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PubMed2003

Prolonged untreated illness duration from prodromal onset predicts outcome in first episode psychoses.

Several, although not all, studies suggest that prolonged duration of untreated illness (DUI) predicts poor outcome in psychotic disorders such as schizophrenia. It is unclear whether this association can be explained by factors such as baseline deficits or poor premorbid adjustment. First episode psychotic patients were evaluated at 1 and 2 years following baseline evaluations. Predictive measures showing significant correlations with outcome were entered in multiple regression analyses with Strauss-Carpenter scale (SC) and Global Assessment of Functioning scale (GAF) outcome scores as dependent variables. Illness duration computed from the onset of the prodrome (DUI-pro), used both as a dichotomous and as a continuous measure, highly significantly predicted both GAF and SC scores at 2 years. On the other hand, baseline functioning significantly predicted the 1-year but not the 2-year outcome. When Premorbid Adjustment Scale (PAS) scores were additionally entered into the analyses in a smaller subset, the relation between DUI-pro and the 2-year outcome scores remained significant. Significant associations were also seen between outcome and baseline neuropsychological deficits involving attention and memory. Further research is needed to examine whether prolonged untreated illness is simply associated with poor outcome or plays a causal role in relation to outcome. The latter, if true, would strongly support therapeutic intervention efforts in the prodromal and early psychotic phases of schizophrenia.

Adolescent↗
PubMed1999

Outcome of schizophrenia in relation to brain abnormalities.

This article reviews the 21 studies that investigated possible relationships between structural brain abnormalities and outcome in schizophrenia. Fifteen studies used computer tomography to visualize brain morphology. In these studies, images were obtained of the ventricles but not of specific brain regions. The remaining six studies used magnetic resonance imaging, examining possible relationships between outcome, ventricular size, and specific brain regions. One out of two studies found relationships between brain structure and outcome. The data suggest that the extent of ventricular enlargement in patients with schizophrenia may be related to outcome. No clear relationship between outcome and changes in specific brain regions was found. Apart from considerations about the methodology of measuring different brain regions, the procedure used to measure outcome is important. Outcome, as it is assessed at various points during the course of illness, may be variable and seems to fluctuate during the first 10 to 15 years of disease. Significantly, to date no studies relating outcome to brain structure have used patient samples with a duration of illness longer than 15 years.

Adult↗
PubMed1999

Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty.

UNLABELLED: In this retrospective cohort study, we compared adverse cardiac outcomes after noncardiac surgery among patients with prior percutaneous transluminal coronary angioplasty (PTCA), patients with nonrevascularized coronary artery disease (CAD), and normal controls. Inpatient hospital discharge abstracts from all nonfederal acute care hospitals in Washington State linked to death certificates were evaluated. Patients > or =45 yr old with prior PTCA who underwent noncardiac surgery from 1987 to 1993 were matched by age, sex, surgery type, and discharge year to 686 patients with CAD and to 2155 normal controls (no CAD). We compared risk for adverse cardiac outcomes (death, myocardial infarction, angina, congestive heart failure, malignant dysrhythmia, cardiogenic shock, coronary artery bypass graft, or PTCA) within 30 days. Patients with PTCA had twice the risk of adverse cardiac outcome as normal controls (odds ratio [OR] 1.98; P < 0.001), with a higher risk of angina (OR 7.84), congestive heart failure (OR 2.06), and myocardial infarction (OR 3.86) but a lower risk of death (OR 0.46; P < 0.001). Patients with PTCA had half the risk of adverse cardiac outcome as patients with CAD (OR 0.50; P < 0.001), including less risk of angina (OR 0.51) and congestive heart failure (OR 0.40; P < 0.001), but no difference in myocardial infarction (P = 0.304) or death (P = 0.436). No difference was found between 142 patients with recent PTCA (< or =90 days before noncardiac surgery) matched to patients with CAD (OR 0.90; P = 0.396). Patients revascularized by PTCA >90 days before noncardiac surgery seem to have a lower risk of poor outcome than nonrevascularized patients, although not as low as normal controls. For recent PTCA patients, the lack of difference compared with CAD patient outcomes requires a larger sample size for verification. Present findings do not lend support to a role for prophylactic PTCA to improve noncardiac surgery outcomes. This investigation did not control for CAD severity, medical management, or comorbidities. Study of these factors is needed before the clinical implications of PTCA for noncardiac surgical risk can be completely assessed. IMPLICATIONS: Hospital records showed patients with prior percutaneous transluminal coronary angioplasty were twice as likely as healthy patients to have an adverse cardiac outcome after noncardiac surgery, although their risk was reduced by half compared with patients with untreated coronary artery disease. Further study of the role of percutaneous transluminal coronary angioplasty in modulating noncardiac surgery risk is needed.

Aged↗
PubMed1992

Multicenter study of general anesthesia. III. Predictors of severe perioperative adverse outcomes.

Little information is available about the incidence of severe adverse outcomes, and even less information is available about the identification and quantification of independent predictors of severe perioperative adverse outcomes. The purpose of this study was to identify and quantitate independent predictors of severe perioperative adverse outcomes in a prospective randomized clinical trial of general anesthesia in 17,201 patients. Twenty-nine prognostic variables for 15 severe outcomes in 847 patients were tested by multiple stepwise logistic regressions from which 20 significant (P less than 0.05) predictors were identified. A history of cardiac failure or myocardial infarction less than or equal to 1 yr; ASA physical status 3 or 4; age greater than 50 yr; cardiovascular, thoracic, abdominal or neurologic surgery; and the study anesthetics were significant predictors of "any severe outcome, including death." There were 17 significant predictors for 10 severe cardiovascular outcomes in 608 patients, including a history of ventricular arrhythmia, hypertension, cardiac failure, myocardial ischemia, myocardial infarction less than or equal to 1 yr or myocardial infarction greater than 1 yr, and smoking; ASA physical status; age; cardiovascular, thoracic, abdominal, eyes-ears-nose-throat/endocrine, neurologic, musculoskeletal, or gynecologic surgery; and the study anesthetics. There were 9 significant predictors for 4 severe respiratory outcomes in 163 patients, including a history of cardiac failure, myocardial ischemia, or chronic obstructive pulmonary disease; obesity; smoking; male gender; ASA physical status; abdominal surgery; and the study anesthetics. Colinearity between related prognostic variables (such as disease and ASA physical status) was assessed using progressively segregated groups of variables in eight stepwise logistic regressions. We conclude that the comprehensive stepwise logistic regression of 29 prognostic variables reported here provides a valid estimate of the risks of severe perioperative outcomes associated with general anesthesia.

Anesthesia, General↗
PubMed2000

Multifactorial analysis of surgical outcome in patients with unruptured middle cerebral artery aneurysms.

OBJECTIVE: To build a predictive tool for assessing both favorable outcome and morbidity in a large series of unruptured aneurysms. SUMMARY BACKGROUND DATA: Some well-known predictors of clinical outcome for patients with ruptured aneurysms are not useful in forecasting outcome for patients with unruptured aneurysms. METHODS: The authors analyzed 93 patients with a total of 101 unruptured middle cerebral aneurysms who underwent surgical clipping. Intraoperative data was reviewed and seven factors that might influence outcome were identified: 1) aneurysm size > 10 mm, 2) presence of a broad neck, 3) presence of intraaneurysmal plaque, 4) clipping of more than one aneurysm during the same surgery, 5) temporary occlusion of the middle cerebral artery, 6) multiple clip applications and repositionings, and 7) use of multiple clips. The entire group of unruptured middle cerebral artery aneurysms was divided into two subgroups on the basis of outcome. Each patient was subsequently analyzed for the Factor Accumulation Index (FAI), the sum of different factors observed in a given patient. RESULTS: The expected outcome subgroup was represented by 86 patients, with a total of 92 aneurysms, and demonstrated the following results: no factors were found in six patients; FAI of 1: 24 patients; FAI of 2: 23 patients; FAI of 3: 12 patients; FAI of 4: 11 patients; FAI of 5: 8 patients; FAI of 6: one patient; FAI of 7: one patient. Seven patients represented the subgroup of unexpected outcomes with total morbidity of 7.5%. There were no deaths. None of the patients in this subgroup accumulated FAI of 0, 1, 2, or 5; otherwise: FAI of 3: two patients; FAI of 4: two patients; FAI of 6: one patient; FAI of 7: two patients. CONCLUSION: It is possible to predict outcome in patients with unruptured middle cerebral artery aneurysm by calculating FAI. The postoperative morbidity increases with an FAI within a range of 3 to 4.

Aneurysm, Ruptured↗
PubMed2005

Evidence-guided education: patients' outcome data should influence our teaching priorities.

How should medical educators choose learning objectives and teaching content in clinical education? Given the information chain reaction, coverage of all significant topics in sufficient depth is not possible. Choosing subjects of high priority is essential if education is to have maximum impact on quality of care. These priorities should not derive from tradition and opinion, but should be informed by patient outcomes, the ultimate standard for assessing educational effectiveness. Building upon prior initiatives linking education to practice, the author uses the term "evidence-guided education" to express the process of influencing curricular choices with evidence from health outcomes. Sources of outcome evidence include incident reports, morbidity and mortality conferences, surveillance of quality of care in particular venues, case series, surveys of adverse events and "near-misses," and malpractice claims. Starting with anecdotal occurrences, additional case-finding may establish patterns of poor outcomes, some of which may be preventable. Credible research data on outcomes can inform prioritization for objectives and content at successive institutional levels, which should improve practices and outcomes, completing the loop of feedback, implementation, and improved health. The closer the educational intervention is to practice, the more accountable it becomes. Thus, EGE is more amenable to evaluation at residents' and practitioners' levels and more difficult at the undergraduate level. However, outcome evidence should still inform undergraduate teaching, since this constitutes the platform for future learning. Severe constraints on learning time mandate prioritization of content and suggest the need for the judicious application of outcome evidence in place of mere opinion.

Education, Medical↗
PubMed2004

Use of outcomes information in acute inpatient rehabilitation.

OBJECTIVE: To describe the ways in which rehabilitation outcomes information is used in the acute inpatient rehabilitation industry and the industry's views on the topic of public disclosure of rehabilitation outcomes information. DESIGN: A mixed-methods approach, featuring data from 39 informational telephone interviews with rehabilitation industry stakeholders followed by a survey of 95 randomly sampled acute inpatient rehabilitation provider organizations. RESULTS: Both the informational interviews and survey findings revealed that there is currently little stakeholder demand for functional outcomes information. Outcomes information is primarily used within provider organizations to track the effectiveness of rehabilitation services. There is general consensus among rehabilitation provider organizations in favor of public disclosure of outcomes information. CONCLUSIONS: Outcomes information is not routinely shared with rehabilitation stakeholders (i.e., payers and consumers). Rehabilitation providers and industry stakeholders generally express favorable attitudes toward public disclosure of outcomes information. Stakeholders' perceptions of current barriers and facilitators of outcomes information provide insight into the steps that can be taken toward greater transparency in the rehabilitation industry.

Activities of Daily Living↗
PubMed1999

Association between nurse-physician collaboration and patient outcomes in three intensive care units.

OBJECTIVE: To investigate the association of collaboration between intensive care unit (ICU) physicians and nurses and patient outcome. DESIGN: Prospective, descriptive, correlational study using self-report instruments. SETTINGS: A community teaching hospital medical ICU, a university teaching hospital surgical ICU, and a community non-teaching hospital mixed ICU, all in upstate New York. SUBJECTS: Ninety-seven attending physicians, 63 resident physicians, and 162 staff nurses. PROCEDURE: When patients were ready for transfer from the ICU to an area of less intensive care, questionnaires were used to assess care providers' reports of collaboration in making the transfer decision. After controlling for severity of illness, the association between interprofessional collaboration and patient outcome was assessed. Unit-level organizational collaboration and patient outcomes were ranked. MEASURES: Healthcare providers' reported levels of collaboration, patient severity of illness and individual risk, patient outcomes of death or readmission to the ICU, unit-level collaboration, and unit patient risk of negative outcome. MAIN RESULTS: Medical ICU nurses' reports of collaboration were associated positively with patient outcomes. No other associations between individual reports of collaboration and patient outcome were found. There was a perfect rank order correlation between unit-level organizational collaboration and patient outcomes across the three units. CONCLUSIONS: The study offered some support for the importance of physician-nurse collaboration in ICU care delivery, a variable susceptible to intervention and further study.

APACHE↗
PubMed2000

Improved outcome prediction in unconscious cardiac arrest survivors with sensory evoked potentials compared with clinical assessment.

OBJECTIVE: To compare the prognostic ability of sensory evoked potentials in cardiac arrest survivors with the outcome predicted by a panel of experienced emergency physicians based on detailed prehospital, clinical, and laboratory data. DESIGN: Inception cohort study. SETTING: Medical intensive care unit and department of emergency medicine at a university hospital. PATIENTS: A total of 162 unconscious, mechanically ventilated patients who survived > or =24 hrs after resuscitation from cardiac arrest. INTERVENTIONS: Recording of sensory evoked potentials and outcome prediction after review of detailed clinical and laboratory data by emergency physicians within 24 hrs after cardiac arrest. MEASUREMENTS AND MAIN RESULTS: At 6 months, the outcome of 36 patients was classified as favorable and 126 patients were rated as poor. After review of prehospital data, emergency physicians predicted favorable vs. poor outcome with a sensitivity of 70% and a specificity of 65%. After additional assessment of data 1 hr after cardiac arrest, the sensitivity of emergency physician predictions increased to 80%, whereas the specificity decreased to 48%. Outcome prediction by emergency physicians was most accurate after obtaining detailed patient data 24 hrs after cardiac arrest (sensitivity, 81%; specificity, 58%). In 35 of 36 patients with favorable outcomes, the cortical evoked potential N70 peak was detected between 72 and 128 msec. Of 113 patients with an N70 peak latency >130 msec or an absent N70 peak, all except one had a poor outcome. By using a cutoff of 130 msec, the N70 peak latency alone had a sensitivity of 94% and a specificity of 97%. The predictive accuracy of the N70 peak latency was significantly higher than the clinical assessment 24 hrs after cardiac arrest (91% vs. 76%, p = .0003). CONCLUSION: In unconscious cardiac arrest survivors, a recording of long-latency sensory evoked potentials is more accurate in predicting individual outcome than an emergency physician review of clinical data.

Analysis of Variance↗
PubMed2001

Plasminogen activator inhibitor type 1 and outcome after successful cardiopulmonary resuscitation.

OBJECTIVE: Patients after successful cardiopulmonary resuscitation have been shown to exhibit elevated plasma concentrations of plasminogen activator inhibitor (PAI) type 1, the main circulating antifibrinolytic protein. It has been suggested that elevations in PAI-1 contribute to cerebral no-reflow after successful cardiopulmonary resuscitation. We analyzed whether PAI-1 concentrations might predict cerebral outcome after cardiopulmonary resuscitation. DESIGN: Prospective, controlled study. SETTING: Intensive care unit at a university hospital. PATIENTS: Thirty-five patients after successful cardiopulmonary resuscitation and 35 control patients who were not critically ill. INTERVENTIONS: Blood sampling for determination of plasma concentrations of active and total PAI-1 antigen. MEASUREMENTS AND MAIN RESULTS: Plasma concentrations of total and active PAI-1 antigen on the second day after successful cardiopulmonary resuscitation were significantly higher in patients after cardiopulmonary resuscitation than in controls (p <.0001) and were unrelated to duration of cardiopulmonary resuscitation. Both active and total PAI-1 antigen were higher in patients who developed acute renal failure after cardiopulmonary resuscitation. Patients with an unfavorable cerebral outcome after cardiopulmonary resuscitation had higher total PAI-1 antigen concentrations compared with patients with good outcome after cardiopulmonary resuscitation (p =.026). We identified 180 ng/mL as the best cutoff value for total PAI-1 antigen with respect to cerebral outcome (chi-square 11.8, p =.001). In a logistic regression analysis, only systemic inflammatory response syndrome (p =.028), acute renal failure after cardiopulmonary resuscitation (p =.017), and cardiopulmonary resuscitation duration >15 mins (p =.042) were significantly and independently associated with cerebral outcome after cardiopulmonary resuscitation. Total PAI-1 antigen reached only borderline significance (p =.058) but nevertheless slightly improved the correct prediction of cerebral outcome after cardiopulmonary resuscitation. CONCLUSIONS: Acute renal failure after cardiopulmonary resuscitation, systemic inflammatory response syndrome, and cardiopulmonary resuscitation duration are better predictors of cerebral outcome after cardiopulmonary resuscitation than PAI-1 antigen, but determination of total PAI-1 antigen nevertheless might improve the early prediction of cerebral outcome after cardiopulmonary resuscitation. Whether elevated PAI-1 concentrations, possibly via prothrombogenic/antifibrinolytic effects, contribute causally to cerebral no-reflow and acute renal failure after cardiopulmonary resuscitation remains to be clarified.

Acute Kidney Injury↗
PubMed2002

Fluid thresholds and outcome from severe brain injury.

OBJECTIVE: To determine, by retrospective analysis, critical thresholds for intracranial pressure, mean arterial pressure, cerebral perfusion pressure, and fluid balance associated with poor outcome in patients with severe brain injury. DESIGN: Retrospective review of patient data from the prospective, randomized, multicenter National Acute Brain Injury Study: Hypothermia, comparing outcome results at 6 months after injury with intracranial pressure, mean arterial pressure, cerebral perfusion pressure, and fluid balance measurements recorded during the 96-hr period after randomization. SETTING: Emergency departments and intensive care units in 11 metropolitan tertiary care university hospitals. PATIENTS: A total of 392 patients, aged 16-65 yrs, with severe, nonpenetrating brain injuries and a Glasgow Coma Scale score of 3-8 after resuscitation, who were enrolled in a study designed to determine the treatment effect of moderate hypothermia in patients with severe brain injury. INTERVENTION: Standard brain injury treatment for 193 randomly assigned patients and standard treatment plus hypothermia for 48 hrs for 199 patients. MEASUREMENTS AND MAIN RESULTS: Intracranial pressure levels of 20, 25, and 30 mm Hg, mean arterial pressure levels of 70 and 80 mm Hg, cerebral perfusion pressure levels of 50, 60, and 70 mm Hg, and fluid balance levels in quartiles were examined for their effect on outcome as measured by the Glasgow Outcome Scale at 6 months after injury. When considered separately, any of the following-intracranial pressure >25 mm Hg, mean arterial pressure <70 mm Hg, or cerebral perfusion pressure <60 mm Hg and fluid balance lower than -594 mL-was associated with an increased percentage of patients with poor outcome. When the variables were combined into a stepwise logistic regression model, Glasgow Coma Scale score at admission, age, mean arterial pressure <70 mm Hg, fluid balance lower than -594 mL, and intracranial pressure > 25 mm Hg, in that order, were the most powerful variables in determining outcome. CONCLUSIONS: Exceeding thresholds of intracranial pressure, mean arterial pressure, cerebral perfusion pressure, and fluid volume may be detrimental to severe brain injury outcome. Fluid balance lower than -594 mL was associated with an adverse effect on outcome, independent of its relationship to intracranial pressure, mean arterial pressure, or cerebral perfusion pressure.

Adolescent↗
PubMedDate not supplied

The effect of nursing professional pay structures and pay levels on hospitals' heart attack outcomes.

The effect of nursing professionals (i.e., nurse aid/orderly, licensed practical nurse, registered nurse) pay structures and pay levels on hospitals risk-adjusted heart attack outcomes was determined. Operationalizing hospitals' heart attack outcomes as their thirty-day risk-adjusted mortality rates, a positive curvilinear relation is hypothesized between pay dispersion and hospitals' heart attack outcomes, whereas a direct relation is hypothesized between pay level and hospitals' heart attack outcomes. Pay level is also hypothesized as a moderator of the relation between pay dispersion and hospitals' heart attack outcomes. Using a sample of 138 California hospitals, support is not found for either the curvilinear relation between hospitals' nursing professionals pay dispersion and hospitals' heart attack outcomes, or the direct relation between nursing professionals' pay level and hospitals' heart attack outcomes. Support is found for the moderation hypothesis in which nursing professionals' pay level moderates the relation between hospitals' nursing professionals pay dispersion and hospitals' heart attack outcomes. Implications for practice are discussed in light of the study's results.

California↗
PubMed1999

Outcomes for community health nursing practice.

OBJECTIVE: The purpose of this study was to develop an easy, practical list of outcomes amenable to community health nursing interventions. This study sought to answer the following question: What outcomes are sensitive to nursing interventions in the community health setting? SUMMARY BACKGROUND DATA: Nursing literature discusses many client outcomes. However, available outcome lists are not always sensitive to nursing interventions by community health nurses. Nurses need a precise list to measure client outcomes resulting from contact between nurses and clients in a variety of community health settings. METHODS AND SUBJECTS: The study used a modified Delphi technique to ensure adequate response from the subjects. Initially, focus groups generated items for the Delphi questionnaires. Using items from the focus groups, the researchers developed three rounds of questionnaires. In each round, nurses stated a level of agreement with each item as an outcome for community health nurses. Twenty-two community health nurses in one Southeastern state participated in four focus groups. One hundred fifty-two community health nurses returned round 1 questionnaires, 68 nurses returned round 2 questionnaires, and 48 nurses returned round 3 questionnaires. RESULTS: The researchers grouped the outcomes into four domains: client's psychosocial components of care, client's physiologic components of care, nursing intervention/implementation components of care, and environmental/community safety components of care. CONCLUSIONS: The findings produced an easy, practical list of 48 nursing outcomes for use in decision making and research by community health nurses in all settings.

Community Health Nursing↗
PubMed1997

Outcome analysis of patients with severe head injuries and prolonged intracranial hypertension.

OBJECTIVE: To describe the functional outcome of a select group of patients with severe head injuries who would a priori be assumed to have a dismal outcome and to determine prognostic factors that can be used for effective family counseling and rational utilization of scarce resources. METHODS: Thirty-seven patients with severe head injuries (admission Glasgow Coma Scale (GCS) score < 8) with prolonged (> 96 hours) intracranial hypertension were studied. Parameters recorded included admission age, GCS, evidence of prehospital hypotension, initial computed tomography findings, intracranial pressure (ICP), cerebral perfusion pressure (CPP), and therapeutic intensity level. RESULTS: Thirty-eight percent of patients in this study achieved a Glasgow Outcome Scale score (GOS) of 4 (moderate disability) or better when assessed 1 year after injury. Patients who achieved these good outcomes were significantly younger (mean 23.6 +/- 8.8 years) than patients who were severely disabled or worse (GOS 1-3) (34.3 +/- 15.0 years) (p = 0.0098). The mean admission GCS in the good-outcome group tended to be higher than that of the poor-outcome group (5.8 +/- 1.5 vs 4.8 +/- 1.6, p = 0.065). When patients with good outcomes (GOS 4 or 5) were compared with those with poor outcomes (GOS 1-3), no significant differences in mean or peak ICP, percentage of time intervals with elevated ICP, lowest recorded CPP, or length of ICP monitoring were detected. CONCLUSION: Younger patients, particularly those with GCS > 5, have the potential for excellent recovery despite prolonged (> 96 hours) intracranial hypertension. These patients will benefit from continued aggressive ICP and CPP management.

Adult↗
PubMed2001

Improved functional outcome for severely injured children treated at pediatric trauma centers.

BACKGROUND: Controversy exists regarding the impact of pediatric trauma centers (PTC) on survival for injured children. However, functional outcome for children treated at PTC compared with adult trauma centers (ATC) has not been evaluated. METHODS: An analysis of children entered in the Pennsylvania Trauma Outcome Study between 1993 and 1997 was conducted. Patients were stratified according to type of trauma center: PTC; Level I ATC; Level II ATC; or ATC with added qualifications (AQ). Functional outcome at discharge was analyzed. RESULTS: For severely injured children, there was an overall trend toward improved functional outcome at PTC compared with ATC AQ and ATC I, but no difference compared with ATC II. PTC showed improved functional outcome at discharge for head injury compared with ATC AQ and ATC I. CONCLUSION: There is an overall trend toward improved functional outcome at discharge for children treated at PTC compared with those treated at ATC AQ and ATC I. Improved outcome for head injury may be a key factor contributing to improved outcome at PTC.

Activities of Daily Living↗
PubMed1999

Do hip replacements improve outcomes for hip fracture patients?

BACKGROUND: Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. OBJECTIVES: To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). DESIGN: Prospective cohort study. PARTICIPANTS: We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. MEASUREMENTS: We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). RESULTS: Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). CONCLUSIONS: Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.

Activities of Daily Living↗
PubMed2002

Is outcomes research on cancer ready for prime time?

Contemporary treatment of patients with cancer has been challenged by the same influences that have stimulated broad interest among stakeholders in assessing the outcomes or "results" of medical care. These interrelated external forces include growing awareness of practice variations, increased recognition of the patient's central role in decision making, acknowledgment that treatment decisions for situations where cure is not possible require explicit metrics to assess trade-offs between length and quality of life, strong interest in cost containment, and broad public concern that efforts to rationalize spending may have led to decreases in quality of care. Clinical and health services researchers interested in cancer diagnosis and treatment have striven to address these issues and have been in the forefront of efforts to develop and use valid measures of health-related quality of life. However, the current challenges to the field of outcomes research are equally applicable to those applying its tools and methods to the study of cancer: lack of standardization of outcomes measures, limited evidence that assessing outcomes of care is followed by improved outcomes in practice, and development of a research infrastructure that links the products of outcomes research with informed, shared decision making in routine practice. The purpose of this article is to provide a brief overview of lessons learned from the first decade of outcomes research sponsored by the Agency for Healthcare Research and Quality that will inform suggested directions for future directions for cancer outcomes research.

Decision Making↗
PubMed1996

Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery.

OBJECTIVE: A prospective study was performed to analyze whether the Glasgow Coma Scale (GCS) was useful in predicting the outcome after early surgical intervention for aneurysmal subarachnoid hemorrhage (SAH). METHODS: In a consecutive series of 765 patients who underwent surgery for aneurysms within 7 days after SAH, the level of consciousness was assessed by the GCS just before surgery and the outcome was graded by the Glasgow Outcome Scale 6 months after surgery. RESULTS: The patient distribution in accordance with the GCS sum scores in descending order from 15 to 3 was as follows: 334, 140, 58, 27, 20, 26, 27, 19, 26, 17, 20, 27, and 24 patients, respectively. In general, the higher the preoperative GCS score was, the better the surgical outcome was. The overall surgical result was significantly correlated with the preoperative GCS score (rs = 0.615, P < 0.001). With respect to the levels that distinguish the outcome along the GCS axis, a significant difference in the outcome was observed only between the GCS scores of 15 and 14 (P < 0.001, Wilcoxon test). CONCLUSION: The GCS proved useful in the preoperative evaluation of patients with SAH, in terms of outcome prediction. It is suggested that the SAH scale proposed by the World Federation of Neurosurgical Societies be reexamined, because differences in outcomes were not clear between the GCS scores of 13 and 12 or between those of 7 and 6, in which Grades III and IV and Grades IV and V are differentiated in the scale, respectively.

Adult↗