of care, and cost of care. DESIGN: Prospective cohort study. SETTING: Five US teaching hospitals between 1989 and 1994. SUBJECTS: A total of 5735 critically ill adult patients receiving care in an ICU for 1 of 9 prespecified disease categories. MAIN OUTCOME MEASURES: Survival time, cost of care, intensity of care, and length of stay in the ICU and hospital, determined from the clinical record and from the National Death Index. A propensity score for RHC was constructed using multivariable logistic regression. Case-matching and multivariable regression modeling techniques were used to estimate the association of RHC with specific outcomes after adjusting for treatment selection using the propensity score. Sensitivity analysis was used to estimate the potential effect of an unidentified or missing covariate on the results. RESULTS: By case-matching analysis, patients with RHC had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03-1.49). The mean cost (25th, 50th, 75th percentiles) per hospital stay was $49 300 ($17 000, $30 500, $56 600) with RHC and $35 700 ($11 300, $20 600, $39 200) without RHC. Mean length of stay in the ICU was 14.8 (5, 9, 17) days with RHC and 13.0 (4, 7, 14) days without RHC. These findings were all confirmed by multivariable modeling techniques. Subgroup analysis did not reveal any patient group or site for which RHC was associated with improved outcomes. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death following RHC. Sensitivity analysis suggested that a missing covariate would have to increase the risk of death 6-fold and the risk of RHC 6-fold for a true beneficial effect of RHC to be misrepresented as harmful. CONCLUSION: In this observational study of critically ill patients, after adjustment for treatment selection bias, RHC was associated with increased mortality and increased utilization of resources. The cause of this apparent lack of benefit is unclear. The results of this analysis should be confirmed in other observational studies. These findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study.

APACHE↗
PubMed1996

Factors associated with change in resuscitation preference of seriously ill patients. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: During serious illness, patient preferences regarding life-sustaining treatments play an important role in medical decisions. However, little is known about life-sustaining preference stability in this population or about factors associated with preference change. METHODS: We evaluated 2-month cardiopulmonary resuscitation (CPR) preference stability in a cohort of 1590 seriously ill hospitalized patients at 5 acute care teaching hospitals. Using multiple logistic regression, we measured the association of patient demographic and health-related factors (quality of life, function, depression, prognosis, and diagnostic group) with change in CPR preference between interviews. RESULTS: Of 1590 patients analyzed, 73% of patients preferred CPR at baseline interview and 70% chose CPR at follow-up. Preference stability was 80% overall-85% in patients initially preferring CPR and 69% in those initially choosing do not resuscitate (DNR). For patients initially preferring CPR, older age, non-African American race, and greater depression at baseline were independently associated with a change to preferring DNR at follow-up. For patients initially preferring DNR, younger age, male gender, less depression at baseline, improvement in depression between interviews, and an initial admission diagnosis of acute respiratory failure or multiorgan system failure were associated with a change to preferring CPR at follow-up. For patients initially preferring DNR, patients with substantial improvements in depression score between interviews were more than 5 times as likely to change preference to CPR than were patients with substantial worsening in depression score. CONCLUSIONS: More than two thirds of seriously ill patients prefer CPR for cardiac arrest and 80% had stable preferences over 2 months. Factors associated with preference change suggest that depression may lead patients to refuse life-sustaining care. Providers should evaluate mood state when eliciting patients' preferences for life-sustaining treatments.

Cardiopulmonary Resuscitation↗
PubMed1996

Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)

In order to describe the outcomes of patients hospitalized with an acute exacerbation of severe chronic obstructive pulmonary disease (COPD) and determine the relationship between patient characteristics and length of survival, we studied a prospective cohort of 1,016 adult patients from five hospitals who were admitted with an exacerbation of COPD and a PaCO2 of 50 mm Hg or more. Patient characteristics and acute physiology were determined. Outcomes were evaluated over a 6 mo period. Although only 11% of the patients died during the index hospital stay, the 60-d, 180-d, 1-yr, and 2-yr mortality was high (20%, 33%, 43%, and 49%, respectively). The median cost of the index hospital stay was $7,100 ($4,100 to $16,000; interquartile range). The median length of the index hospital stay was 9 d (5 to 15 d). After discharge, 446 patients were readmitted 754 times in the next 6 mo. At 6 mo, only 26% of the cohort were both alive and able to report a good, very good, or excellent quality of life. Survival time was independently related to severity of illness, body mass index (BMI), age, prior functional status, PaO2/FI(O2), congestive heart failure, serum albumin, and the presence of cor pulmonale. Patients and caregivers should be aware of the likelihood of poor outcomes following hospitalization for exacerbation of COPD associated with hypercarbia.

APACHE↗
PubMed1995

Health values of the seriously ill. SUPPORT investigators.

OBJECTIVE: To assess 1) the health values and health ratings of seriously ill hospitalized patients, their surrogate decision makers, and their physicians; 2) the determinants of health values; and 3) whether health values change over time. DESIGN: Prospective, longitudinal, multicenter study. SETTING: 5 academic medical centers. PARTICIPANTS: 1438 seriously ill patients with at least one of nine diseases who had a projected overall 6-month mortality rate of 50%; their surrogates; and their physicians. MEASUREMENTS: Time-tradeoff utilities (reflecting preferences for a shorter but healthy life) and health ratings. RESULTS: At study day 3, patients had a mean time-tradeoff utility of 0.73 +/- 0.32 (median [25th, 75th percentile], 0.92 [0.63, 1.0]), indicating that they equated living 1 year in their current state of health with living 8.8 months in excellent health. However, scores varied widely; 34.8% of patients were unwilling to exchange any time in their current state of health for a shorter life in excellent health (utility, 1.0), and 9.0% were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility, 0.04). Health rating scores averaged 57.8 +/- 24.0 (median [25th percentile, 75th percentile], 60 [50, 75]) on a scale of 0 (death) to 100 (perfect health). The patients' mean time-tradeoff score exceeded that of their paired surrogates (n = 1041) by 0.08 (P < 0.0001). Time-tradeoff scores were related to psychosocial well-being; health ratings; desire for resuscitation and extension of life rather than relief of pain and discomfort; degree of willingness to live with constant pain; and perceived prognosis for survival and independent functioning. Scores of surviving patients increased by an average of 0.06 after 2 months (P < 0.0001) and 0.08 after 6 months (P < 0.0001). CONCLUSIONS: Health values of seriously ill patients vary widely, are higher than patients' surrogates believe, are related to few other preference and health status measures, and increase over time.

Aged↗
PubMed1995

The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments.

OBJECTIVE: To develop and validate a prognostic model that estimates survival over a 180-day period for seriously ill hospitalized adults (phase I of SUPPORT [Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments]) and to compare this model's predictions with those of an existing prognostic system and with physicians' independent estimates (SUPPORT phase II). DESIGN: Prospective cohort study. SETTING: 5 tertiary care academic centers in the United States. PARTICIPANTS: 4301 hospitalized adults were selected for phase I according to diagnosis and severity of illness; 4028 patients were evaluated from phase II. MEASUREMENTS: A survival model was developed using the following predictor variables: diagnosis, age, number of days in the hospital before study entry, presence of cancer, neurologic function, and 11 physiologic measures recorded on day 3 after study entry. Physicians were interviewed on day 3. Patients were followed for survival for 180 days after study entry. RESULTS: The area under the receiver-operating characteristics (ROC) curve for prediction of surviving 180 days was 0.79 in phase I, 0.78 in the phase II independent validation, and 0.78 when the acute physiology score from the APACHE (Acute Physiology, Age, Chronic Health Evaluation) III prognostic scoring system was substituted for the SUPPORT physiology score. For phase II patients, the SUPPORT model had equal discrimination and slightly improved calibration compared with physician's estimates. Combining the SUPPORT model with physician's estimates improved both predictive accuracy (ROC curve area = 0.82) and the ability to identify patients with high probabilities of survival or death. CONCLUSIONS: A limited amount of readily available clinical information can provide a foundation for long-term survival estimates that are as accurate as physicians' estimates. The best survival estimates combine an objective prognosis with a physician's clinical estimate.

APACHE↗
PubMed1995

Preferences for cardiopulmonary resuscitation: physician-patient agreement and hospital resource use. The SUPPORT Investigators.

OBJECTIVE: To describe the association between hospital resource utilization and physicians' knowledge of patient preferences for cardiopulmonary resuscitation (CPR) among seriously ill hospitalized adult patients. DESIGN: Prospective cohort study. SETTING: Five U.S. academic medical center, 1989-1991. PATIENTS: A sample of 2,636 patients with self- or surrogate interviews and matching physician interviews describing patient preferences for CPR, from a cohort of 4,301 patients with life-threatening illnesses enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). MEASURES: Patient, surrogate, and physician reports of preferences for resuscitation, and resource use derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1990 dollars. RESULTS: Nearly one-third of the patients preferred to forego resuscitation. Of the 2,636 paired physician-patient answers, nearly one-third did not agree about preferences for resuscitation. The physicians' views of the patients' preferences and those preferences themselves were both associated with resource use. Standardized adjusted hospital resource consumption, expressed as average cost in dollars during the enrollment hospitalization, was lowest when the physician agreed with the patient preference for a do-not-resuscitate order ($20,527), and highest when the patient did not have a preference and the physician believed the patient wanted resuscitation in the case of a cardiopulmonary arrest ($34,829). Hospital resource use was intermediate when patient-physician pairs evidenced either lack of agreement or communication, or awareness of options about resuscitation. CONCLUSIONS: Both physician and patient preferences for CPR influence total hospital resource consumption. Physician misunderstanding of patient preferences to forego CPR was associated with increased use of hospital resources, and could have led to a course of care at odds with patients' expressed preferences in the event of cardiac arrest. Increasing physicians' knowledge of patient preferences, and increasing communication to help patients understand that options for medical care that include foregoing resuscitation efforts, might reduce hospital expenditures for the seriously ill.

Academic Medical Centers↗
PubMed1993

Physician judgment in clinical settings: methodological influences and cognitive performance.

Understanding the quality of physicians' intuitive judgments is essential in determining the appropriate use of their judgments in medical decision-making (vis-a-vis analytical or actuarial approaches). As part of this process, the quality of physicians' predictions must be assessed because prediction is fundamental to common clinical tasks: determining diagnosis, prognosis, and therapy; establishing monitoring intervals; performing screening and preventive maneuvers. Critical evaluation of predictive capabilities requires an assessment of the components of the prediction process: the data available for prediction, the method used for prediction, and the accuracy of prediction. Although variation in and uncertainty about the underlying data elements are often acknowledged as a source of inaccurate predictions, prediction also can be confounded by both methodological and cognitive limitations. During the past two decades, numerous factors have been recognized that may bias test characteristics (sensitivity and specificity). These same factors may also produce bias in intuitive judgments. The use of cognitive processes to simplify judgment tasks (e.g., the availability and representativeness heuristics) and the presence of certain biases in the judgment process (e.g., ego, regret) may present obstacles to accurate estimation of probabilities by physicians. Limitations on the intuitive use of information (cognitive biases) have been demonstrated in both medical and nonmedical decision-making settings. Recent studies have led to a deepening understanding of the advantages and disadvantages of intuitive and analytical approaches to decision making. Here, many aspects of the basis for this understanding are reviewed.

Chemistry, Clinical↗
PubMed1993

Aggressive therapy does not substantially alter the long-term course of rheumatoid arthritis. So what else is new?

A consensus has evolved that there is little evidence supporting the view that the second line agents significantly alter long-term outcomes in rheumatoid arthritis. Consequently, changes in approaches to treatment currently being employed include earlier use of existing second line agents, their use in combinations, and greater use of corticosteroids. Our awareness that our current drugs, at best, fall considerably short of attaining the therapeutic results we would like to achieve causes us to look forward to the development of rationally derived biologic agents with considerable anticipation.

Arthritis, Rheumatoid↗
PubMed1991

A risk-benefit analysis of elective bilateral oophorectomy: effect of changes in compliance with estrogen therapy on outcome.

A bilateral oophorectomy at the time of elective hysterectomy is often performed to prevent ovarian cancer. The assumption that endogenous estrogen can be easily replaced with supplemental medication fosters the decision for routine oophorectomy. Published reports on the use of postmenopausal estrogen indicate that compliance is less than perfect. This fact could affect the overall outcome. Decision analysis techniques with Markov cohort modeling were used to evaluate the policy of elective bilateral oophorectomy. Results from studies judged methodologically sound were combined to determine values representing the influence of estrogen on coronary heart disease, breast cancer, and osteoporotic fracture. The decision tree also explicitly incorporated patient compliance. When compliance with estrogen therapy is assumed to be perfect, oophorectomy yields longer life expectancy than retaining the ovaries. When actual drug-taking behavior is considered, retaining the ovaries results in longer survival. This analysis highlights the importance of including the effects of patient compliance with treatment recommendations when the impact of a health policy decision such as prophylactic surgery is assessed.

Adult↗
PubMed1991

Organizing the Metro Firm System for research.

During the mid-1970s, four similar groups of patients and providers were created with the institution of the Firm System at Cleveland Metropolitan General Hospital (Metro). In the early 1980s, ongoing randomization was initiated for patients and physicians, setting the stage for the performance of randomized controlled trials. Techniques such as stratification and blocking are used with randomization to ensure that equivalent numbers and characteristics of patients and physicians are distributed among the firms. Comparability of key patient and physician features across firms has been documented during the baseline periods of several recent firm studies. Dissimilarities among firms can occur secondary to differential drop-out of patients (residue cohort effect), or to administrative decisions that adversely affect the structural or operational integrity of the system. Prestudy evaluations of equivalence and vigilant system maintenance programs are methods to identify and minimize important differences among firms.

Female↗