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PubMed2001

Ethnicity, nutrition, and birth outcomes in nulliparous women.

OBJECTIVE: Ethnic differences in birth outcomes are well established, but it is not clear whether differences in nutrition may partly explain unaccounted differences in birth outcomes. Our purpose was to evaluate the relationship of nutrition to ethnic differences in birth outcomes. STUDY DESIGN: This was a multicenter, prospective study of 4589 healthy nulliparous women who were enrolled in the Calcium for Preeclampsia Prevention trial conducted from 1992 to 1995. Main outcome measures were birth weight, gestational age at delivery, preterm birth, and small for gestational age birth after the data were controlled for maternal characteristics and intake of total calories, protein, carbohydrate, fat, and 13 vitamin and mineral constituents that were obtained from a 24-hour recall at 13 to 21 weeks' gestation. RESULTS: Black and non-Hispanic white women differed significantly in birth outcomes, with odds ratios of 2.06 (95% confidence interval, 1.48-2.86) for small for gestational age and 1.38 (95% confidence interval, 0.98-1.95) for preterm birth, after adjustment for maternal characteristics. These odds ratios were hardly changed by the further adjustment for all nutritional variables, even though there were substantial nutritional differences between black and white women. Differences in birth outcomes between Hispanic and non-Hispanic white women were small. Hispanic women who spoke only Spanish were better nourished than those Hispanic women who spoke English, but this had only a modest effect on birth outcomes. CONCLUSION: Nutritional variation among women in the United States does not appear to have a significant role in the explanation of ethnic differences in birth outcomes.

Adult↗
PubMed2001

A prognostic model for assessment of the outcome of endodontic treatment: Effect of biologic and diagnostic variables.

OBJECTIVE: Many biological variables, endodontic treatment factors, and restorative considerations have been suggested in the literature to affect the outcome of endodontic treatment. However, few attempts have been made recently to study these variables further. The purpose of this study was to identify the biologic and endodontic treatment-associated variables that are most predictive of treatment outcome for conventional endodontic therapy and to determine the magnitude of risk these variables pose on the outcome. STUDY DESIGN: The population of this historical prospective cohort study comprised a total of 200 teeth with 441 root canals. Diagnostic and treatment information was abstracted from the original patient records. An endodontic follow-up examination was conducted 4 +/- 0.5 years after obturation. Each tooth/root was analyzed according to 3 indices of periradicular status at 2 time points. The main outcome measure was the presence of apical periodontitis. The criteria used for evaluation of the outcome were modified from Strindberg. Data were subjected to univariate and multivariate analysis. Logistic regression models were fit by using various clinical measures to determine which combination of biologic and treatment-associated factors best predicted treatment outcome. RESULTS: The preoperative pulp diagnosis, the periapical diagnosis, the preoperative periapical radiolucency size, and the sex of the patients were revealed, by means of univariate analysis, to exert a significant influence on endodontic treatment outcome (P <.05). In the logistic regression model, the strongest effect on postoperative healing was the presence and magnitude of preoperative apical periodontitis. In the presence of this variable, no other factor contributed value to the prediction. The correct prediction of this model was 74.7% (P <.05). CONCLUSION: The major biologic factors influencing the outcome of endodontic treatment appear to be the extent of microbiological insult to the pulp and periapical tissue, as reflected by the periapical diagnosis and the magnitude of periapical pathosis.

Acute Disease↗
PubMed2002

Functional outcome after thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Repair of thoracoabdominal aortic aneurysms (TAAAs) is performed for the improvement of long-term survival and the preservation of function. The determination of functional outcome and the identification of predictors of survival and functional recovery after TAAA repair are key to proper patient selection. METHODS: This retrospective review of clinical data was performed in an academic medical center. The demographics, Crawford aneurysm type (I-18, II-33, III-22, IV-28), preoperative risk factors, operative characteristics, and postoperative complications and outcomes were recorded from the medical records for 101 consecutive patients who underwent TAAA repair (58 elective and 43 urgent/emergent). Functional status and living situation at hospital discharge and 12 months after discharge were determined from follow-up examination records or telephone contact with surviving patients. The patients then were categorized into "good" (survival, home, discharge to rehabilitation center, ambulatory) or "bad" (death, discharge to or residence in a long-term care facility, non-ambulatory) outcomes. RESULTS: The postoperative mortality rate was 17.8% (10% in elective cases and 28% in urgent cases), and significant postoperative complications occurred in 77% of the cases (pulmonary complications in 41%, renal complications in 28%, and cord injury in 12%). The mean length of stay was 22.8 + 23.6 days, and at discharge, 80% of the patients were sent to home or rehabilitation and 20% were sent to long-term care facilities. At 1 year, 15 additional patients had died. All but two patients who had been initially discharged to rehabilitation had returned home, but only two patients who had been discharged to long-term care facilities had returned home and both were nonambulatory. Therefore, the survival rate at 1 year was 67%, and only 52.4% of the patients had a "good" outcome at 1 year (survival rate was 78% and rate of "good" outcome was 63% in patients who underwent elective TAAA repair). Independent predictors of postoperative death and "bad" outcome were age more than 75 years, preoperative heart disease, duration of visceral ischemia, use of left atrial femoral bypass graft, postoperative renal dysfunction, and number of organs failing after surgery. CONCLUSION: Survival and good functional outcome after TAAA repair is significantly less common than expected and is primarily predicted with intraoperative factors and postoperative complications. Improved operative techniques and limitation of visceral ischemia reperfusion injury may improve outcome after TAAA repair.

Aged↗
PubMed1998

Knowledge of and attitudes to the health outcomes approach among community mental health professionals.

A focus on health outcomes has significant potential for increasing health gain if adopted by health care staff as part of their professional practice. Understanding health care staff attitudes and receptiveness towards health outcomes may facilitate uptake of this workplace innovation. Community mental health clinicians (n = 101) were sent a questionnaire assessing their knowledge of and attitudes to the health outcomes approach, their expectations as to its likely impact on them, as well as features of their workplace in general. Analysis of the 65 returned questionnaires identified some pessimism about what focusing on health outcomes would achieve for community mental health clinicians or their clients. Training in practical applications of health outcomes measures, involvement in and ownership of health outcomes projects and recognition of health outcomes achievements would facilitate adoption of a health outcomes approach by community mental health clinicians.

Adult↗
PubMed2001

Psychological intervention influences the outcome of laparoscopic antireflux surgery in patients with stress-related symptoms of gastroesophageal reflux disease.

BACKGROUND: Psychological aspects such as stress, emotions, illness behaviour or personality are known to affect the severity of symptoms of gastroesophageal reflux disease (GERD) and can influence medical outcome in some patients. The aim of the present study was to evaluate the efficacy of psychological intervention within routine surgical care on the surgical outcome of laparoscopic antireflux surgery (LARS) in patients with stress-related GERD symptoms during a 1-year follow-up. METHODS: Out of a sample of 196 consecutive patients who required LARS (Nissen fundoplication), a group of 89 (45%) believed that stress was a factor in the cause of their symptoms (stress-related versus stress-unrelated GERD patients). Patients with stress-related symptoms were randomly assigned to the psychological intervention (PI group; n = 42) or control group with routine surgical care (RC group; n =42). Five patients were excluded from the study. Assessments of surgical outcome were: objective clinical data such as DeMeester score or lower oesophageal sphincter pressure, Gastrointestinal Quality-of-Life Index (GIQLI), evaluation of potential side effects such as subjective degree of dysphagia, general impairment as a result of LARS, and patient satisfaction with surgery. RESULTS: There were no significant differences in objective clinical data between the different treatment groups before and after surgery. Before surgery, patients with stress-related symptoms had a lower GIQLI and an increased spectrum of gastrointestinal (GI) symptoms compared with patients without stress-related symptoms. A significant impact (P < 0.05-0.01) of psychological intervention on quality-of-life data, especially in GI symptoms, degree of dysphagia and general impairment, could be calculated after surgery. No differences in satisfaction with therapy were detectable. Comparing outcome, no significant differences between patients without stress-related GERD symptoms and the PI group were found. Generally, quality-of-life data in all patients improved significantly and patient satisfaction was excellent or good in 98.9% one year after surgery. In two patients a laparoscopic refundoplication was necessary because of a 'slipping Nissen'. CONCLUSIONS: These findings indicate that there is no impact of psychological intervention on objective clinical data. Patients with stress-related GERD symptoms profit significantly from psychological intervention in patient-related factors of surgical outcome such as quality of life or degree of several aspects such as dysphagia and general impairment. Generally, LARS in patients with stress-related GERD symptoms is an effective and safe procedure which improves quality of life with fewer side effects. Psychological intervention reduces non GERD-related GI symptoms and makes the outcome comparable to the outcome of patients without stress-related symptoms. We therefore suggest that surgical treatment alone in patients with stress-related GERD symptoms is incomplete and that psychological intervention can optimize surgical outcome in these patients.

Adult↗
PubMed2003

AMEE Guide No. 25: The assessment of learning outcomes for the competent and reflective physician.

Two important features of contemporary medical education are recognized. The first is an emphasis on assessment as a tool to ensure quality in training programmes, to motivate students and to direct what they learn. The second is a move to outcome-based education where the learning outcomes are defined and decisions about the curriculum are based on these. These two trends are closely related. If teachers are to do a better job of assessing their students, they need an understanding of the assessment process, an appreciation of the learning outcomes to be assessed and a recognition of the most appropriate tools to assess each outcome. Assessment tools selected should be valid, reliable, practical and have an appropriate impact on student learning. The preferred assessment tool will vary with the outcome to be assessed. It is likely to be some form of written test, a performance test such as an OSCE in which the student's competence can be tested in a simulated situation, and a test of the student's behaviour over time in clinical practice, based on tutors' reports and students' portfolios. An assessment profile can be produced for each student which highlights the learning outcomes the student has achieved at the required standard and other outcomes where this is not the case. For educational as well as economic reasons, there should be collaboration across the continuum of education in test development as it relates to the assessment of learning outcomes and in the implementation of a competence-based approach to assessment.

Attitude of Health Personnel↗
PubMed1998

Risk Score Estimation: a new method to determine optimal timing of aneurysm clipping for improved management outcome.

The outcome of 703 patients who underwent surgery following aneurysmal subarachnoid hemorrhage were analyzed with regards to age, associated medical conditions, vasospasm and clinical status at the time of operation. Patients with Hunt and Hess grade I, II, and III had a 96%, 90% and 93% favorable (good and fair) outcome respectively. In contrast only 58% of patients with grade IV had the same result. The outcome was unfavorable in 13% of the patients who were older than 60 years of age and only in 9% of the patients between 30-59 years of age. All the patients younger than 30 years old had a good outcome. Associated medical condition increased the incidences of poor outcome (7% vs. 12%). Patients harboring vertebro basilar aneurysms had a poorer outcome, as opposed to those with aneurysms located in the anterior circulation (20% vs. 8%). The presence of angiographic vasospasm alone did not influence outcome. A proposed point value was given for each of the adverse factors and from this the optimal surgical time was determined for each individual patient. This concept of Risk Score Estimation approach may improve the management outcome of patients with ruptured intracranial aneurysms.

Adult↗
PubMed2000

Outcome from poor grade aneurysmal subarachnoid haemorrhage--which poor grade subarachnoid haemorrhage patients benefit from aneurysm clipping?

Patients with poor grade aneurysmal subarachnoid haemorrhage (SAH) are associated with high mortality and morbidity, and hence are often treated conservatively. This study has set out to determine the outcome for all poor grade subarachnoid haemorrhage patients, and attempts to identify a subgroup with a more favourable prognosis. During a prospective audit of patients with aneurysmal SAH, patients of poor grade [World Federation of Neurological Surgeons (WFNS) IV (and not obeying commands) and V] were sedated, paralysed and ventilated for transfer to the Regional Neurosurgical Unit. Any intraventricular blood and/or hydrocephalus was treated by external ventricular drainage. Following a 24-h period for active blood gas, fluid and electrolyte resuscitation, patients were assessed after reversal of sedation. Selection for angiography and potential aneurysm surgery was restricted to those who showed a purposeful response to painful stimulation. Patients who could readily obey commands were not considered 'true' poor grade and were excluded from analysis. In 102 patients with 'true' poor grade SAH admitted between 1991 and 1997, the overall management outcome at 6 months was poor (favourable outcome 25%, mortality 67%). Following reversal of sedation, 55 patients demonstrated a purposeful response and proceeded to angiography, of whom 37 underwent clipping and three coiling of aneurysm. The outcome in this aneurysm treated subgroup was favourable in 53% (mortality 28%). If patients over the age of 65 years are excluded, the management outcome was favourable in 35% (mortality 58%), with those patients proceeding to clipping or coiling of aneurysms having a favourable outcome in 57% (mortality 27%). Patients over the age of 65 years with poor grade SAH had a favourable outcome in only 6% (mortality 85%). The mortality for poor grade SAH patients remains high. However, following resuscitation and correction of any acute hydrocephalus, a patient subgroup identified on simple clinical criteria can be identified who can expect a better outcome.

Adolescent↗
PubMed2000

Outcome after shunt implantation in severe head injury with post-traumatic hydrocephalus.

OBJECT: Post-traumatic hydrocephalus (PTH) is considered a frequent complication after severe head injury (HI). There is little known about outcome following shunt implantation. METHODS: A hospital-based retrospective cross-over study investigated the outcome of 48 patients after severe HI, who had undergone ventricular shunt implantation due to PTH (40 males, mean age at injury 36 years, mean duration from HI to shunt implantation 27 weeks). Telephone interviews with the patients or with caring family members by means of a detailed questionnaire were performed after a mean observation period of 3.3 years after shunt implantation. Outcome was categorized using the Glasgow Outcome Scale (GOS): I: 12 patients, II: 7, III: 16, IV: 9, V: 4 at follow-up. CONCLUSIONS: 52.1% had a clear-cut benefit from shunt implantation, whereas 47.9% had not. Post-traumatic seizures were observed in 31 of 48 patients. Other complications after shunt implantation occurred in 20) patients. Revision of shunt implantation was performed in 15 patients (nine due to technical failure, three haemorrhage, one delayed primary wound closure, and two unknown). Two patients clearly deteriorated after operation (one severe frontal bleeding, one sepsis). The best predictive parameter for outcome after shunt implantation was the pre-operative status, patients in a better clinical condition (pre-operative GOS score 3-severe disabled vs 4-persistent vegetative state) had a better outcome. Patient's age at injury did not seem to influence the outcome. Clinical and computertomographic findings were of rather moderate predictive value as regards short- and long-term outcome after shunt implantation. Cisternography does not seem to be of additional help in the establishment of definite diagnosis of PTH.

Adolescent↗
PubMed2003

Traumatic brain injury: classification of initial severity and determination of functional outcome.

PURPOSE: The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. METHOD: The literature on valid and reliable measurements used in TBI-research for classifying initial severity and final outcome was reviewed. RESULTS: Classifying initial severity in patients with head injury according to clinical condition or CT-parameters is valid. Classifying outcome according to measurement tools of disability showed adequate validity and reliability. CONCLUSIONS: Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.

Brain Injuries↗
PubMed2004

Proton MRS in acute traumatic brain injury: role for glutamate/glutamine and choline for outcome prediction.

Proton magnetic resonance spectroscopy (MRS) is being used to evaluate individuals with acute traumatic brain injury and several studies have shown that changes in certain brain metabolites (N-acetylaspartate, choline) are associated with poor neurologic outcomes. The majority of previous MRS studies have been obtained relatively late after injury and none have examined the role of glutamate/ glutamine (Glx). We conducted a prospective MRS study of 42 severely injured adults to measure quantitative metabolite changes early (7 days) after injury in normal appearing brain. We used these findings to predict long-term neurologic outcome and to determine if MRS data alone or in combination with clinical outcome variables provided better prediction of long-term outcomes. We found that glutamate/glutamine (Glx) and choline (Cho) were significantly elevated in occipital gray and parietal white matter early after injury in patients with poor long-term (6-12-month) outcomes. Glx and Cho ratios predicted long-term outcome with 94% accuracy and when combined with the motor Glasgow Coma Scale score provided the highest predictive accuracy (97%). Somatosensory evoked potentials were not as accurate as MRS data in predicting outcome. Elevated Glx and Cho are more sensitive indicators of injury and predictors of poor outcome when spectroscopy is done early after injury. This may be a reflection of early excitotoxic injury (i.e., elevated Glx) and of injury associated with membrane disruption (i.e., increased Cho) secondary to diffuse axonal injury.

Adolescent↗
PubMed2001

Measuring the quality of urinary continence care in long-term care facilities: an analysis of outcome indicators.

BACKGROUND: the National Centre for Health Outcomes Development has produced outcome indicators for the assessment of quality of care in the management of urinary incontinence. Three measures relate to the management of older people in long-term care: the prevalence of incontinence, the use of indwelling catheters and clinical assessment rates. OBJECTIVE: to evaluate the recommended outcome measures in clinical practice. METHOD: participating centres included residential homes, nursing homes and long-stay wards. We sent a structured questionnaire to each centre for qualitative assessment of the acceptability of the outcome indicators. We analysed data collected by nurses and other staff who used the urinary incontinence section of the Royal College of Physicians Continuous Assessment Review and Evaluation scheme audit tool for long-term care. RESULTS: there were 1125 residents in 17 residential homes, 14 nursing homes and five long-stay wards. The overall prevalence of urinary incontinence was 34% in residential homes (range 2-86%), 70% in nursing homes (38-100%) and 71% in long-stay wards (4-97%). Catheterization rates were 5% in residential homes (0-20%), 10% in nursing homes (0-44%) and 6% in long-stay wards (0-20%). Rates of full clinical assessment were 48, 24 and 36% respectively. CONCLUSION: there is great variability in these outcome measures within and between settings. Interpretation of outcome results requires more precise details on case-mix and the definition of outcome measures. Individual units found the audit tool helpful, but we advise caution with interpretation of outcomes between units.

Aged↗
PubMed2004

A repeated measures approach for simultaneous modeling of multiple neurobehavioral outcomes in newborns exposed to cocaine in utero.

Multiple binary outcomes are encountered frequently in epidemiologic research. This work was motivated by the Maternal Lifestyle Study, 1993-1995, where newborns exposed prenatally to cocaine and a comparison cohort were examined for the presence of central and autonomic nervous system (CNS/ANS) signs. Thus, each infant contributed to multiple, possibly interrelated, binary outcomes that may collectively constitute one syndrome (even though specific outcomes that are affected by cocaine are of scientific interest). Because it is neither scientifically appropriate nor statistically efficient to fit separate models for each outcome, here we adopt a multivariate repeated measures approach to simultaneously model all the CNS/ANS outcomes as a function of cocaine exposure and other covariates. This formulation has a number of advantages. First, it implicitly recognizes that all the CNS/ANS outcomes may together constitute one syndrome. Second, simultaneous modeling boosts statistical efficiency by allowing for correlations among the outcomes, and it avoids multiple comparisons. Third, it allows for outcome-specific exposure effects, so that the specific signs that are affected by cocaine exposure can be identified.

Bias↗
PubMed1995

Overview of pharmacoeconomics and pharmaceutical outcomes evaluations.

The principles, methods, and applications of pharmacoeconomics and pharmaceutical outcomes evaluations are discussed. Pharmacoeconomics may be defined as balancing the cost with the consequences (outcomes) of pharmaceutical therapies and services. As a type of outcomes evaluation, pharmacoeconomics looks beyond just the direct or acquisition cost of a pharmaceutical by including its impact on total health resource utilization and costs. Outcomes research attempts to answer the question, What difference does the pharmaceutical make in patient outcomes under real-world conditions? The economic, clinical, and humanistic outcomes (ECHO) model for a pharmacoeconomic evaluation views the drug as some combination of its clinical, economic, and humanistic attributes. Safety and effectiveness are no longer the only salient attributes of a drug; the effect on total health resource utilization, cost, and quality of life must also be evaluated. The four types of pharmacoeconomic methods are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. As disease state management continues to emerge as a cost-management, quality assurance strategy, formularies per se will wane in importance and pharmacoeconomic and outcomes data will increase in relevance as health professionals endeavor to find the most efficient and effective combinations of medical care. Pharmacoeconomics as a component of outcomes research will help pharmacists decide which clinical circumstances, patient characteristics, and practice settings are most suitable for particular interventions.

Costs and Cost Analysis↗
PubMed2004

Patient-based outcome results from a cluster randomized trial of shared decision making skill development and use of risk communication aids in general practice.

BACKGROUND: Shared decision-making (SDM) between professionals and patients is increasingly advocated from ethical principles. Some data are accruing about the effects of such approaches on health or other patient-based outcomes. These effects often vary substantially between studies. OBJECTIVE: Our aim was to evaluate the effects of training GPs in SDM, and the use of simple risk communication aids in general practice, on patient-based outcomes. METHODS: A cluster randomized trial with crossover was carried out with the participation of 20 recently qualified GPs in urban and rural general practices in Gwent, South Wales. A total of 747 patients with known atrial fibrillation, prostatism, menorrhagia or menopausal symptoms were invited to a consultation to review their condition or treatments. After baseline, participating doctors were randomized to receive training in (i) SDM skills; or (ii) the use of simple risk communication aids, using simulated patients. The alternative training was then provided for the final study phase. Patients were randomly allocated to a consultation during baseline or intervention 1 (SDM or risk communication aids) or intervention 2 phases. A randomly selected half of the consultations took place in 'research clinics' to evaluate the effects of more time for consultations, compared with usual surgery time. Patient-based outcomes were assessed at exit from consultation and 1 month follow-up. These were: COMRADE instrument (principal measures; subscales of risk communication and confidence in decision), and a range of secondary measures (anxiety, patient enablement, intention to adhere to chosen treatment, satisfaction with decision, support in decision making and SF-12 health status measure). Multilevel modelling was carried out with outcome score as the dependent variable, and follow-up point (i.e. exit or 1 month later for each patient), patient and doctor levels of explanatory variables. RESULTS: No statistically significant changes in patient-based outcomes due to the training interventions were found: COMRADE risk communication score increased 0.7 [95% confidence interval (CI) -0.92 to 2.32] after risk communication training and 0.9 (95% CI -0.89 to 2.35) after SDM training; and COMRADE satisfaction with communication score increased by 1.0 (95% CI -1.1 to 3.1) after risk communication, and decreased by 0.6 (95% CI 2.7 to -1.5) after SDM training. Patients' confidence in the decision (2.1 increase, 95% CI 0.7-3.5, P < 0.01) and expectation to adhere to chosen treatments (0.7 increase, 95% CI 0.04-1.36, P < 0.05) were significantly greater among patients seen in the research clinics (when more time was available) compared with usual surgery time. Most outcomes deteriorated between exit and 1 month later. There was no interaction between intervention effects. CONCLUSION: Patients can be more involved in treatment decisions, and risks and benefits of treatment options can be explained in more detail, without adversely affecting patient-based outcomes. SDM and risk communication may be advocated from values and ethical principles even without evidence of health gain or improvement in patient-based outcomes, but the resources required to enhance these professional skills must also be taken into consideration. These data also indicate the benefits of extra consultation time.

Adult↗
PubMed1996

Prognostic factors for functional outcome of total knee replacement: a prospective study.

BACKGROUND: The objective was to investigate whether baseline physical functioning, medical, psychosocial, or demographic variables predict functional outcome in patients undergoing total knee replacement. METHODS: A prospective cohort study was performed between December 1991 and August 1993. Consecutive, unilateral tricompartmental total knee replacement patients aged > or = 55 yr with osteoarthritis, who met criteria, were enrolled and evaluated one month before and 3 months after total knee replacement. The primary outcome measure was the Medical Outcome Study 36 Item Short Form Health Survey (known as the SF36) Physical Functioning Scale score. The outcome evaluator was not involved in patient care. RESULTS: A hierarchical multiple regression analysis was performed to calculate the contribution of baseline variables to TKR outcome. Of the 27% of outcome variance explained by the model, demographic variables accounted for 4%, psychosocial variables (motivation, role functioning-emotional, and social functioning) for 19% (p = .013), medical variables (previous reconstruction, comorbidity, body mass index, bodily pain) for 2%, and baseline physical function for 2%. CONCLUSIONS: Psychosocial variables are significantly related to total knee replacement functional outcome. Assessment of baseline psychological and social functioning may identify a subset of patients at risk for worse outcome. Specific interventions for these patients should be developed and evaluated as components of patient management prior to and after the procedure.

Activities of Daily Living↗
PubMed1998

Using health outcomes data to compare plans, networks and providers.

PURPOSE: To analyze the challenge of using health outcomes data to compare plans, networks and providers. ANALYSIS: Different questions require different designs for collecting and interpreting health outcomes data. When evaluating effectiveness of treatments, tests or other technologies, the question is what processes improve health outcomes? For this purpose, the strongest evidence comes from a double-blind randomized controlled trial. In program evaluations, the question is 'what is the impact of this policy and related programs on health outcomes?' For this purpose, we may be able to randomize subjects, but are more likely to have a quasi-experimental or an epidemiological design. When we compare plans, networks and providers for quality improvement purposes the question is 'do these specific plans perform differently from one another?', or, 'are these specific plans improving their performance over time?' We want to isolate for study the effects attributable to specific plans. Designs that yield strong evidence cannot be applied because we lack experimental control. CONCLUSIONS: When we already have strong evidence linking specific processes of care with specific outcomes, comparing process data may reveal more about performance of plans, networks and providers than comparing outcomes data. Comparisons of process data are easier to interpret and more sensitive to small differences than comparisons of outcomes data. Outcomes data are most useful for tracking care given by high volume providers over long periods of time, targeting areas for quality improvement and for detecting problems in implementation of processes of care.

Benchmarking↗
PubMed2001

Process versus outcome indicators in the assessment of quality of health care.

This paper reviews the relative strengths and weaknesses of outcome and process measures as performance indicators in health care. Differences in outcome may be due to case mix, how the data were collected, chance, or quality of care. Health care is only one determinant of health and other factors have important effects on health outcomes, such as nutrition, environment, lifestyle and poverty. The advantages of process measures are that they are more sensitive to differences in the quality of care and they are direct measures of quality. However, outcome measures are of greater intrinsic interest and can reflect all aspects of care, including those that are otherwise difficult to measure such as technical expertise and operator skill. Outcome indicators can be improved if efforts are made to standardize data collection and case mix adjustment systems are developed and validated. It is argued that this is worth doing only where it is likely that variations in health care might lead to significant variations in health outcome and where the occurrence of the outcome is sufficiently common that the outcome indicator will have the power to detect real differences in quality. If these conditions are not met, then alternative strategies such as process measurement and risk management techniques may be more effective at protecting the public from poor quality care.

Clinical Competence↗