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Effect of institutional volume and academic status on outcomes of coronary interventions: The IMPACT-II experience

AMERICAN HEART JOURNAL 1999年第5期138卷 976-982页

作者： Gilchrist, IC Gardner, LH Muhlestein, JB Arnold, AM Lincoff, AM Califf, RM Tcheng, JE Topol, EJ Penn State Univ Milton S Hershey Med Ctr Hershey PA 17033 USA Duke Univ Clin Res Inst Durham NC 27706 USA St Lukes Med Ctr Salt Lake City UT USA Cleveland Clin Fdn Cleveland OH 44195 USA

Background Rates of morbidity and mortality after interventional procedures are reported to be inversely associated with institutional volume. Methods This study assessed both procedural volume and academic status at the 82 US centers that participated in the IMPACT-II trial. Interventional volumes at the sites ranged from 90 to 3300 cases per year. Patients were randomly assigned to a platelet glycoprotein IIb/IIIa inhibitor (eptifibatide) or placebo during procedures done by experienced operators. The primary end point was the composite of death, myocardial infarction, nonelective repeat coronary intervention, or nonelective coronary artery bypass surgery at 80 days, or placement of an intracoronary stent for abrupt closure during the initial procedure. Results Baseline patient characteristics and median length of stay were similar between the academic and nonacademic centers. In univariable analysis, volume as a continuous variable had a nonlinear relation with the incidence of the composite end point, with better outcomes noted at the highest volume institutions. Academic status did not predict outcome. When added to a predictive model that contained the variables unstable angina,weight, prior coronary artery bypass grafting, heart rate, and platelet count, procedural volume continued to be associated with the composite outcome (P = .04). Conclusions We conclude that among hospitals participating in this trial, there is a nonlinear relation between annual interventional volume and outcomes. This relation is complex, involving variations in periprocedural infarction rates and additional, undefined institutional differences (other than academic status) that result in differences in procedural outcome.

关键词：医学科学研究中心/标准医学科学研究中心/统计学和数值数据心绞痛不稳定型/药物疗法心绞痛不稳定型/死亡率随访研究医院大学/标准医院大学/统计学和数值数据住院时间多机构系统/标准多机构系统/统计学和数值数据结果评价(卫生保健) 肽类/治疗应用血小板聚集抑制剂/治疗应用血小板糖蛋白GPⅡb-Ⅲa复合物/拮抗剂和抑制剂回顾性研究存活率美国/流行病学老年人女(雌)性人类男(雄)性中年人

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Realizing the potential of clinical judgment: A real-time strategy for predicting outcomes and cost for medical inpatients

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AMERICAN JOURNAL OF MEDICINE 2000年第3期109卷 189-195页

作者： Charlson, ME Hollenberg, JP Hou, J Cooper, M Pochapin, M Pecker, M Cornell Univ Weill Med Coll Div Gen Internal Med Dept Med New York NY 10021 USA New York Presbyterian Hosp New York NY USA

PURPOSE: We sought to determine whether illness severity and anticipated level of function, as evaluated at the time of admission, were associated with outcomes and costs of care for patients admitted to the medical service. METHODS: hll 1,759 patients admitted to the medical service at a large urban academic medical center between July 1, 1997, and September 30, 1997 (excluding those admitted directly to the intensive care units or for protocol chemotherapy), were evaluated and categorized by the admitting intern by illness severity (not ill, mildly ill, moderately ill, severely ill, or moribund) and anticipated level of function at discharge (excellent, good, fair, or poor) as part of their routine sign-out process. Interns' ratings were always available within 24 to 28 hours of admission. In-hospital mortality, length of stay, cost of hospitalization, and anticipated billing revenue were evaluated. RESULTS: Patients who were more severely ill had significantly greater in-hospital mortality. For example, mortality was 1.1% (11 of 972) among those who were not ill or mildly ill, 3.6% (26 of 724) among those who were moderately ill, and 15% (9 of 60) among those who were severely ill. Illness severity (P = 0.003) and anticipated functional status (P < 0.01) were significant predictors of in-hospital mortality. Illness severity and function were also significant predictors of greater length of stay and greater costs of hospitalization (all P < 0.0001). The 389 patients who were moderately ill with fair or poor anticipated function were associated with the largest cumulative losses (about $330,ODD during the 3-month period), whereas the 798 mildly ill patients with good or excellent function were associated with the largest cumulative profits ($550,000). CONCLUSION: Physicians' estimates of patients' illness severity and anticipated function at the time of discharge, as made by interns using a system designed to help them sign out to their colleagues, predict outcomes

关键词：医学科学研究中心/经济学医学科学研究中心/统计学和数值数据临床工作能力医院费用医院死亡率医院市区/经济学医院市区/统计学和数值数据判断住院时间/统计学和数值数据纽约市比值比 ROC曲线疾病严重程度指数治疗结果利用情况审核/统计学和数值数据成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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The changing status of inpatient dermatology at American academic dermatology programs

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JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY 1999年第5期40卷 755-757页

作者： Kirsner, RS Yang, DG Kerdel, FA Univ Miami Sch Med Dept Dermatol & Cutaneous Surg Miami FL USA Univ Miami Sch Med Dept Epidemiol & Publ Hlth Miami FL USA

Background: Changes in health care delivery financing such as the adoption of the diagnosis-related groups (DRG) in 1983 has affected inpatient services of dermatology programs across the United States. Objective: The purpose of this study was to define the present status of inpatient dermatology at academic medical centers compared with 1982. Methods: Questionnaires inquiring about the state of inpatient service were sent to the chairpersons of each dermatology residency program in the United States. Results: Of the 71 programs responding, 79% reported a reduction in inpatient activity. Nearly half of the dermatology programs with dedicated dermatology beds in 1982 reported not continuing to have these in 1997 (41 to 24). The average number of patients admitted for skin disease decreased from 119 in 1982 to 36.5 in 1997, and the average daily census decreased from 8.9 to 2.2. Conclusion: There has been a decline in the number of patients hospitalized by academic dermatology departments and a shift of some patients hospitalized to beds where the attending is other than a dermatologist.

关键词：医学科学研究中心/统计学和数值数据门诊医疗/统计学和数值数据皮肤病学/教育皮肤病学/统计学和数值数据诊断相关患者组/统计学和数值数据医院病床数/统计学和数值数据住院/统计学和数值数据保险健康/统计学和数值数据实习医师和住院医师职务病人入院/统计学和数值数据皮肤疾病/流行病学皮肤疾病/治疗美国/流行病学人类

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Quality of care for patients hospitalized with heart failure at academic medical centers

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AMERICAN HEART JOURNAL 1999年第6期137卷 1028-1034页

作者： Nohria, A Chen, YT Morton, DJ Walsh, R Vlasses, PH Krumholz, HM Yale Univ Sch Med Yale New Haven Hosp Ctr Outcomes Res & EvaluatSect Cardiovasc Med New Haven CT USA Yale Univ Sch Med Yale New Haven Hosp Ctr Outcomes Res & EvaluatDept Med New Haven CT USA Qualidigm Middletown CT USA Univ Healthsyst Chicago IL USA

Background The purpose of this study was to determine the standard of care provided by academic medical centers For the management of congestive heart failure (CHF). Methods and Results The standard of care was estimated by assessing adherence to the treatment guidelines published by the US Agency for Health Care Policy and Research among 522 patients hospitalized at 7 university hospitals with a diagnosis of CHF. Data were abstracted by retrospective chart review. Of the 522 patients analyzed, 435 (83%) had a left ventricular ejection fraction (LVEF) measured or documented. Among these patients, 192 were considered "ideal" candidates for angiotensin-converting enzyme (ACE) inhibitor therapy tie, with systolic dysfunction [LVEF <40%] and no contraindications to ACE inhibitors). In this cohort of "ideal" candidates, 138 (72%) were receiving ACE inhibitors at hospital discharge, including 60 (44%) who were prescribed doses recommended in large clinical trials. Compliance with patient education guidelines was assessed in all 487 patients who were alive at the time of discharge. Of these patients, 365 (75%) received dietary counseling, 404 (83%) were educated about exercise, 54 (11%) were instructed to follow daily weights, and 468 (96%) were counseled regarding medication compliance. Among the 87 smokers who were alive at time of discharge, 8 (9%) had documented advice to quit smoking. Conclusions This study indicates that academic medical centers performed fairly well on the assessment of LVEF, the prescription of ACE inhibitors at discharge, and on education regarding diet, exercise, and compliance with medications. However, the results suggest opportunities for improvement in ACE inhibitor dosing and patient education regarding the importance of monitoring daily weights and smoking cessation.

关键词：医学科学研究中心/标准医学科学研究中心/统计学和数值数据血管紧张素转换酶抑制药/治疗应用心脏病学科医院/标准心脏病学科医院/统计学和数值数据数据收集/方法住院/统计学和数值数据 Logistic模型质量指标卫生保健卫生保健质量/标准卫生保健质量/统计学和数值数据美国老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey

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PSYCHOLOGICAL MEDICINE 1999年第4期29卷 823-832页

作者： Martucci, M Balestrieri, M Bisoffi, G Bonizzato, P Covre, MG Cunico, L De Francesco, M Marinoni, MG Mosciaro, C Piccinelli, M Vaccari, L Tansella, M Univ Verona Ist Psichiat I-37100 Verona Italy Univ Udine DPMSC I-33100 Udine Italy

Background. This study aimed to assess psychiatric morbidity and to collect information on disability, life events and family support in a representative sample of patients admitted to a general hospital. Methods. On the basis of information collected in a pilot study a systematic sample of patients consecutively admitted to seven general medical and seven surgical wards of the Academic General Hospital of Verona was selected and interviewed using a two-phase screening procedure and standardized instruments (GHQ-12, HADS, BDQ and CIDI-PHC), All data were analysed using appropriately weighted logistic regression procedures. Results. A total of 1039 patients completed the GHQ-12 and 298 (28.7 %) were high-scorers: 363 patients were interviewed with CIDI-PHC. The prevalence of ICD-10 cases was 26.1%. The most common psychiatric diagnoses were current depression (12.8 %) and generalized anxiety disorder (10.8 %), followed by alcohol related disorders (5 %). A higher prevalence of ICD-10 cases was found in medical wards, among females, patients older than 24 years, unemployed and separated/divorced people. Life events were associated with psychopathology, and so was the number of disability days. Although 49.8 % of ICD-10 cases were identified by the hospital doctors as having a psychological disorder, 23.1% of ICD-10 cases were referred to the liaison psychiatric service. Conclusion, The results of the present study stress the need to collect epidemiologically-based data on psychological disorders and their recognition not only in general practice, but also in general hospital settings, in order to have a more complete picture of the pathways to specialist care.

关键词：医学科学研究中心/统计学和数值数据横断面研究残疾鉴定医院综合/统计学和数值数据发病率意大利/流行病学生活变动事件精神障碍/诊断精神障碍/流行病学精神障碍/心理学病人入院/统计学和数值数据精神病状态评定量表转诊和会诊/统计学和数值数据危险因素社会支持青少年成年人老年人女(雌)性人类男(雄)性中年人

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Incidental appendectomy during radical cystectomy: An interdepartmental survey and review of the literature

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UROLOGY 2000年第2期56卷 241-244页

作者： Neulander, EZ Hawke, CK Soloway, MS Univ Miami Sch Med Dept Urol Miami FL 33101 USA

Objectives. To survey and review the incidence of appendectomy performed during radical cystectomy and urinary diversion. We were interested in the reasons behind the decision and if continent diversions have changed the policy. Methods. We performed a selective survey among urologists in academic centers throughout the United States regarding their practice of incidental appendectomy during radical cystectomy. We also reviewed the literature regarding the rationale for incidental appendectomy in general and during radical cystectomy in particular. Results. Among the 13 departments and 26 urologists replying to the survey, 9 (69%) departments and 20 (77%) individual clinicians are not performing routine incidental appendectomy. In 2 departments, it is considered a matter of choice, and, in 4 (31%) departments, appendectomy is performed routinely. Many believe that the low risk of subsequent appendicitis does not justify the procedure and that the appendix may be useful for future reconstruction. A review of the literature suggests that incidental appendectomy during radical cystectomy is not necessary. Conclusions. Incidental appendectomy during radical cystectomy is not necessary and is no longer being performed in many academic centers. The risk of subsequent appendicitis is extremely low. The decision may depend on the form of urinary diversion planned. UROLOGY 56: 241-244, 2000. (C) 2000, Elsevier Science Inc.

关键词：医学科学研究中心/统计学和数值数据阑尾切除术/统计学和数值数据阑尾炎/流行病学阑尾炎/预防和控制阑尾炎/外科学膀胱切除术/统计学和数值数据卫生保健调查发病率专业业务/统计学和数值数据美国/流行病学膀胱/外科学尿流改道术/统计学和数值数据泌尿科学/统计学和数值数据人类

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Medical emergencies: the experience of staff of a UK dental teaching hospital

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BRITISH DENTAL JOURNAL 2000年第6期188卷 320-324页

作者： Atherton, GJ Pemberton, MN Thornhill, MH Univ Manchester Dent Hosp Dept Orthodont Manchester M15 6FH Lancs England Halifax Gen Hosp Calderdale Health Care NHS Trust Halifax NS HX3 0PW Canada Univ Manchester Dent Hosp Dept Dent Med & Surg Manchester M15 6FH Lancs England St Bartholomews & Royal London Hosp Sch Med & Dent Oral Dis Res Ctr London E1 2AD England

Objective To assess the frequency of faints and other medical emergencies experienced by staff of a UK dental hospital. To investigate the training they had received in the management of medical emergencies, their perception of readiness to deal with emergencies and future training needs. Subjects All 193 clinical staff (dentists, hygienists, nurses and radiographers) of the University Dental Hospital of Manchester. Design Structured questionnaire with covering letter, reminders sent to non-responders. Results There was an 82% response. Fainting was the commonest event: other medical emergency events were experienced with an average frequency of 1.8 events per year with the highest frequency reported by staff in oral surgery. Most expressed a need for further training. only 3% felt no need. Conclusions Medical emergencies occur in dental hospital practice more frequently but in similar proportions to that found in general dental practice. There is a perceived need for further training among dental hospital staff in the management of medical emergencies.

关键词：医学科学研究中心/统计学和数值数据牙科诊所急症/流行病学急救医学/教育英格兰/流行病学晕厥/流行病学晕厥/治疗人类

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Study of the relationships of physical and mental health to patient satisfaction.

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Journal for healthcare quality : official publication of the National Association for Healthcare Quality 1999年第6期21卷 39-46页

作者： Welton, R. Parker, R. University of Maryland Medical Center Baltimore United States

This study examined the relationships of patients' self-report of their physical and mental health to their satisfaction with care received during recent hospitalization. These associations were examined within and across 11 service groups in a mid-Atlantic academic medical center. The sample size of 944 patients was distributed among the service groups, with 68-105 patients in each service. The instruments were a portion of the institution's patient satisfaction survey and the SF-12 (a 12-item generic measure of health status), both administered through telephone interviews. Across all hospital services, the relationships between satisfaction and health were too weak to interpret, with only 0.36% and 0.81% of the variance explained between overall satisfaction with care delivery and physical and mental health, respectively. At the service level, however, a number of significant but weak associations were found between satisfaction and health status in the otolaryngology, orthopedic, cardiothoracic, and transplant populations. Mental health and patients' likelihood to return to the hospital were negatively correlated in the neurology/neurosurgery populations, indicating that at higher levels of mental function, patients reported lower likelihood of their returning to the hospital.

关键词：医学科学研究中心/标准医学科学研究中心/统计学和数值数据卫生保健调查健康状况医院科室/标准医院科室/统计学和数值数据中大西洋地区病人满意度/统计学和数值数据自我评价(心理学) 女(雌)性人类男(雄)性中年人

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