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Biomedical subjects

R S Phillips

Publications and source records attributed to R S Phillips.

At least 127 records · Page 7Linked to original sources
PubMed1996

Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatmentm.

OBJECTIVES: To evaluate the pain experience of seriously ill hospitalized patients and their satisfaction with control of pain during hospitalization. To understand the relationship of level of pain and dissatisfaction with pain control to demographic, psychological, and illness-related variables. DESIGN: Prospective, cohort study. SETTING: Five teaching hospitals. PATIENTS: Patients for whom interviews were available about pain (n = 5,176) from a total of 9,105 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were interviewed after study enrollment about their experiences with pain. When patients could not be interviewed due to illness, we used surrogate (usually a family member) responses calibrated to patient responses (from the subset of interviews with both patient and surrogate responses). Ordinal logistic regression was used to study the association of variables with level of pain and satisfaction with its control. Nearly 50% of patients reported pain. Nearly 15% reported extremely severe pain or moderately severe pain occurring at least half of the time, and nearly 15% of those patients with pain were dissatisfied with its control. After adjustment for confounding variables, older and sicker patients reported less pain, while patients with more dependencies in activities of daily living, more comorbid conditions, more depression, more anxiety, and poor quality of life reported more pain. Patients with colon cancer reported more pain than patients in other disease categories. Levels of reported pain varied among the five hospitals and also by physician specialty. After adjustment for confounding variables, dissatisfaction with pain control was more likely among patients with more severe pain, greater anxiety, depression, and alteration of mental status, and lower reported income; dissatisfaction with pain control also varied among study hospitals and by physician specialty. CONCLUSIONS: Pain is common among severely ill hospitalized patients. The most important variables associated with pain and satisfaction with pain control were patient demographics and those variables that reflected the acute illness. Pain and satisfaction with pain control varied significantly among study sites, even after adjustment for many potential confounders. Better pain management strategies are needed for patients with the serious and common illnesses studied in SUPPORT.

Adult↗
PubMed1996

Seriously ill hospitalized adults: do we spend less on older patients? Support Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatments.

OBJECTIVE: To determine the effect of age on hospital resource use for seriously ill adults, and to explore whether age-related differences in resource use are explained by patients' severity of illness and preferences for life-extending care. STUDY DESIGN: Prospective cohort study. SETTING: Five geographically diverse academic acute care medical centers participating in the SUPPORT Project. PATIENTS: A total of 4301 hospitalized adults with at least one of nine serious illnesses associated with an average 6-month mortality of 50%. MEASUREMENTS: Resource utilization was measured using a modified version of the Therapeutic Intervention Scoring System (TISS); the performance of three invasive procedures (major surgery, dialysis, and right heart catheter placement); and estimated hospital costs. RESULTS: The median patient age was 65; 43% were female, and 48% died within 6 months. After adjustment for severity of illness, prior functional status, and study site, when compared with patients younger than 50, patients 80 years or older were less likely to undergo major surgery (adjusted odds ratio .46), dialysis (.19), and right heart catheter placement (.59) and had median TISS scores and estimated hospital costs that were 3.4 points and $ 71.61 lower, respectively. These differences persisted after further adjustment for patients' preferences for life-extending care. CONCLUSIONS: Compared with similar younger patients, seriously ill older patients receive fewer invasive procedures and hospital care that is less resource-intensive and less costly. This preferential allocation of hospital services to younger patients is not based on differences in patients' severity of illness or general preferences for life-extending care.

Academic Medical Centers↗
PubMed1996

Reconstitution of B-cell-depleted mice with B cells restores Th2-type immune responses during Plasmodium chabaudi chabaudi infection.

In mice depleted of B cells from birth by treatment with anti-immunoglobulin M(mu) antibodies, progression from a Th1- to a Th2-regulated immune response during primary infection with Plasmodium chabaudi chabaudi fails to occur. While Th1-type immunity limits parasitemia, in the absence of B cells, chronic low-grade infections persist. Here, we show that reconstituting immune, and to a lesser extent naive, B cells to mice rendered deficient in B-cell function through anti-immunoglobulin M(mu) pretreatment restores the CD4+ T-cell response to the Th2 type later in P. c. chabaudi infection and with it the capacity to eliminate infection. This finding provides clear evidence that B cells are required for switching the balance of immune regulation between CD4+ T cells from Th1 to Th2 during P.c. chabaudi infection and supports the concept that B cells, through antibody production, are needed for effective antimalarial immunity.

Animals↗
PubMed1996

Portal hypertensive gastropathy.

PHG is a common condition that is now recognized as a complication of advanced liver disease. This vascular disorder has been shown to be a significant cause of upper gastrointestinal bleeding in patients with portal hypertension. Although its pathogenesis is directly related to portal hypertension, the exact mechanisms remain to be determined. Decreased mucosal blood flow and passive congestion of the gastric submucosal layer appear to play a role in the development of PHG. Its endoscopic appearance is characterized by a "snake skin" mucosal pattern with gastric biopsies revealing vascular congestion. PHG may present as either acute or chronic gastrointestinal bleeding and has been noted to worsen after endoscopic sclerotherapy and band ligation therapy for esophageal varices. Unlike variceal bleeding, this condition cannot be treated with either sclerotherapy or band ligation. Effective treatment requires a reduction in portal pressure. This can be accomplished through the use of beta-blockers, radiographic or surgical shunting, or liver transplantation.

Animals↗
PubMed1995

Site-directed mutagenesis of tyrosine-71 to phenylalanine in Citrobacter freundii tyrosine phenol-lyase: evidence for dual roles of tyrosine-71 as a general acid catalyst in the reaction mechanism and in cofactor binding.

Tyr71 is an invariant residue in all known sequences of tyrosine phenol-lyase (TPL). The substitution of Tyr71 in TPL by phenylalanine results in a mutant Y71F TPL with no detectable activity (greater than 3 x 10(5)-fold reduction) for beta-elimination of L-tyrosine. Y71F TPL can react with S-alkylcysteines, but these substrates exhibit kcat values reduced by 10(3)-10(4)-fold, while the kcat/Km values are reduced by 10(2)-10(3)-fold, compared to wild-type TPL. However, for substrates with good leaving groups (S-(o-nitrophenyl)-L-cysteine,beta-chloro-L-alanine, and O-benzoyl-L-serine), Y71F TPL exhibits kcat values 1.85-7% those of wild-type TPL. Y71F TPL forms very stable quinonoid complexes with strong absorbance at 502 nm from L-phenylalanine, tyrosines (L-tyrosine, 3-fluoro-L-tyrosine, and [alpha-2H]-3-fluoro-L-tyrosine), and S-alkylcysteines (S-methyl-L-cysteine, S-ethyl-L-cysteine, and S-benzyl-L-cysteine). The time courses of the formation of quinonoid intermediates in these reactions are biphasic. The slow phase shows a dependence on concentration of PLP and is due to the cofactor binding steps, while the fast phase is due to the amino acid alpha-deprotonation and reprotonation steps. The rate constants for the fast phase of the reactions of Y71F TPL with L-phenylalanine and S-methylcysteine are similar to those for alpha-deprotonation or reprotonation steps in the reactions of wild-type TPL. The PLP binding constant of Y71F TPL is estimated to be 1 mM by spectrophotometric titration, compared to 0.6 microM for wild-type TPL.(ABSTRACT TRUNCATED AT 250 WORDS)

Base Sequence↗
PubMed1995

The role of the catalytic base in the protein tyrosine kinase Csk.

A potential distinguishing feature between protein tyrosine kinases and homologous serine/threonine kinases is the function of the catalytic base in these enzymes. In this study, we show that a peptide containing the unnatural amino acid trifluorotyrosine shows remarkably similar efficiency as a substrate of the tyrosine kinase Csk (C-terminal Src kinase) compared with the corresponding tyrosine-containing peptide despite a 4-unit change in the phenolic pKa. These results argue against the importance of early tyrosine deprotonation by a catalytic base in Csk. To further explore the role of the proposed catalytic base, the Csk mutant protein D314E was produced. This mutant displayed a significant reduction in kcat (approximately 10(4)) but relatively little effect on substrate Km values compared with wild-type Csk. Examination of the thio effect (kcat-ATP/kcat-adenosine 5'-O-(thiotriphosphate)) for D314E Csk led to the suggestion that a role of aspartate 314 may be to enhance the reactivity of the gamma-phosphate of ATP toward electrophilic attack. These results may have significant impact on protein tyrosine kinase inhibitor design.

Amino Acid Sequence↗
PubMed1995

Site-directed mutagenesis of His343-->Ala in Citrobacter freundii tyrosine phenol-lyase. Effects on the kinetic mechanism and rate-determining step.

His343 in Citrobacter freundii tyrosine phenol-lyase is conserved in all known sequences of both tyrosine phenol-lyase and tryptophan indole-lyase; it is located near the active-site Lys257 in C. freundii tyrosine phenol-lyase [Antson, A. A., Demidkina, T. V., Gollnick, P., Danter, Z., Von Tersch, R.L., Long, J., Berezhnoy, S. N., Phillips, R. S., Harutyunyan, E. H. & Wilson, K. S. (1993) Biochemistry 32, 4195--4206]. In order to evaluate the role of His343 in the reaction mechanism of tyrosine phenol-lyase and tryptophan indole-lyase, we have mutated it to Ala; the former mutant is referred to as [H343A]tyrosine phenol lyase. All substrates for alpha, beta-elimination (except S-ethyl-L-cysteine) exhibited lower kcat (10-30%) and kcat/Km (1-10%) values with [H343A]tyrosine phenol-lyase than with the wild-type enzyme. The mutant also shows slower rates of deuterium isotope exchange for L-phenylalanine and L-methionine than does the wild type. The pH-dependent behavior in the reaction of 3-fluoro-L-tyrosine with wild-type tyrosine phenol-lyase is identical to that of L-tyrosine described previously [Kiick, D. M. & Phillips, R. S. (1988) Biochemistry 27, 7333-7338]. The pH profile of kcat/Km for this reaction exhibits two pKa values with an average of 7.7 +/- 0.2, indicating that the catalytic mechanism requires two essential basic groups. The pH profile of kcat/Km for 3-fluoro-L-tyrosine with [H343A]tyrosine phenol-lyase also exhibits two pKa values with an average of 7.8 +/- 0.3. However, kcat for 3-fluoro-L-tyrosine is pH-dependent for the mutant, exhibiting two pKa values with an average of about 7.8, whereas it is pH-independent for the wild type. Steady-state kinetic isotope effects on the reactions with wild-type and [H343A]tyrosine phenol-lyase were examined at various pH values. For the wild type, the values of the isotope effects on kcat and kcat/Km for 3-fluoro-L-[alpha-2H]-tyrosine are independent of pH and equal to 3.9 +/- 0.2 and 2.2 +/- 0.3, respectively, while the corresponding values for [H343A]tyrosine phenol-lyase are 5.4 +/- 0.2 and 3.8 +/- 0.3, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Alanine↗
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

Surrogates' predictions of seriously ill patients' resuscitation preferences.

BACKGROUND: Seriously or terminally ill patients are frequently incapacitated and unable to express their preferences regarding cardiopulmonary resuscitation (CPR). In this situation, family members or other surrogate decision makers are often asked whether they believe the patient would want to be resuscitated. We evaluated the concordance of patient CPR preferences and surrogate perceptions of the patient preferences in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a large, multicenter study of seriously ill hospitalized patients. METHODS: We compared patient preferences and surrogate perceptions in 1226 pairings in which both patient and surrogate responded to CPR decision questions. We also examined factors that might influence patient-surrogate concordance. RESULTS: Twenty-nine percent of patients with paired data did not want to be resuscitated; 26% of surrogates did not believe the patient they represented would want to be resuscitated. Within pairs, the overall exact agreement with respect to CPR decisions was 74%. For patients favoring CPR, only 16% of the surrogates misconstrued the patient's wishes. For patients who did not want to be resuscitated, however, 50% of the surrogates did not reflect the patient's wishes. If patients reported telling surrogates their CPR preference, concordance was significantly improved if the surrogate believed the patient did not want to be resuscitated and was significantly worsened if the surrogate believed the patient wanted CPR. This finding is likely an artifact of patients being more likely to report their preference to surrogates if that preference was not to be resuscitated. CONCLUSIONS: Surrogates' perceptions of patient CPR preferences are often inaccurate, particularly for those patients who do not want to be resuscitated. Methods to improve communication between patients and surrogates on CPR preferences should be developed and evaluated.

Adult↗
PubMed1995

Prediction of visual function after cataract surgery. A prospectively validated model.

OBJECTIVE: To develop a model to predict visual functional improvement after cataract extraction with intraocular lens implantation based on preoperative data. DESIGN: A prospective study with serial evaluations of visual function preoperatively and at 3 and 12 months after surgery. SETTING: The General Eye Service of the Massachusetts Eye and Ear Infirmary. Boston, Mass, and 33 ophthalmology practices in Boston. PATIENTS: Patients (N = 426; ages, > or = 65 years) who were undergoing cataract surgery. METHODS: Twelve-month improvement in visual function was measured by using the Activities of Daily Vision Scale (ADVS). Ordinal logistic regression was used to identify correlates of improved ADVS scores in 281 patients (derivative set). Potential factors included the preoperative visual acuity, preoperative ADVS score, four chronic ocular diseases, eight medical conditions, and demographic characteristics. Five predictors were identified and used to construct a prediction rule. The accuracy of the prediction rule was evaluated in an independent group of 145 patients (validation set). RESULTS: Postoperatively, 40% of the 281 patients in the derivative set had substantial improvement in their ADVS scores, and 53 (19%) had some improvement. Predictors of improvement included younger age (P < .001), a poorer preoperative ADVS score (P < .001), posterior subcapsular cataract (P = .09), and absence of age-related cataract (P = .09), and absence of age-related macular degeneration (P = .07) and/or diabetes (P = .006). When applied to the independent sample of 145 patients, these five characteristics classified the patients into three groups in which the probabilities of substantial improvement were 85%, 34%, and 3%, thus verifying the discriminatory power of the prediction rule. CONCLUSIONS: Preoperative data can identify patients who are likely to have improvements in visual function after cataract surgery. Such findings may be useful in the selection of patients for this high-volume procedure.

Activities of Daily Living↗
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↗
PubMed1995

The mechanism of Escherichia coli tryptophan indole-lyase: substituent effects on steady-state and pre-steady-state kinetic parameters for aryl-substituted tryptophan derivatives.

We have examined the reaction of Escherichia coli tryptophan indole-lyase with fluoro, chloro, methyl and hydroxytryptophans using steady-state kinetics, rapid-scanning and single wavelength stopped-flow spectrophotometry, and rapid chemical quench methods. All of the 16 tryptophan derivatives examined are substrates for alpha, beta-elimination catalyzed by tryptophan indole-lyase. The steady-state kinetic parameter, kcat/Km, did not show a consistent trend with the steric bulk of the substituent, but Km increased for larger substituents. Rapid-scanning stopped-flow spectra show that all tryptophan analogues undergo covalent reaction with the pyridoxal-5'-phosphate cofactor to give equilibrating mixtures of external aldimine and quinonoid intermediates, but the relative amounts of each intermediate are strongly dependent on the nature and position of the substituent. The dissociation constants for external aldimine formation, Kd, obtained from single-wavelength stopped-flow experiments decreased for most substituted tryptophans, which suggests that part of the binding energy is derived from hydrophobic interactions between the enzyme and the indole ring of tryptophan. In contrast, the rate constants of quinonoid intermediate formation and reprotonation and of indole elimination were quite variable, depending on the position and the nature of the substituent. Overall, 6-substituted tryptophans have the most consistent reactivity, which indicates that there may be space in the enzyme active site near the 6-position. There is a good linear correlation between log (kcat/Km) and log (kf/Kd) (apparent second order rate constant for quinonoid intermediate formation), with a slope of 0.66. This suggests that quinonoid intermediate formation contributes only about 66% of the activation energy for the reaction, and thus a later step in the reaction must be partially rate-limiting. Rapid chemical quench experiments demonstrate a 'burst' of indole in the reaction of L-tryptophan under single turnover conditions, confirming that a step subsequent to the elimination is partially rate-determining. In contrast, 5-methyl-L-tryptophan does not exhibit a significant 'burst', suggesting that 5-methylindole elimination is nearly completely rate-determining. These results support the proposed mechanism and demonstrate that there are significant effects of aryl substituents on the distribution of covalent intermediates and on the rate-determining step in the alpha, beta-elimination reaction catalyzed by E. coli tryptophan indole-lyase.

Binding Sites↗
PubMed1995

Standard biopsy forceps versus large-capacity forceps with and without needle.

Endoscopic biopsy forceps vary in size and design. The purpose of this prospective randomized study was to compare the quality and quantity of gastric tissue obtained by needle and non-needle versions of standard biopsy forceps and newly designed large capacity forceps. Fifty consecutive patients who underwent endoscopy with gastric biopsy forceps were enrolled in the study. There was no significant difference in the presence of crush artifact between the two forceps, both with and without the presence of a needle. Both needle and non-needle versions of the large capacity biopsy forceps were found to obtain significantly larger sized specimens (p = 0.02) than needle and non-needle versions of the standard biopsy forceps. Overall, there was no significant difference in the depth of specimen obtained when comparing the large capacity forceps to standard forceps. Needle versions of each forceps were found to obtain significantly deeper biopsies than non-needle versions of each forceps. In conclusion, our study found that large capacity forceps obtained larger specimens than standard biopsy forceps. Further clinical trials with a larger study population need to be undertaken to determine the impact of these findings on the determination of diagnoses.

Analysis of Variance↗
PubMed1995

The nurse's role in end-of-life treatment discussions: preliminary report from the SUPPORT Project.

The methods of the Study to Understand Prognosis and Preferences of Outcomes and Risks of Treatment (SUPPORT), a five year, five-center study of decision making and communication in patients near the end of life, are described. Aspects of the study propose to describe the role of the staff nurse and the specially trained nurse facilitator in decision making in patients near the end of life. The nurse is in a unique position to initiate discussions about patient preferences for end-of-life treatment and quality of life; however, a review of related research describes discordance between clinicians' understanding and patients' preferences for treatment. Ethical issues, practice barriers, and practice innovations in end-of-life treatment are discussed.

Cohort Studies↗
PubMed1995

Predicting in-hospital mortality. The importance of functional status information.

Monitoring risk-adjusted outcomes is the centerpiece of efforts to ensure health care quality. Because data collection is expensive, questions arise concerning what information is essential to adjust for risk. This investigation used retrospective analysis of existing, computerized clinical databases containing laboratory test results, information on chronic coexisting conditions, and nursing evaluations of functional status to predict in-hospital mortality. We studied persons admitted to one tertiary teaching hospital between 1987 and 1992 for cerebrovascular disease or pneumonia. Predictive models for each of the conditions were developed using logistic regression; the results were validated with split samples. We compared the predictive value of the nursing functional status assessments and the clinical laboratory data. For each study condition, the functional status data had as much prognostic information as the laboratory data. Specifically, a nurse's report that a patient required total assistance for bathing was the best single predictor of in-hospital mortality in the models for patients with either cerebrovascular disease or pneumonia. If hospitals admit patients with different levels of functional impairment, it is important to account for these differences before comparing outcomes across facilities. Assessments of functional status are a simple, inexpensive measure that may have considerable value.

Activities of Daily Living↗
PubMed1995

Use of follow-up services by patients referred from a walk-in unit: how can patient compliance be improved?

Timely use of necessary follow-up services is an important dimension of ambulatory care quality. Using a hospital-based walk-in center, this study identified patients who were referred for follow-up care and examined factors related to compliance with these referrals. The participants were 696 adults seen in a hospital-based walk-in unit between June 1, 1992, and December 1, 1992. Patients completed a self-administered questionnaire including questions about sociodemographic characteristics, prior use of health services, and the Medical Outcomes Study (MOS) 36-Item Health Survey. Medical findings, follow-up recommendations, insurance status, and compliance with follow-up referrals were ascertained using chart review, the hospital's computing system, and clinic records. Fifty percent of the patients were referred for follow-up medical care; 55% of these complied with follow-up referrals. Factors associated with referral for follow-up care included older age, inability to afford a physician, longer duration of chief complaint, the patient's belief that follow-up care would be needed, and worse MOS pain score. The most important factor associated with compliance with follow-up referral was scheduling appointments while patients were still in the walk-in unit. Patients with such scheduled appointments were almost 10 times more likely than others to receive follow-up (adjusted odds ratio = 9.6, 95% confidence interval = 4.4-21.2). The most important step a provider can take to improve compliance with follow-up referral is to schedule appointments before patients are sent home. This should presumably improve quality of ambulatory care.

Adult↗