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PubMed2002

Does prospective monitoring improve cataract surgery outcomes in Africa?

AIMS: To determine if prospective monitoring influences cataract surgical outcomes in east Africa. METHODS: A prospective observational study of all routine extracapsular cataract extractions with posterior chamber lens implants carried out at Kikuyu Eye Unit, Kenya, between 1 January 1999 and 31 December 1999. RESULTS: Out of 1845 eligible eyes 1800 were included in the study. Two months' follow up was available in 67.2% of patients. The proportion achieving a good outcome increased steadily from 77.1% in the first quarter to 89.4% in the fourth quarter (chi(2) for trend, p<0.001). There was no change in the incidence of operative complications; however, the proportion of patients achieving a good visual outcome following vitreous loss increased from 47.2% in the first 6 months to 71.0% in the last 6 months (chi(2) p<0.05). Of the eyes with poor outcome (best corrected acuity <6/60 at 2 months) half were due to pre-existing eye diseases. The proportion of patients with known ocular comorbidity decreased from 10.2% in the first quarter to 5.9% in the fourth quarter (chi(2) for trend, p<0.05). Poor outcome was associated with age over 80 years, known diabetes, preoperative bilateral blindness, any ocular comorbidity, and intraoperative vitreous loss. CONCLUSIONS: This study demonstrates improvement in visual outcome results after cataract surgery over a 1 year period. Monitoring of outcomes appears to be associated with a change in surgeons' attitudes, leading to greater emphasis on appropriate case selection, better management of surgical complications, and improved visual outcomes.

Aged↗
PubMed2005

Systematic review to determine whether participation in a trial influences outcome.

OBJECTIVE: To systematically compare the outcomes of participants in randomised controlled trials (RCTs) with those in comparable non-participants who received the same or similar treatment. DATA SOURCES: Bibliographic databases, reference lists from eligible articles, medical journals, and study authors. REVIEW METHODS: RCTs and cohort studies that evaluated the clinical outcomes of participants in RCTs and comparable non-participants who received the same or similar treatment. RESULTS: Five RCTs (six comparisons) and 50 cohort studies (85 comparisons) provided data on 31,140 patients treated in RCTs and 20,380 comparable patients treated outside RCTs. In the five RCTs, in which patients were given the option of participating or not, the comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions considered. 73 dichotomous outcomes were compared, of which 59 reported no statistically significant differences. For patients treated within RCTs, 10 comparisons reported significantly better outcomes and four reported significantly worse outcomes. Significantly heterogeneity was found (I2 = 89%) among the comparisons of 73 dichotomous outcomes; none of our a priori explanatory factors helped explain this heterogeneity. The 18 comparisons of continuous outcomes showed no significant differences in heterogeneity (I2 = 0%). The overall pooled estimate for continuous outcomes of the effect of participating in an RCT was not significant (standardised mean difference 0.01, 95% confidence interval -0.10 to 0.12). CONCLUSION: No strong evidence was found of a harmful or beneficial effect of participating in RCTs compared with receiving the same or similar treatment outside such trials.

Humans↗
PubMed2004

Association between early and three month cognitive outcome after off-pump and on-pump coronary bypass surgery.

OBJECTIVE: To describe the association between cognitive outcome in the first postoperative week and that at three months after both off-pump and on-pump coronary bypass surgery, and to make a direct comparison of early cognitive outcome after off-pump versus on-pump surgery. DESIGN: Randomised trial with an additional prediction study within the two randomised groups. SETTING: Three centres for heart surgery in the Netherlands. PATIENTS: 281 patients, mean age 61 years. INTERVENTIONS: Participants were randomly assigned to off-pump or on-pump coronary bypass surgery. MAIN OUTCOME MEASURES: Cognitive outcome, assessed by psychologists who administered neuropsychological tests one day before and four days and three months after surgery. A logistic regression model was used to study the predictive association between early cognitive outcome, together with eight clinical variables, and cognitive outcome after three months. RESULTS: Cognitive outcome in the first week after surgery was determined for 219 patients and was a predictor of cognitive decline after three months. This association was stronger in on-pump patients (odds ratio (OR) 5.24, p < 0.01) than in off-pump patients (OR 1.80, p = 0.23). Early decline was present in 54 patients (49%) after off-pump surgery and 61 patients (57%) after on-pump surgery (OR 0.73, p = 0.25). CONCLUSIONS: In patients undergoing first time coronary bypass surgery, early cognitive decline predicts cognitive outcome after three months. Early cognitive decline is not significantly influenced by the use of cardiopulmonary bypass.

Cognition Disorders↗
PubMed2004

Outcomes following childhood head injury: a population study.

OBJECTIVES: To identify outcomes following head injury (HI) among a population of children admitted to one hospital centre and to compare outcomes between different severity groups. METHODS: A postal follow up of children admitted with HI to one National Health Service Trust, between 1992 and 1998, was carried out. Children were aged 5-15 years at injury (mean 9.8), followed up at a mean of 2.2 years post-injury. Parents of 526 injured children (419 mild, 58 moderate, 49 severe) and 45 controls completed questionnaires. Outcomes were assessed using the King's Outcome Scale for Childhood Head Injury (KOSCHI). RESULTS: Frequent behavioural, emotional, memory, and attention problems were reported by one third of the severe group, one quarter of the moderate, and 10-18% of the mild. Personality change since HI was reported for 148 children (28%; 21% mild HI, 46% moderate, 69% severe). There was a significant relationship between injury severity and KOSCHI outcomes. Following the HI, 252 (48%) had moderate disability (43% mild HI, 64% moderate, 69% severe), while 270 (51%) made a good recovery (57% mild HI, 36% moderate, 22% severe). There was a significant association between social deprivation and poor outcome (p = 0.002). Only 30% (158) of children received hospital follow up after the HI. All children with severe disability received appropriate follow up, but 64% of children with moderate disability received none. No evidence was found to suggest a threshold of injury severity below which the risk of late sequelae could be safely discounted. CONCLUSIONS: Children admitted with mild HI may be at risk of poor outcomes, but often do not receive routine hospital follow up. A postal questionnaire combined with the KOSCHI to assess outcomes after HI may be used to identify children who would benefit from clinical assessment. Further research is needed to identify factors that place children with mild HI at risk of late morbidity.

Adolescent↗
PubMedDate not supplied

Outcomes research in otology.

Among the otolaryngologic subspecialties, otology has historically been at the forefront of outcomes research in our specialty. Many traditional outcomes reporting tools have been consistently employed in the study of otologic disease and treatment outcomes including standardized reporting schemes for Meniere's disease and facial nerve dysfunction. However, recent interest has surfaced in disease-specific quality-of-life outcomes measures for many otologic diseases such as sensorineural hearing loss, conductive hearing loss and suppurative otitis media. Several reliable and validated outcomes tools are available for the assessment of the impact on quality of life and treatment outcomes for common otologic afflictions that carry with them significant quality-of-life burdens. Furthermore, similar outcomes tools have been developed that allow a scientific appraisal of disease status and quality of life for dizziness and tinnitus, which have been traditionally difficult to quantify. Increasing familiarity with these outcomes tools will allow investigators to accurately assess and compare treatments for these otologic diseases and justify treatment initiatives in the future.

Hearing Aids↗
PubMed2003

Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator.

BACKGROUND AND PURPOSE: Although early recanalization is a powerful predictor of stroke outcome after thrombolysis, some stroke patients remain disabled despite tissue plasminogen activator (tPA)-induced recanalization. Therefore, we sought to investigate whether the predictive accuracy of early recanalization on stroke outcome is improved when combined with clinical and radiological information. METHODS: We evaluated 177 patients with nonlacunar strokes in the middle cerebral artery (MCA) treated with intravenous tPA who were followed up during 3 months. Transcranial Doppler monitoring of recanalization was conducted during the first hours after tPA administration. The relative contribution of clinical, transcranial Doppler, and radiological information on stroke outcome was evaluated. We used logistic regression to derive a predictive model for good outcome (modified Rankin Scale score < or =2) after thrombolysis. RESULTS: Median National Institutes of Health Stroke Scale (NIHSS) score before tPA was 16. At 3 months, 87 patients (49.2%) became functionally independent (modified Rankin Scale score < or =2). In a logistic regression model, degree of recanalization within 300 minutes (P<0.001), proximal MCA occlusion (P<0.001), baseline NIHSS score (P=0.0013), systolic blood pressure (P=0.0116), and early ischemic changes on CT (P=0.0253) independently predicted outcome at 3 months. A 5-item score was developed on the basis of the factors significantly associated with stroke outcome in the logistic regression (total score range, 0 to 7). The likelihood of good outcome at 3 months was 0.82 (95% CI, 0.72 to 0.92) in patients who scored 0 to 2, 0.51 (95% CI, 0.36 to 0.66) in those who scored 3 to 4, and 0.15 (95% CI, 0.05 to 0.25) in those who scored 5 to 7 points. CONCLUSIONS: The combination of clinical, radiological, and hemodynamic information predicts with a high accuracy long-term stroke outcome during or shortly after intravenous tPA administration.

Academic Medical Centers↗
PubMed1999

Time course of serum neuron-specific enolase. A predictor of neurological outcome in patients resuscitated from cardiac arrest.

BACKGROUND AND PURPOSE: The prediction of neurological outcome in comatose cardiac arrest survivors has enormous ethical and socioeconomic implications. The purpose of the present study was to investigate the prognostic relevance of the time course of serum neuron-specific enolase (NSE) as a biochemical marker of hypoxic brain damage. METHODS: Serial analysis of serum NSE levels was performed in 56 patients resuscitated from witnessed, nontraumatic, normothermic, in- or out-of-hospital cardiac arrest. The neurological outcome was evaluated with the use of the cerebral performance category (CPC) within 6 months after restoration of spontaneous circulation (ROSC). The Mann-Whitney U test was used to compare patients with good (CPC 1 to 2) and bad (CPC 3 to 4) neurological outcome. The diagnostic performance at different time points after ROSC was described in terms of areas under receiver operating characteristic curves according to standard methods. RESULTS: Patients with a bad neurological outcome (CPC 3 to 4) had significantly higher NSE levels than those with a good neurological outcome at 12 (P=0.004), 24 (P=0.04), 48 (P<0.001), and 72 hours (P<0.001) after ROSC. The maximum NSE level measured within 72 hours after ROSC was also significantly higher in patients with a bad neurological outcome (P<0.001). The NSE value at 72 hours after ROSC was the best predictor of neurological outcome (area under the curve=0.92+/-0.04). In addition, we also found a significant difference in the time course of NSE concentrations during the first 3 days after ROSC. CONCLUSIONS: Serum NSE levels are valuable adjunctive parameters for assessing neurological outcome after cardiac arrest.

Adolescent↗
PubMed2001

Association of apolipoprotein E polymorphism with outcome after aneurysmal subarachnoid hemorrhage: a preliminary study.

BACKGROUND AND PURPOSE: Variation in the outcome after aneurysmal subarachnoid hemorrhage (SAH) is not fully explained by known prognostic factors. APOE genotype is the most important genetic determinant of susceptibility to Alzheimer's disease, and it is also shown to be associated with the outcome after traumatic brain injury. We studied the association of apolipoprotein E polymorphism with the outcome after aneurysmal SAH. METHODS: A total of 160 consecutive patients were admitted after SAH to a neurosurgical unit. The clinical assessment after the SAH was performed with the Hunt and Hess grading scale. The severity of the bleeding as visualized on CT was assessed by Fisher's grading system. Outcome was assessed with the Glasgow Outcome SCALE: APOE genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism. RESULTS: 126 patients had aneurysmatic SAH, and detailed information on outcome and APOE genotype was available for 108 patients (86%). Sixteen (40%) of 40 patients with APOE epsilon4 had an unfavorable outcome compared with 13 (19%) of 68 without the APOE epsilon4 allele (OR 2.8, 95% CI 1.18 to 6.77). Association was more significant after adjustment for age, rebleeding, clinical status on admission, and CT scan findings (OR 7.1, 95% CI 1.9 to 26.3; P=0.0035). CONCLUSIONS: Our findings show a significant genetic association of APOE polymorphism with outcome after spontaneous aneurysmal SAH. Genetic factors thus seem to explain a part of individual differences in the recovery of SAH.

Apolipoproteins E↗
PubMed2005

Report of the National Heart, Lung, and Blood Institute working group on outcomes research in cardiovascular disease.

The National Heart, Lung, and Blood Institute convened a working group on outcomes research in cardiovascular disease (CVD). The working group sought to provide guidance on research priorities in outcomes research related to CVD. For the purposes of this document, "outcomes research" is defined as investigative endeavors that generate knowledge to improve clinical decision making and healthcare delivery to optimize patient outcomes. The working group identified the following priority areas: (1) national surveillance projects for high-prevalence CV conditions; (2) patient-centered care; (3) translation of the best science into clinical practice; and (4) studies that place the cost of interventions in the context of their real-world effectiveness. Within each of these topics, the working group described examples of initiatives that could serve the Institute and the public. In addition, the group identified the following areas that are important to the field: (1) promotion of the use of existing data; (2) facilitation of collaborations with other federal agencies; (3) investigations into the basic science of outcomes research, with an emphasis on methodological advances; (4) strengthening of appropriate study sections with individuals who have expertise in outcomes research; and (5) expansion of opportunities to train new outcomes research investigators. The working group concluded that a dedicated investment in CV outcomes research could directly improve the care delivered in the United States.

Cardiovascular Diseases↗
PubMed2001

Structural brain abnormalities in chronic schizophrenia at the extremes of the outcome spectrum.

OBJECTIVE: This study investigated the relationship between outcome and structural brain abnormalities in schizophrenia. METHOD: Intracranial volume and volumes of the cerebrum, gray and white matter, lateral and third ventricles, frontal lobes, thalamus, and cerebellum were measured in 20 patients with a poor outcome, 25 with a favorable outcome, and 23 healthy comparison subjects with magnetic resonance imaging. RESULTS: Thalamic volume was significantly smaller both in poor-outcome patients and good-outcome patients. In contrast, only poor-outcome patients displayed significantly smaller cerebral gray matter, particularly prefrontal, and enlargement of the lateral and third ventricles. No significant differences were found for intracranial, cerebellar, or cortical CSF volumes. CONCLUSIONS: Smaller thalamic volumes in schizophrenia may reflect a greater susceptibility for the disorder and seem unrelated to outcome. In contrast, gray matter volume loss of the cerebrum, particularly in the frontal lobes, and lateral and third ventricular enlargement appear related to outcome in schizophrenia.

Age of Onset↗
PubMed2005

Predictive values of neurocognition and negative symptoms on functional outcome in schizophrenia: a longitudinal first-episode study with 7-year follow-up.

OBJECTIVE: The relationship between cognition and outcome in people with schizophrenia has been established in studies that, for the most part, examined chronic patients and were cross-sectional in design. The purpose of this study was to analyze the relationships between neurocognitive variables assessed at illness onset and functional outcome in a longitudinal design. An additional area of interest was whether the severity of negative symptoms would predict outcome independently from neurocognitive variables or whether there would be an overlap in their predictive power. METHOD: The authors administered a comprehensive cognitive battery and clinical assessments to 99 subjects who were in their first episode of illness and analyzed the relationship of cognition and symptom severity at intake with community outcome after an average follow-up period of 7 years. RESULTS: Verbal memory, processing speed and attention, and the severity of negative symptoms at intake were related to subsequent outcome. Global psychosocial functioning was predicted by negative symptoms and attention. Verbal memory was the significant predictor of the degree of impairment in recreational activities. Impairment in relationships was predicted by negative symptoms and memory, whereas attention and negative symptoms were predictive of work performance. There was an overlap in the variance in outcome explained by cognitive variables and negative symptoms. CONCLUSIONS: Verbal memory and processing speed and attention are potential targets for psychosocial interventions to improve outcome. Results from cross-sectional or chronic patient studies do not necessarily correspond to the findings of this prospective first-episode study in which cognition appears to explain less of the variance in outcome.

Adaptation, Psychological↗
PubMed2002

Using performance standards to evaluate social programs with incomplete outcome data. General issues and application to a higher education block grant program.

The idea of program evaluation is both simple and appealing. Program outcomes are measured and compared to some minimum performance standard or threshold. In practice, however, evaluation is difficult. Two fundamental problems of outcome measurement must be addressed. The first, which we call the problem of auxiliary outcomes, is that we do not observe outcome of interest. The second, which we call the problem of counterfactual outcomes, is that we do not observe the threshold standard. This article examines how performance standard should be set and applied in the face of these problems in measuring outcomes. The central message is that the proper way to implement standards varies with the prior information an evaluator can credibly bring to bear to compensate for incomplete outcome data. By combining available data with credible assumptions on treatments and outcomes, the performance of a program may be deemed acceptable, unacceptable, or indeterminate.

Data Collection↗
PubMed1997

A review of outcome indicators in the treatment of chronic limb oedema.

OBJECTIVES: To provide an overview of physical and psychological outcome indicators which have been used to evaluate conservative treatments for chronic oedema. METHODS OF FINDING PAPERS: Papers were located via the MedLine, CINAHL and GEARS databases, and the British Lymphology Interest Group Key References lists. ISSUES REVIEWED: The literature reveals that only a small amount of work has addressed conceptual issues in outcome evaluation. Above all, outcome indicators have been adopted in clinical practice in a haphazard manner, with little discussion regarding the purpose of outcome assessment/measurement and little agreement on the most appropriate assessment/measurement techniques. RESULTS: Eleven outcome indicators appear in the literature, each of which is discussed in terms of instrumentation and application in clinical practice. Practitioners have focused on objective measures, with change in limb volume the outcome measure most commonly used. CONCLUSION: It is concluded that more rigour is needed in many aspects of outcome evaluation. Practitioners and researchers in this field should become more questioning of existing evaluation practices, and should explore the many potential outcome indicators, such as limb movement and limb function, which have to date been neglected.

Chronic Disease↗
PubMed1981

Assessment of patients' preferences for therapeutic outcomes.

We sought to characterize patients' preferences in drug therapy decisions with uncertain outcomes by analyzing their responses to hypothetical therapeutic scenarios. In each scenario, the patient chose between two drugs with equivalent effects, one having two possible outcomes occurring by chance (uncertain outcome) and the other having a single outcome (certain outcome). Most patients chose a certain and intermediate therapeutic effect rather than taking a chance between no effect and a very large favorable effect. When the outcomes were adverse drug effects, there was a strong opposite trend. Rather than preferring a certain and intermediate adverse drug effect, most patients were willing to risk a possible severe drug side effect in order to have a chance of experiencing no adverse reaction. Thus, patients' willingness to accept risks in therapy decisions involving uncertain outcomes may depend on whether the outcomes are favorable or unfavorable.

Adult↗
PubMed2005

Long-term outcome of patients with schizophrenia: a review.

OBJECTIVE: To review empirical studies that assess outcome of patients with schizophrenia and evaluate the degree to which reported outcome is affected by research methodology, treatment variables, prognostic factors, epidemiologic factors, and patient resilience. METHOD: We reviewed studies that used control subjects and lasted for a decade or more, comparing them with respect to research methodology and choice of outcome variables. RESULTS: Like other mental illnesses and medical illness in general, the natural course of schizophrenia showed itself to have a threefold division of mild, moderate, and severe. Although a great deal of variance in outcome occurred across the studies reviewed, schizophrenia is nevertheless a disorder with relatively poor outcome. Patients with schizophrenia consistently showed poorer courses and outcomes than patients with other psychotic and nonpsychotic psychiatric disorders. On the positive side, subgroups of schizophrenia patients had extended periods of recovery-some without the benefit of extensive mental health aftercare treatment-and patients with schizophrenia did not show a progressive downhill course. CONCLUSION: While documenting the heterogeneity in outcome and the generally poorer outcomes of patients with schizophrenia, the studies reviewed also alert us to the danger of suicide and early death in schizophrenia. In addition, they expose problems in clinical management and treatment and also help us anticipate the possibility of intervals or periods of recovery, some of which appear spontaneously and may be tied to individual patient factors such as resilience.

Follow-Up Studies↗
PubMed1997

The varied outcomes of schizophrenia.

OBJECTIVE: To review variations in outcomes in schizophrenia across individual, historical, and cross-cultural boundaries, as well as within specific domains of functioning. METHOD: Research literature on the outcomes of schizophrenia appearing within the last 8 years was reviewed. RESULTS: First, a review of follow-up studies published in the developed world suggests that heterogeneity in outcome across individuals with schizophrenia remains the rule, with affective symptoms, later and acute onset, and responsiveness to biological treatments predictive of good outcome. Negative symptoms are associated with poor outcome, cognitive impairments, and incapacity in social and work domains. Deterioration appears to occur within the first few months of onset if not already in the prodrome, with recent early-course studies finding longer duration of untreated psychosis associated with insidious onset, negative symptoms, social and work incapacity, and poor outcome. Second, a review of recent cross-cultural and historical studies provides evidence that outcome varies across time and place, schizophrenia having a more favourable outcome in the developing world and becoming a more benign disorder over the course of this century. Third, a review of studies of the domains of functioning within individuals identifies 4 relatively independent dimensions of depression and negative, psychotic, and disorganized symptoms. Cognitive deficits, which are associated with negative symptoms, also constitute a relatively stable dimension over time, showing neither marked deterioration nor improvement once established early in the course of disorder. CONCLUSIONS: The early appearance and stability over time of negative symptoms and cognitive impairments call for assertive intervention efforts early in the course of disorder to prevent chronicity and prolonged disability.

Follow-Up Studies↗
PubMed1998

The 15-year outcome of Chinese patients with schizophrenia in Hong Kong.

OBJECTIVE: To explore the differential outcome of schizophrenia in developed and developing countries. The 15-year outcome of patients with schizophrenia in Hong Kong is reported. METHOD: In a 15-year retrospective outcome study, 100 patients with first-onset schizophrenia in 1977-1978 were randomly selected for outcome assessment from a pool of 797 patient files. The patterns of outcome were assessed by the same set of instruments and methodology as in other centres, since Hong Kong is 1 of the World Health Organization (WHO) centres for the International Study of Schizophrenia (ISoS). RESULTS: Nineteen subjects were untraceable, and 10 subjects committed suicide. More than one-half of the subjects had a good symptomatic outcome, while about 20% of the subjects were rated as having a good psychosocial adjustment. Over the entire 15-year period, 96% of the subjects were maintained on medications, and 79% were living with family members. CONCLUSION: Despite Hong Kong's developed economy, its schizophrenia outcome is similar to that in developing countries. The existence of good family support and active follow-up treatment may be important contributory factors to better outcome.

Adult↗
PubMedDate not supplied

Positive pregnancy outcomes in Mexican immigrants: what can we learn?

OBJECTIVE: To provide an integrated review of the literature of potential explanations for better than expected pregnancy outcomes in Mexican immigrants, focusing on socioeconomics, social support, desirability of pregnancy, nutrition, substance use, religion, acculturation, and prenatal care. DATA SOURCES: Computerized searches of MEDLINE and CINAHL databases, as well as reference lists from published articles on low birth weight and prematurity in immigrants and acculturation in immigrants from January 1989 to December 2002. Search terms were Mexican immigrant women, childbearing, and pregnancy outcome, and only English-language articles were reviewed. STUDY SELECTION: Literature was selected from refereed publications in the areas of nursing, medicine, public health, family, and sociology. DATA EXTRACTION: Data were extracted using keywords pertinent to pregnancy outcome in Mexican immigrants. DATA SYNTHESIS: Despite having many of the risk factors for poor pregnancy outcomes, Mexican immigrants have superior birth outcomes when compared to U.S.-born women. Social support, familism, healthy diet, limited use of cigarettes and alcohol, and religion may play a role in improved outcomes. The superior outcomes diminish with the process of acculturation as the individual adapts to her new culture. CONCLUSIONS: Low birth weight and prematurity are public health concerns in the United States. Through further study of the factors that lead to superior birth outcomes among Mexican immigrant women, rates of low birth weight and prematurity in the United States may be reduced.

Acculturation↗