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The effectiveness of day treatment with persistently mentally ill in rural areas

DISABILITY AND REHABILITATION 2000年第9期22卷 423-426页

作者： Husted, J Wentler, SA Univ Minnesota Morris MN 56267 USA

Purpose/Method: This study investigated the effectiveness of day treatment programmes in rural Minnesota by comparing 2 groups in terms of yearly rates of re-hospitalization. Results: It was found that the group that responded positively to day treatment was much less likely to be re-hospitalized. Their rates of re-hospitalization were much lower than the state of Minnesota. The other group that dropped out of day treatment has a re-hospitalization rate as much as 10 times higher. Conclusion : This demonstrates the cost effectiveness of day treatment programmes.

关键词：双相情感障碍/康复慢性病费用效益分析日间住院医疗/经济学抑郁症/康复精神障碍/康复明尼苏达结果评价(卫生保健) 中止治疗的病人/统计学和数值数据病人再入院/统计学和数值数据精神病/康复乡村卫生服务/经济学人类

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The use and outcomes of outpatient mastectomy in Florida

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AMERICAN JOURNAL OF SURGERY 2000年第4期179卷 253-259页

作者： Ferrante, J Gonzalez, E Naazneen, P Roetzheim, R Univ S Florida Dept Family Med Tampa FL 33612 USA Univ S Florida H Lee Moffit Canc Ctr & Res Inst Tampa FL 33612 USA

BACKGROUND: To identify patient characteristics associated with outpatient mastectomies and their outcomes. METHODS: Patients diagnosed with breast cancer and treated with mastectomies in Florida in 1994 were identified from state discharge abstracts and the state tumor registry. The relationship between clinical/demographic characteristics and the odds of having an outpatient mastectomy was identified using multiple logistic regression. Outcomes were assessed by calculating the risk of being rehospitalized within 30 days of discharge. RESULTS: Twenty percent of mastectomies were performed on an outpatient basis. Outpatient mastectomies were more likely to be performed on women who were older, who lived in higher income communities, or who were uninsured. Health insurance type was not associated with having an outpatient mastectomy. Women undergoing outpatient mastectomy were more likely to be readmitted within 30 days of discharge;however, the excess risk was very small (0.7%). CONCLUSIONS: The risks from outpatient mastectomy are small. Ongoing monitoring of outcomes and assessment of patient satisfaction are needed. Am J Surg. 2000;179:253-260. (C) 2000 by Excerpta Medica, Inc.

关键词：门诊外科手术/统计学和数值数据门诊外科手术/利用卡方分布置信区间佛罗里达住院时间/统计学和数值数据乳房切除术改良根治性/统计学和数值数据乳房切除术改良根治性/利用乳房切除术单纯/统计学和数值数据乳房切除术单纯/利用病人再入院/统计学和数值数据社会经济因素女(雌)性人类

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Comparing outpatient and inpatient diabetes education for newly diagnosed pediatric patients

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DIABETES EDUCATOR 1999年第6期25卷 895-906页

作者： Siminerio, LM Charron-Prochownik, D Banion, C Schreiner, B Childrens Hosp Pittsburgh Dept Pediat Endocrinol Pittsburgh PA 15213 USA

PURPOSE The purpose of this study was to compare the efficacy of outpatient vs inpatient programs on medical, cognitive, behavioral, and psychosocial outcomes. METHODS Using three large, tertiary medical centers in the United States, the sample of 32 children newly diagnosed with diabetes and their parents were recruited. Children and parents who received outpatient education were compared with those who received inpatient education. The following outcome variables were compared: (1) rates of hospital readmissions and/or emergency room visits for either severe hypoglycemia or Ketoacidosis, (2) knowledge, (3) sharing of responsibilities, (4) adherence, (5) family functioning, (6) coping, and (7) quality of life. RESULTS In general, no statistically significant differences were found between the groups. A trend was noted in the outpatient group with regard to improved use of emergency precautions on the adherence measure, roles on the family functioning measure, maintaining family integration on the parental coping measure, and disposition on the children's coping instrument. CONCLUSIONS Findings support the safety and efficacy of the outpatient program method.

关键词：门诊医疗/方法糖尿病 1型/并发症糖尿病 1型/心理学糖尿病 1型/治疗急诊室医院/利用住院病人/教育结果评价(卫生保健) 双亲/教育双亲/心理学病人教育(主题)/方法病人再入院/统计学和数值数据方案评价青少年儿童女(雌)性人类男(雄)性

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Trends in clinical and economic outcomes of coronary angioplasty from 1992 to 1995: A population-based analysis

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AMERICAN HEART JOURNAL 1999年第6期137卷 1012-1018页

作者： Cohen, EA Young, W Slaughter, PM Oh, P Naylor, CD Univ Toronto Sunnybrook Hlth Sci Ctr Dept Med Div Cardiol Toronto ON M4N 3M5 Canada Inst Clin Evaluat Sci Toronto ON Canada

Background The impact of recent developments in coronary angioplasty on the brood spectrum of patients treated in routine practice is largely undefined. Analysis of population-based data can provide insight into trends in clinical outcomes and associated costs of coronary angioplasty procedures. Methods and Results With the use of a comprehensive hospital discharge database covering more than 11 million Canadians, we analyzed 12,748 first-time angioplasty procedures performed from 1992 to 1995 inclusive. Patient demographics and major adverse events were recorded. With the use of forward linkage, readmissions within 12 months were classified according to procedure performed and/or most responsible diagnosis, The proportion of patients readmitted, the number of readmissions per index procedure, and diagnosis-specific readmission costs were compared by calendar year. Over the 4-year study period, there was a 21% increase in the annual volume of index procedures. There were no statistically significant differences between 1992 and 1995 in sex distribution, mean age, comorbid conditions, length of stay, or need for coronary bypass surgery related to the index procedure. The all-cause readmission rate declined from 51.6% to 47.2% between 1992 and 1995 (P <.001), primarily because of a decline in the admission rate for repeat revascularization from 24.8% to 19.6% (P <.001). The 12-month readmission cost declined by $435 (1994 Canadian dollars) per patient. Conclusions The clinical outcomes of coronary angioplasty in a broad cohort of patients have improved in recent years. Although readmissions within year of an angioplasty procedure remain common, the number related to repeat revascularization has declined, with an associated decline in downstream costs.

关键词：队列研究费用效益分析医院费用/统计学和数值数据医院费用/发展趋势住院/经济学住院/统计学和数值数据住院/发展趋势安大略病人再入院/经济学病人再入院/统计学和数值数据病人再入院/发展趋势再治疗/经济学再治疗/统计学和数值数据再治疗/发展趋势支架/经济学支架/统计学和数值数据支架/发展趋势治疗结果人类中年人

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Predictors of readmission among elderly survivors of admission with heart failure

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AMERICAN HEART JOURNAL 2000年第1期139卷 72-77页

作者： Krumholz, HM Chen, YT Wang, Y Vaccarino, V Radford, MJ Horwitz, RI Yale Univ Sch Med Dept Med Sect Cardiovasc Med New Haven CT 06520 USA Yale Univ Sch Epidemiol & Publ Hlth Sect Chron Dis Epidemiol New Haven CT 06520 USA Yale Univ Sch Med Dept Med New Haven CT 06520 USA Yale New Haven Hosp Ctr Outcomes Res & Evaluat New Haven CT 06504 USA Qualidigm Middletown CT USA

Background Readmission rates for patients discharged with heart failure approach 50% within 6 months. Identifying factors to predict risk of readmission in these patients could help clinicians focus resource-intensive disease management efforts on the high-risk patients. Methods The study sample included patients 65 years of age or older with a principal discharge diagnosis of heart Failure who were admitted to 18 Connecticut hospitals in 1994 and 1995. We obtained patient and clinical data from medical record review. We determined outcomes within 6 months after discharge, including all-cause readmission, heart failure-related readmission, and death, from the Medicare administrative database. We evaluated 2176 patients, including 1129 in the derivation cohort and 1047 in the validation cohort. Results of 32 patient and clinical factors examined, 4 were found to be significantly associated with readmission in a multivariate model. They were prior admission within 1 year, prior heart failure, diabetes, and creatinine level >2.5 mg/dL at discharge. The event rates according to number of risk predictors were similar in the derivation and the validation sets for all outcomes. in the validation cohort, rates for all-cause readmission and combined readmission or death were 26% and 31% in patients with no risk predictors, 48% and 54% in patients with 1 or 2 risk predictors, and 59% and 65% in patients with 3 or all risk predictors. Conclusions Few patient and clinical factors predict readmission within 6 months after discharge in elderly patients with heart failure. Although we were unable to identify a group of patients at very low risk, a group of high risk patients were identified for whom resource-intensive interventions designed to improve outcomes may be justified.

关键词：康涅狄格/流行病学 Medicare/统计学和数值数据病人入院病人再入院/统计学和数值数据预后登记/统计学和数值数据回顾性研究危险因素存活率美国老年人老年人 80以上女(雌)性人类男(雄)性

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Ten-year outcome: patients with schizoaffective disorders, schizophrenia, affective disorders and mood-incongruent psychotic symptoms

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BRITISH JOURNAL OF PSYCHIATRY 2000年第5期177卷 421-426页

作者： Harrow, M Grossman, LS Herbener, ES Davies, EW Univ Illinois Coll Med Dept Psychiat MC912 Chicago IL 60612 USA Univ Chicago Dept Psychol Chicago IL 60637 USA

Background It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders. Aims To provide longitudinal data on clinical course and outcome in schizophrenia or affective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications. Method A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic-disorders and depression were assessed at hospitalisation and then followed up four times over 10 years. Results At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05). Conclusions Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course. Declaration of interest Supported by a research grant from the National institute of Mental Health, USA.

关键词：急性病情感障碍精神病性/诊断情感障碍精神病性/药物疗法情感障碍精神病性/康复方差分析随访研究住院/统计学和数值数据病人再入院/统计学和数值数据预后前瞻性研究精神病/诊断精神病/药物疗法精神病/康复精神分裂症/诊断精神分裂症/药物疗法精神分裂症/康复治疗结果成年人女(雌)性人类男(雄)性

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Unplanned readmissions of patients with congestive heart failure: Do they reflect in-hospital quality of care or patient characteristics?

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AMERICAN JOURNAL OF MEDICINE 2000年第5期109卷 386-390页

作者： Kossovsky, MP Sarasin, FP Perneger, TV Chopard, P Sigaud, P Gaspoz, JM Hop Univ Geneva Med Clin 2 CH-1211 Geneva 14 Switzerland Hop Univ Geneva Qual Care Unit CH-1211 Geneva Switzerland Hop Univ Geneva Grp Rech & Anal Syst CH-1211 Geneva 14 Switzerland Hop Univ Geneva Soins Hosp CH-1211 Geneva 14 Switzerland Univ Geneva Inst Social & Prevent Med Geneva Switzerland Geneva Univ Hosp Dept Internal Med Geneva Switzerland

PURPOSE: To determine if early unplanned readmissions of patients hospitalized for heart failure are associated with suboptimal in-hospital care or with the clinical and demographic characteristics of the patient. SUBJECT AND METHODS: We performed a case-control study among patients discharged with a principal diagnosis of heart failure. Cases included all patients unexpectedly readmitted within 31 days of discharge;controls were randomly selected from among those not readmitted. Quality of care was measured using explicit criteria reflecting the admission work-up, evaluation and treatment, and readiness for discharge. RESULTS: Ninety-one cases and 351 controls were included. There was no significant association between early unplanned readmissions and the scores for quality of the admission work-up or evaluation and treatment during the stay. There was a significant association between readiness for discharge and subsequent early readmission: for each 10% decrease in the proportion of fulfilled criteria, the odds of readmission increased by 14% (95% confidence interval [CI] 1.01 to 1.28, P = 0.04) for all-cause readmissions and by 19% (95% CI: 1.04 to 1.36, P = 0.01) for heart-failure-related readmissions. In a multiple logistic regression model, previous diagnosis of heart failure (odds ratio [OR] = 2.9, 95% CI: 1.7 to 4.8, P < 0.001), age (OR = 3.3, 95% CI: 1.3 to 8.5, P = 0.01 for patients aged 65 to 79 years and OR = 4.1, 95% CI: 1.6 to 11, P = 0.004 for patients aged 80 years and older), and history of cardiac revascularization (OR = 2.1, 95% CI: 1.2 to 3.9, P = 0.01) showed a stronger association with early unplanned all-cause readmissions than the readiness-for-discharge score (OR = 1.16, 95% CI: 1.02 to 1.31, P = 0.02). Similar findings were seen for heart failure-related readmissions. CONCLUSIONS: Among patients with heart failure, early unplanned readmissions were not associated with suboptimal admission work-up or evaluation and treatment but were weakly

关键词：病例对照研究人口统计学医院教学/标准医院教学/利用病案病人再入院/统计学和数值数据试验预期值卫生保健质量疾病严重程度指数瑞士老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Sex differences in the clinical care and outcomes of congestive heart failure in the elderly

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AMERICAN HEART JOURNAL 1999年第5期138卷 835-842页

作者： Vaccarino, V Chen, YT Wang, Y Radford, MJ Krumholz, HM Yale Univ Sch Med Dept Epidemiol & Publ Hlth New Haven CT 06520 USA Yale Univ Sch Med Sect Cardiovasc Med Dept Internal Med New Haven CT USA Yale New Haven Hosp Ctr Outcomes Res & Evaluat CORE New Haven CT 06504 USA Connecticut Peer Review Org Middletown CT USA

Background There is evidence for sex differences in treatment and outcome of ischemic heart disease. However, little and conflicting data exist about sex differences in the care and outcome of elderly patients with heart failure. Methods We compared mortality rate, readmission, and use of selected treatments and procedures between women and men in a database of 2445 patients (1426 women) aged greater than or equal to 65 admitted for heart failure to 18 Connecticut hospitals in 1994 and 1995. Demographic and clinical data were abstracted from the medical records. Results Women were older and more likely to have a history of hypertension whereas men more often had previous coronary heart disease. Women had more preserved left ventricular systolic function and higher systolic blood pressure on presentation than men. Treatments on day 1 (aspirin, angiotensin-converting enzyme [ACE] inhibitors, and diuretics), procedures during admission (assessment of left ventricular function, coronary angiography, and revascularization), and use of ACE inhibitors among ideal candidates at discharge were similar in men and women. Six-month rehospitalization rates were also similar. Although 30-day mortality rate did not differ between men and women, 6-month and 1-year mortality rates were lower in women after age adjustment (relative risk for 6-month death 0.81, 95% confidence interval, 0.68-0.95). In multivariable analysis, sex differences in mortality rate were reduced (relative risk 0.90, 95% confidence intervals, 0.75-1.08). History of hypertension, systolic blood pressure on admission, and left ventricular function mostly explained the observed sex differences in mortality rate. Conclusions Female and male patients hospitalized for heart failure have a similar hospital course, treatment pattern, and readmission rates, but women live longer than men. When baseline differences are accounted for, the mortality risk of women and men becomes very similar.

关键词：血管紧张素转换酶抑制药/治疗应用阿司匹林/治疗应用血压康涅狄格/流行病学冠状血管造影术利尿药/治疗应用药物疗法联合随访研究心脏导管插入术心肌血管重建术病人再入院/统计学和数值数据血小板聚集抑制剂/治疗应用回顾性研究疾病严重程度指数性征每搏输出量存活率治疗结果老年人老年人 80以上女(雌)性人类男(雄)性

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Predictors of 30-day hospital readmission after coronary artery bypass

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ANNALS OF THORACIC SURGERY 2000年第1期70卷 169-174页

作者： Stewart, RD Campos, CT Jennings, B Lollis, SS Levitsky, S Lahey, SJ Beth Israel Deaconess Med Ctr Div Cardiothorac Surg Boston MA 02215 USA Harvard Univ Sch Med Boston MA USA

Background. Risk factors for 30-day hospital readmission following coronary artery bypass grafting (CABG) have not been established. Methods. We prospectively followed 485 consecutive patients who underwent isolated primary CABG at our institution in 1997. Patients were contacted by telephone at 30 days following operation to determine readmission status. Results. The overall readmission rate was 16% (76 of 485). Female gender (25% versus 11%, p = 0.001) and diabetes (22% versus 12%, p = 0.005) were associated with significantly higher readmission rates. The relationship between female gender and readmission persisted after correcting for age and other comorbidities. Congestive heart failure trended towards a significant relationship with increased readmission rate (22% versus 14%, p = 0.09). There were no significant associations between 30-day readmission rate and age, hypertension chronic obstructive pulmonary disease, history of myocardial infarction, peripheral vascular disease, creatinine level of greater than or equal to 1.4 mg/dL, or decreased left ventricular ejection fraction (< 40%). Conclusions. These data show that most of the classic risk factors for postoperative mortality are not necessarily associated with increased readmission. However, female gender and diabetes are associated with greater than twice the risk of 30-day readmission following CABG. (Ann Thorac Surg 2000;70:169-74) (C) 2000 by The Society of Thoracic Surgeons.

关键词：冠状动脉分流术随访研究病人再入院/统计学和数值数据手术后并发症/流行病学预后前瞻性研究危险因素时间因素老年人女(雌)性人类男(雄)性

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Prediction of hospital readmission for heart failure: Development of a simple risk score based on administrative data

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第6期33卷 1560-1566页

作者： Philbin, EF DiSalvo, TG Henry Ford Hosp Sect Heart Failure & Cardiac Transplantat Div Cardiovasc Med Detroit MI 48202 USA Massachusetts Gen Hosp Cardiac Unit Heart Failure & Transplantat Boston MA 02114 USA Harvard Univ Sch Med Boston MA 02115 USA

OBJECTIVES The purpose of this study waste develop a convenient and inexpensive method for identifying an individual's risk for hospital readmission for congestive heart failure (CHF) using information derived exclusively from administrative data sources and available at the time of an index hospital discharge. BACKGROUND Rates of readmission are high after hospitalization for CHF. The significant determinants of rehospitalization are debated. METHODS Administrative information on all 1995 hospital discharges in New York State which were. assigned International Classification of Diseases-9-Clinical Modification codes indicative of CHF in the principal diagnosis position were obtained. The following were compared among hospital survivors who did and did not experience readmission: demographics, comorbid illness, hospital type and location, processes of care, length of stay and hospital charges. RESULTS A total of 42,731 black or white Patients were identified. The subgroup of 9,112 patients (21.3%) who were readmitted were distinguished by a greater proportion of blacks, a higher prevalence of Medicare and Medicaid insurance, more comorbid illnesses and the use of telemetry monitoring during their index hospitalization. Patients treated at rural hospitals, those discharged to skilled nursing facilities and those having echocardiograms or cardiac catheterization were less likely to be readmitted. Using multiple regression methods, a simple methodology was devised that segregated patients into low, intermediate and high risk for readmission. CONCLUSION Patient characteristics, hospital features, processes of care and clinical outcomes may be used to estimate the risk of hospital readmission for CHF. However, some of the variation in rehospitalization risk remains unexplained and may be the result of discretionary behavior by physicians and patients. (C) 1999 by the American College of Cardiology.

关键词：非洲裔美国人/统计学和数值数据非洲大陆世系人群共病现象欧洲大陆世系人群/统计学和数值数据心力衰竭/流行病学心力衰竭/人种学心力衰竭/康复 Medicaid/统计学和数值数据 Medicare/统计学和数值数据纽约/流行病学结果与过程评价(卫生保健) 病人再入院/统计学和数值数据危险疾病严重程度指数美国老年人老年人 80以上女(雌)性人类男(雄)性中年人

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