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Objective: To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative. Methods: A retrospective cohort study using hospital discharge abstracts of 5672 patients, aged 18 years and above, with sepsis-associated stays between February 2012 and January 2013 at an academic medical center and 5 community hospitals in Texas. Results: Sepsis was present on admission in almost 85% of cases and acquired in-hospital in the remainder. The overall inpatient death rate was 17.2%, but was higher in hospital-acquired sepsis (38.6%, medical; 29.2%, surgical) and Stages 2 (17.6%) and 3 (36.4%) compared with Stage 1 (5.9%). Patients treated at the academic medical center had a higher death rate (22.5% vs. 15.1%, P

The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP).This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome.Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P = 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P = 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P = 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P = 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P0.0001).Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.

To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients.This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded.Twenty-four-bed surgical ICU at a quaternary academic medical center.Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included.Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm).The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309-0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5-16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95).Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.

Racial/ethnic health care disparities are well described in people living with HIV/AIDS, although the processes underlying observed disparities are not well elucidated.A retrospective analysis nested in the University of Alabama at Birmingham 1917 Clinic Cohort observational HIV study evaluated patients between August 2004 and January 2007. Factors associated with appointment nonadherence, a proportion of missed outpatient visits, were evaluated. Next, the role of appointment nonadherence in explaining the relationship between African American race and virologic failure (plasma HIV RNA50 copies/mL) was examined using a staged multivariable modeling approach.Among 1221 participants, a broad distribution of appointment nonadherence was observed, with 40% of patients missing at least 1 in every 4 scheduled visits. The adjusted odds of appointment nonadherence were 1.85 times higher in African American patients compared with whites [95% confidence interval (CI) = 1.61 to 2.14]. Appointment nonadherence was associated with virologic failure (odds ratio = 1.78, 95% CI = 1.48 to 2.13) and partially mediated the relationship between African American race and virologic failure. African Americans had 1.56 times the adjusted odds of virologic failure (95% CI = 1.19 to 2.05), which declined to 1.30 (95% CI = 0.98 to 1.72) when controlling for appointment nonadherence, a hypothesized mediator.Appointment nonadherence was more common in African American patients, associated with virologic failure, and seemed to explain part of observed racial disparities in virologic failure.

To determine whether patients' decisions are an important determinant of nonuse of invasive cardiac procedures and whether decisions vary by race.Observational prospective cohort.Patients (N= 681) enrolled at the exercise treadmill or the cardiac catheterization laboratories at a large Veterans Affairs hospital.Doctors' recommendations and patients' decisions were determined by both direct observation of doctor and patient verbal behavior and by review of medical charts. Performance of coronary angiography, angioplasty, and bypass surgery were determined by chart review for a minimum of 3 months follow-up.Coronary angiography was recommended after treadmill testing for 83 of 375 patients and 72 patients underwent angiography. Among 306 patients undergoing angiography, recommendations for coronary angioplasty or bypass surgery were given to 113 and 45 patients and were completed for 98 and 33 patients, respectively. Recommendations were not significantly different by race. However, 4 of 83 (4.8%) patients declined or did not return for recommended angiograms and this was somewhat more likely among black and Hispanic patients, compared with white patients (13% and 33% vs 2%; P =.05). No patients declined angioplasty and 2 of 45 (4.4%) patients declined or did not return for recommended bypass surgery. Other recommended procedures were not completed after further medical evaluation (n = 32). There was no difference (P.05) by race/ethnicity in doctor-level reasons for nonreceipt of recommended invasive cardiac procedures.Patient decisions to decline recommended invasive cardiac procedures were infrequent and may explain only a small fraction of racial disparities in the use of invasive cardiac procedures.

PURPOSE: To examine variation in men’s long-term regret of treatment decisions, ie, surgical versus chemical castration, for metastatic prostate cancer and its associations with quality of life. METHODS: Survey of previously treated patients to assess treatment decisions and quality of life, supplemented with focus groups. Two items addressing whether a patient wished he could change his mind and the belief that he would have been better off with the treatment not chosen were combined in classifying survey respondents as either satisfied or regretful. χ2 and t tests were used to test associations between regret and treatment history, complications, and quality of life. RESULTS: Survey respondents included 201 men aged 45 to 93 years (median, 71 years), who had begun treatment (71% chemical castration, 29% orchiectomy) a median of 2 years previously. Most reported complications: hot flashes (70%), nausea (34%), and erectile dysfunction (81%). Most were satisfied with the treatment decision, but 23% expressed regret. Regretful men more frequently reported surgical (43%) versus chemical (36%) castration (P = .030) and nausea in the past week (54% v 32%; P = .010) but less frequently reported erectile dysfunction (56% v 72%; P = .048). Regretful men indicated poorer scores on every measure of generic and prostate cancer–related quality of life. Qualitative analyses revealed substantial uncertainty about the progress of their disease and the quality of the decisions in which patients participated. CONCLUSION: Regret was substantial and associated with treatment choice and quality of life. It may derive from underlying psychosocial distress and problematic communication with physicians when decisions are being reached and over subsequent years.

BACKGROUND Little data exist supporting the association of quality of care and nonfatal adverse outcomes in hospitalized patients, yet those outcomes are routinely scrutinized in quality assessment efforts. OBJECTIVE To determine whether measurable differences in quality of care are associated with the occurrence of non-fatal, in-hospital, and treatment-related complications. DESIGN Retrospective cohort study. SUBJECTS A total of 2,268 patients who were discharged alive from 9 Southwestern Veterans Affairs Medical Centers with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or diabetes mellitus. MEASURES Retrospective chart review was performed to collect information on patient severity of illness, in-hospital complication occurrence, and process quality of care. Process quality was assessed as the adherence scores for admission work-up and for treatment during the hospital stay. Process quality represents the proportion of applicable admission or treatment criteria that were met by that patient's care providers. Once severity of illness was taken into account Cox proportional hazards regression was used to assess the independent contribution of process quality of care to complication occurrence. RESULTS Higher admission work-up adherence scores for COPD patients and higher treatment adherence scores for COPD and diabetes patients were associated with a lower risk of complication occurrence. The adjusted risk ratios of complications for higher versus lower adherence scores (with 95% CI) were 0.64 (0.43, 0.97) and 0.52 (0.33, 0.80) for admission and treatment, respectively, in COPD patients, and 0.51 (0.31, 0.83) for treatment in diabetics. No significant association was found in CHF patients. CONCLUSION Better admission work-up and treatment quality in COPD patients, as well as treatment quality in diabetic patients, are associated with lower risk of nonfatal treatment-related complications in the study population.

Between 1992 and 1994, the Department of Veterans Affairs (VA) experimented with mobile clinics to provide health care for rural veterans. The objective was to assess the health status of rural mobile clinics' patients and compare this with patients receiving care in VA hospital-based clinics. This study hypothesized that hospital-based clinic patients would be more ill (i.e., have a greater reduction in health status). The Medical Outcomes Study (MOS) Short Form was used to evaluate patients' health status. Most patients sought care for the management of chronic disease. Patients in both groups had similar types of diseases. Mobile clinic patients were as ill as hospital-based patients (i.e., similar health status scores). This study shows that rural veterans have a case mix and a reduction in health status similar to that of VA hospital-based patients. Planners should account for this health reduction when planning the kinds of facilities and services needed in rural areas.

Men who pursue active treatment for metastatic prostate cancer face a choice between medical or surgical castration. While both alternatives have documented side-effects (e.g. loss of libido, breast enlargement and tenderness, hot flashes, and nausea), their psychosocial impacts are not well understood. As part of a study of patients' treatment decision making, we have sought to construct a patient-based measure of the salient disease and treatment-related qualities of life experienced by these men subsequent to treatment. Focus groups (15 with patients, two with wives) were used to develop candidate Likert scale questionnaire items representing quality of life issues that patients said were important. These items were combined with assessments of symptoms, comorbidity, and generic measures of functional status and well-being in a mail survey of patients treated at the Houston VAMC and two other Houston hospitals (n = 201, response rate = 63%). Psychometric analyses (principal components and multitrait scaling) were used to identify distinct dimensions of life quality; correlations with generic measures, and symptom reports were used in validation analyses. Qualitative analyses of focus group data identified three major domains of life quality: self-perceptions, anxiety about the effects of treatment, and concern with the process of decision making and treatment. Psychometric analyses identified nine reliable and valid indicators of prostate cancer-related quality of life: body image, sexual problems, spouse affection, spouse worry, masculinity, cancer-related self-image, cancer distress, cancer acceptance, and regret of treatment decision. Internal consistency (alpha) ranged form 0.71 to 0.90. Correlations with reference scales (e.g. MOS Mental Health Index, Profile of Mood States) and symptom status supported concurrent validity. Prostate cancer patients perceive a number of important psychosocial consequences of their treatment. These consequences are represented by nine scales comprising a brief (35 items) disease and treatment sensitive health-related quality of life instrument, which we will use in monitoring the outcomes of patients' treatment choices.

The reasons why many patients seemingly benefit from arthroscopic treatment of osteoarthritis of the knee remain obscure. The purpose of this pilot study was to determine if a placebo effect might play a role in arthroscopic treatment of this condition. After giving full informed consent, including full knowledge of the possibility and nature of a placebo surgery, five subjects were randomized to a placebo arthroscopy group, three subjects were randomized to an arthroscopic lavage group, and two subjects were randomized to a standard arthroscopic debridement group. The physicians performing the postoperative assessment and the patients remained blinded as to treatment. Patients who received the placebo surgery reported decreased frequency, intensity, and duration of knee pain. They also thought that the procedure was worthwhile and would recommend it to family and friends. Thus, there may be a significant placebo effect for arthroscopic treatment of osteoarthritis of the knee. The small numbers in this preliminary study preclude a valid statistical analysis, and no conclusions can be drawn regarding the superiority of one treatment over another. A larger study is needed to evaluate fully the efficacy of an arthroscopic procedure for this condition and to decide if it is reasonable to expend health care resources for this treatment; the larger study should include a placebo control group.

Patient noncompliance with treatment regime undermines the effectiveness of medical care, resulting in an unpredictable progression of the primary disease and a greater likelihood of complications. Hemodialysis patients are well suited for studying noncompliance because their treatment is prolonged and intensive, and medical regimens are clear cut and easily determined with objective measures. Moreover, noncompliant behavior by these patients not only endangers their life in the long run, but also results in negative effects within a day or two. Despite severe consequences, noncompliance with their medical regimen is the norm for dialysis patients rather than the exception. A large-scale study of chronic, outpatient hemodialysis patients (N = 1230 patients, response rate = 96%) treated in a variety of facility types (N = 29 facilities) was conducted to investigate prevalence and associated demographic characteristics of noncompliance with four treatment regimens--protein and potassium restrictions in the diet, medication regimen, and fluid restrictions. Few patients were noncompliant with diet regimens (9% with protein and 2% with potassium restrictions) but half were noncompliant with medication taking (50.2%) and fluid restrictions (49.5%). The prevalence of noncompliance with medication and fluid regimens was consistent with previous studies of dialysis patients but the prevalence of noncompliance with diet was much lower than that reported elsewhere. Prevalence of noncompliant patients varied between studies according to the cut-point used to establish compliance criteria, where more stringent cut-points inflated the percentage and more lenient cut-points reduced the percentage. Thus, there is a need to establish uniform criteria in order to test real differences in compliance between patient groups vs simply differences in measurement.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective Our goal was to develop an interactive DVD to help African American and Caucasian American adults with hypertension learn how to become better communicators during medical interactions. Material was to be presented in several formats, including patients’ narratives (stories). Methods To develop the narratives we recruited members of the target audience and elicited stories and story units in focus groups, interviews, and seminars. Story units were ranked-ordered based on conformance with the theory of planned behavior and narrative qualities and then melded into cohesive stories. The stories were recounted by actors on the DVD. Results 55 adults (84% women; 93% African American) participated in a focus group, interview, or seminar; transcripts yielded 120 story units. The most highly rated units were woven into 11 stories. The six highest rated stories/actor–storytellers were selected for presentation on the DVD. Conclusion We achieved our goal of developing an easy-to-use, story-driven product that may teach adults how to talk effectively with their doctors about hypertension. The DVD's effectiveness should be tested in a randomized trial. Practice implications Behavioral interventions aimed at improving patients’ ability to communicate during doctor visits may be useful adjuncts in the achievement of BP goals.

No national data exist regarding racial/ethnic differences in the use of interventions for patients at the end of life.To test whether among 3 cohorts of hospitalized seriously ill veterans with cancer, noncancer or dementia the use of common life-sustaining treatments differed significantly by race/ethnicity.Retrospective cohort study during fiscal years 1991-2002.Hospitalized veterans55 years, defined clinically as at high-risk for 6-month mortality, not by decedent data.Utilization patterns by race/ethnicity for 5 life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans and Hispanics, controlling for age, disease severity and clustering of patients within Veterans Affairs (VA) medical centers.Among 166,059 veterans, both differences and commonalities across diagnostic cohorts were found. African Americans received more or the same amount of end-of-life treatments across disease cohorts, except for less resuscitation [OR = 0.84 (0.77-0.92), p = 0.002] and mechanical ventilation [OR = 0.89 (0.85-0.94), por = 0.0001] in noncancer patients. Hispanics were 36% (cancer) to 55% (noncancer) to 88% (dementia) more likely to receive transfusions than Caucasians (p0.0001). They received similar rates as Caucasians for all other interventions in all other groups, except for 161% higher likelihood for mechanical ventilation in patients with dementia. Increased end-of-life treatments for both minority groups were most pronounced in the dementia cohort. Differences demonstrated a strong interaction with the disease cohort.Differences in level of end-of-life treatments were disease specific and bidirectional for African Americans. In the absence of generally accepted, evidence-based standards for end-of-life care, these differences may or may not constitute disparities.

Obstructive lung diseases are associated with high rates of depression and anxiety, yet many patients are never screened or treated. This study evaluated the five-question Depression and Anxiety modules of the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Questionnaire as a telephone screen in 1,632 patients with chronic breathing disorders at a Veterans Affairs Medical Center in Houston, TX. Subsequent testing of 828 patients with the Beck Depression Inventory-II and the Beck Anxiety Inventory showed that the sensitivity and specificity, respectively, of the Depression and Anxiety modules of the PRIME-MD Patient Questionnaire screening were 94.6% and 49.5% (Depression); 93.7% and 32.2% (Anxiety); and 97.7%, and 36.0% (combined screen), with an overall accuracy of 80.7%. In such populations, these two modules of the PRIME-MD Patient Questionnaire may be a useful screening tool.

The objectives of this study were to assess the prevalence, screening, and recognition of depression and anxiety in persons with chronic breathing disorders, including COPD.Cross-sectional study.The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC).A large sample of 1,334 persons with chronic breathing disorder diagnoses who received care at the MEDVAMC.The prevalence of anxiety and depression was measured in a large sample of persons with a chronic breathing disorder diagnosis who received care at the MEDVAMC, using the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questions. The positive predictive value of the PRIME-MD questions was then determined. The prevalence of anxiety and depressive diagnoses in patients determined to have COPD was then measured, using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID).Of patients screened with the PRIME-MD, 80% screened positive for depression, anxiety, or both. The predictive value of a positive phone screen for either depression or anxiety was estimated to be 80%. In the subsample of patients who had COPD and received a diagnosis using the SCID, 65% received an anxiety and/or depressive disorder diagnosis. Of those patients, only 31% were receiving treatment for depression and/or anxiety.It is troubling that a mere 31% of COPD patients with depression or anxiety are being treated, particularly given their high prevalence in this population. Practical screening instruments may help increase the recognition of anxiety and depression in medical patients, as suggested by the excellent positive predictive value of the PRIME-MD in our study.

Hospital profiles are increasingly constructed using risk-adjusted clinical data abstracted from patient records.We sought to compare hospital profiles based on risk adjusted death within 30 days of surgery from administrative versus clinical data in a national cohort of surgical patients.This was a cohort study that included 78,546 major noncardiac operations performed between October 1, 1991 and December 31, 1993 in 44 Veterans Affairs hospitals. Administrative data were used to develop and validate multivariable logistic regression models of 30-day postoperative death for all surgery and 4 surgical specialties (general, orthopedic, thoracic, and vascular). Previously developed and validated clinical models were obtained and reproduced for matching operations using data from the VA National Surgical Quality Improvement Program. Observed-to-expected 30-day mortality ratios for administrative and clinical data were calculated and compared for each hospital.In multivariable logistic regression models using administrative data, characteristics such as patient age, race, marital status, admission from a nursing home, interhospital transfer, admission on the weekend, weekend surgery, and risk strata consisting of groups of principal and comorbidity diagnoses were predictive of postoperative mortality (P0.05). Correlations of the clinical and administrative observed-to-expected ratios were 0.75, 0.83, 0.64, 0.78, and 0.86 for all surgery, general, orthopedic, thoracic, and vascular surgery, respectively. When compared with clinical models, administrative models identified outlier hospitals with sensitivity of 73%, specificity of 89%, positive predictive value of 51%, and negative predictive value of 96%.Our data suggest that risk adjustment of mortality using administrative data may be useful for screening hospitals for potential quality problems.

Background: Many healthcare organizations use diagnosis-based risk adjustment systems for predicting costs. Health self-report may add information not contained in a diagnosis-based system but is subject to incomplete response. Objective: The objective of this study was to evaluate the added predictive power of health self-report in combination with a diagnosis-based risk adjustment system in concurrent and prospective models of healthcare cost. Research Design: This was a cohort study using Department of Veterans Affairs (VA) administrative databases. We tested the predictive ability of the Adjusted Clinical Group (ACG) methodology and the added value of SF-36V (short form functional status for veterans) results. Linear regression models were compared using R2, mean absolute prediction error (MAPE), and predictive ratio. Subjects: Subjects were 35,337 VA beneficiaries at 8 VA medical centers during fiscal year (FY) 1998 who voluntarily completed an SF-36V survey. Measures: Outcomes were total FY 1998 and FY 1999 cost. Demographics and ACG-based Adjusted Diagnostic Groups (ADGs) with and without 8 SF-36V multiitem scales and the Physical Component Score and Mental Component Score were compared. Results: The survey response rate was 45%. Adding the 8 scales to ADGs and demographics increased the crossvalidated R2 by 0.007 in the prospective model. The 8 scales reduced the MAPE by $236 among patients in the upper 10% of FY 1999 cost. Conclusions: The limited added predictive power of health self-report to a diagnosis-based risk adjustment system should be weighed against the cost of collecting these data. Adding health self-report data may increase predictive accuracy in high-cost patients.

Although rarely studied, physician-patient interactions immediately following diagnostic tests are significant medical events because during these encounters the physician and patient often make decisions about major and sometimes invasive treatment. This investigation analyzed patterns of physician-patient communication following coronary angiography with particular attention to behaviors important to decision-making: physician information-giving, physician use of partnership-building, and active forms of patient participation (e.g., asking questions, being assertive, expressing concerns). We were particularly interested in effects related to the patient's race in light of documented evidence of racial disparities in cardiac care and outcomes. From audiotape recordings, 93 physician-patient interactions after coronary angiogram in a catheterization laboratory in a large US Veterans Affairs Medical Center were coded to measure the frequency of physicians' information-giving and partnership-building and the frequency of active patient participation. We also stratified these behaviors according to whether the behavior was prompted (e.g., physician information in response to a patient's question; a patient's opinion solicited by the doctor) or self-initiated. Several findings were noteworthy. First, these interactions were very brief and dominated by the physician. Second, although physician information-giving increased with more active patient participation, which in turn was correlated with physicians' use of partnership-building, proportionally little of the physicians' information (8%) and active patient participation (9%) was directly prompted by the other interactant. Finally, there was a tendency for physicians to self-initiate less information giving to black patients and for black patients to self-initiate less active participation than white patients. Although these differences were attenuated when other variables (e.g., the physician's training, disease severity) were included in the analysis, the pattern suggests a potential cycle of passivity where certain patients tend to receive fewer informational resources and these patients in turn do less to prompt the doctor for more.

To develop a reliable and valid instrument for measuring and monitoring joint-specific pain.Developed using patient interviews, reviews of pain literature, and expert input from orthopedic surgeons, the final Joint-Specific Multidimensional Assessment of Pain (J-MAP) includes the 6-item Pain Sensory and the 4-item Pain Affect subscales. Scores on the J-MAP Pain Sensory and Affect subscales range from 0 to 100, with higher scores indicating more pain intensity and worse pain distastefulness, respectively. Following the assessment of the factor structure, patients' scores (n = 180) on the J-MAP subscales were converted to equal interval scores using Rasch analyses. A psychometric evaluation of the items and Rasch-calibrated scores was conducted and included an assessment of reliability, validity, and responsiveness for use with patients with radiographic knee osteoarthritis.Evidence from the factor analyses showed that the J-MAP Pain Sensory and Affect items made up 2 distinct factors. Internal consistency estimates for the J-MAP subscales exceeded 0.85. The J-MAP subscales showed evidence for validity and were shown to be internally and externally responsive, demonstrating greater responsiveness than the Arthritis Impact Measurement Scale or the Medical Outcome Study Short Form-36 pain subscales. Finally, evidence was found supporting the J-MAP subscales' ability to distinguish target joint pain from pain emanating from other musculoskeletal conditions.The J-MAP is a reliable, valid, and responsive measure for assessing joint-specific pain at a single time point, or changes over time for one or a group of patients with knee osteoarthritis. With this initial evidence of its psychometric rigor, further testing of the measurement properties of the J-MAP in other joints and in other populations should be undertaken.

In patients with uninvestigated dyspepsia, a common initial management strategy in primary care is to prescribe a course of empiric antisecretory therapy and to refer those patients who do not respond for endoscopy. The objective of this research was to evaluate the effects of an empiric course of antisecretory therapy on dyspepsia-related health in patients with uninvestigated dyspepsia.We conducted a double blind, randomized, placebo-controlled trial in which patients with uninvestigated dyspepsia were randomized to a 6-wk course of omeprazole 20 mg p.o. b.id. versus placebo capsules p.o. bi.d. and followed over 1 yr. The patients were at least 18 yr old with at least a 1-wk history of dyspepsia without alarm features. Dyspepsia-related health was measured using the Severity of Dyspepsia Assessment (SODA), a valid, reliable, disease-specific outcome measure. The primary outcome was treatment failure, defined by a SODA Pain Intensity scoreor = 29 (scores, 2-47) during follow-up. Patients who were treatment failures underwent endoscopy.We enrolled 140 patients. The mean age was 51 yr, and seven (5%) were women. At 2 wk there were fewer treatment failures in the omeprazole group: 12 of 71 patients (17%) in the omeprazole group failed compared with 24 of 69 (35%) in the placebo group (p = 0.037, log rank test). Also, at 6 wk there were fewer failures in the omeprazole group: 21 of 71 patients (30%) in the omeprazole group failed compared with 31 of 69 (45%) in the placebo group in 0.067, log rank test). However, at the 1-yr follow-up, there was no significant difference in treatment failure rates in the two groups: 37 of 71 patients (52%) in the omeprazole group failed compared with 41 of 69 (59%) in the placebo group (p = 0.28, log rank test).In patients with uninvestigated dyspepsia, as compared with a strategy that would entail prompt endoscopy for all patients, an initial 6-wk course of either placebo or omeprazole reduces the need for endoscopy over a 1-yr follow-up. Compared with placebo, an initial 6-wk course of omeprazole delays, but does not reduce, the need for endoscopy. For proton pump inhibitor therapy to reduce the need for endoscopy, it may need to be given continuously.

Hospitals are ranked based on risk-adjusted measures of postoperative mortality, but definitions differ about which deaths following surgery should be included.To determine whether varying the case definition of deaths following surgery that are included in coronary artery bypass surgery quality assessment affects the identification of outlier hospitals.The study used a prospective cohort design.A total of 15,288 patients undergoing coronary artery bypass surgery without other cardiac procedures from October 1993 to March 1996 at all (N = 43) Veterans Affairs hospitals that conduct cardiac surgery.The first measure included any death occurring within 30 days after surgery, regardless of cause, in or out of the hospital (30-day mortality). The second measure included 30-day mortality plus any death occurring 30 days to 6 months after surgery that was judged to be a direct result of a perioperative complication of the surgery (all procedure-related mortality).Hospital performance as assessed by the two different definitions of death varied substantially. The rankings of hospitals differed for 86% (37/43) of hospitals. Twenty-one percent (9/43) changed their quartile of rank, and five hospitals changed their outlier status. The correlation of observed-to-expected ratios was high (r = 0.96), but there was disagreement of outlier status (kappa = 0.71).Judgments regarding the quality of a hospital's performance of coronary artery bypass surgery vary depending on the definition of postoperative mortality that is used. Further research is needed to assess what definition is most appropriate to identify quality of care problems.

The objective of this study was to describe patterns of hospital and clinic use and survival for a large nationwide cohort of patients with heart failure. A retrospective cohort study of patients treated in the Veterans Affairs medical care system was conducted using linked administrative databases as data sources. In 1996, the average heart failure cohort member had 1-2 hospitalizations, 14 inpatient days, 6-7 visits with the primary physician, 15 other visits for consultations or tests, and 1-2 urgent care visits per 12 months. The overall risk-adjusted 5-year survival rate was 36%. Hospital use rates in the cohort fell dramatically between 1992 and 1996. One-year survival rates increased slightly over the period. Patients with heart failure are heavy users of services and have a very poor prognosis. Utilization and outcome data indicate the need for major efforts to assure quality of care and to devise innovative ways of delivering comprehensive services.

In previous work, we developed a multidimensional measure of dyspepsia-related health. To evaluate the adequacy of this instrument as an outcome measure for a large-scale, multicenter, randomized clinical trial, we used Rasch analysis to address three questions: (1) Are the scales interval-level? (2) Do the scales measure precisely across the entire range of dyspepsia outcomes? (3) Do the scales' items have an optimal number of response categories? We found that the scales were not interval-level and that they did not measure effectively at low or high levels of the dyspepsia-related outcomes. Our results also suggest that patients were capable of discriminating among only four- to seven-item response categories. Further studies are needed to identify items that effectively measure high and low levels of dyspepsia-related outcomes and to validate that decreasing the number of response categories improves the psychometric properties of these scales.

The authors describe the role the Veterans Affairs (VA) medical system plays as a provider of clinic and hospital services by examining utilization levels and users' characteristics.The Veterans Affairs hospital discharge database, the Veterans Affairs outpatient clinic files, and the veteran population files were used to estimate the number of persons using the Veterans Affairs medical care system in 1994 and the intensity of their clinic and hospital use. Demographic and clinical characteristics of users were tabulated.In 1994, 2.7 million veterans, 10.3% of all US veterans, and approximately 23% of veterans who would have met the statutory eligibility requirements for Veterans Affairs care, used the hospital and/or clinic components of the Veterans Affairs medical system. Sixty-three percent of the system's users were younger than age 65, and 10.5% were women. These 2.7 million veterans had 901,665 Veterans Affairs hospital stays, 15.5 million bed-days, and 31.2 million outpatient visits in fiscal year 1994. The average number of hospitalizations per hospital user was 1.71; the average number of visits per clinic user was 11.7. Medical, surgical, and psychiatric diagnosis-related groups (DRGs) accounted for 56%, 21%, and 23%, respectively, of hospitalizations, but psychiatric diagnosis-related groups accounted for 43% of all inpatient days. Principal medicine clinic visits and psychiatry clinic visits accounted for 21% and 16% of Veterans Affairs ambulatory care.Because the patient population served by the Veterans Affairs system is skewed in a number of ways, its contribution as a provider of health services in the United States varies by gender, age, socioeconomic status, and diagnosis.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly placed in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival.

To determine whether the quality of care during a hospital stay is associated with unplanned readmission within 14 days.Case-control study.12 Veterans Affairs hospitals.Men discharged after a hospitalization for diabetes (n = 593), chronic obstructive lung disease (n = 1172), or heart failure (n = 748). The ratio of controls (men without an unplanned readmission within 14 days to any Veterans Affairs hospital) to cases (men with such a readmission) was 3:1.Unplanned readmission to any of the 159 Veterans Affairs hospitals within 14 days of discharge. Quality of care during the index stay was assessed by chart review using disease-specific explicit criteria for the process of inpatient care, which were developed by panels composed of expert physicians. Adherence scores (the percentage of applicable criteria that were met) were calculated for the admission workup, evaluation and treatment, and readiness for discharge.After adjustment was made for demographic characteristics, severity of illness, and need for care, adherence scores correlated with early unplanned readmission (P0.05). For patients with diabetes and heart failure, decreased readiness-for-discharge adherence scores correlated with increased risk for readmission (P = 0.001 and P = 0.016, respectively). In patients with obstructive lung disease, decreased admission-workup scores correlated with increased risk for readmission (P = 0.013). One of 7 readmissions in patients with diabetes, 1 of 5 readmissions in patients with heart failure, and 1 of 12 readmissions in patients with obstructive lung disease were attributable to substandard care.Lower quality of inpatient care increases the risk for unplanned early readmission in patients with heart failure, diabetes, or obstructive lung disease. Under certain circumstances, readmission is associated with remediable deficiencies in the process of inpatient care.

Background Regulatory and professional bodies issue an ever-increasing number of guidance documents on the ethics and methods of clinical trials, but the quality of clinical trials of invasive therapeutic procedures continues to be a concern. We interviewed aspiring and accomplished surgical trialists to understand how they use guidance documents and other resources in their work. Methods We performed a qualitative research study involving semistructured interviews of a diverse sample of 15 surgical trialists. Results Professional development as a surgical trialist was haphazard, inefficient, and marked by avoidable mistakes. Four types of resources played constructive roles: formal education; written materials on clinical trials; experience with actual trials; and interpersonal interactions with peers, experts, collaborators, and mentors. Recommendations for improvement centered on education, mentoring, networking, participating in trials, and facilitation by department chairs. Conclusions The haphazard and unstructured nature of the current system is adding unnecessarily to the numerous challenges faced by surgical trialists.

During the 1980s several changes occurred within and outside the Veterans Affairs medical system which may have affected levels of Veterans Affairs (VA) hospital use. We performed a secondary analysis of the 1980-1990 national VA hospital discharge database and Veteran Population Files to examine trends in VA hospital use and to assess effects of the aging of the veteran population. Between 1980 and 1990 discharges increased by 7% despite a 6% drop in the number of veterans. Overall the crude discharge rate increased by 13% and the user rate by 1%. Most of the change was attributable to the fact that as the decade progressed, the veteran population was comprised of proportionately older veterans, who are higher users of hospital care than younger veterans. The 11% increase in the multiple stay ratio was not attributable to aging. Examination of age-specific utilization rates showed that veterans younger than age 45 had consistent increases in use, whereas use by older veterans declined. Our findings indicate that change in the age composition of the veteran population is responsible for some but not all of the increase in VA hospital use in the last decade. The increase in use by young veterans may reflect increasing barriers to access to non-VA care. Declines in use by older veterans may indicate that VA has been successful in shifting the locus of care from the hospital to the ambulatory and long-term care settings.

Objective: To determine whether the manner in which residents conduct work rounds is associated with the adequacy of their care processes and the outcomes of their patients. Methods: Two types of data were collected: time and motion data for residents (n=12) during work rounds, and clinical and outcome data for the patients they cared for during the observation period (n=211). Five residents were classified as data gatherers because they spent twice as much time gathering clinical data about their patients as they spent engaging in other activities. Three physicians blinded to the resident’s identity rated the quality of the care process and assessed the frequency of undesirable events occurring during the stay and after discharge. Results: A data-gathering style was associated with higher quality of care as judged by both process and outcomes. The data gatherers were more likely to comply with the “stability of medications before discharge” criterion (86% of the data gatherers’ cases vs 73% of others’, p=0.07), and their patients were less likely to have unanticipated problems, in that fewer required calls from nurses (20% vs 37%, p

To determine the incidence of and risk factors for perioperative myocardial infarction with noncardiac surgery and to test the accuracy of a risk stratification system.Prospective cohort study.A large urban Veterans Affairs hospital.A total of 1487 men older than 40 years undergoing major, nonemergent, noncardiac operations.Infarction was established by at least two of the following: development of new Q waves, typical change in creatine kinase MB, and positive technetium pyrophosphate scintigraphy. Patients were stratified preoperatively into high-, intermediate-, low-, and negligible-risk strata based on clinical markers corresponding to different levels of coronary artery disease prevalence.Patients with coronary disease (high-risk stratum) had a 4.1% incidence of infarction (13 of 319; 95% CI, 1.8% to 6.4%); patients with peripheral vascular disease but no evidence of coronary disease (intermediate-risk stratum) had a 0.8% incidence (2 of 260, upper bound of CI, 2.0%); patients with high atherogenic risk factor profiles but no clinical atherosclerosis (low-risk stratum) had a 0% incidence (0 of 256, upper bound of CI, 1.2%). No cardiac deaths occurred in 652 men who had no atherosclerosis and low atherogenic risk factor profiles (the negligible-risk stratum). Factors independently associated with infarction included age more than 75 years (adjusted odds ratio, 4.77; CI, 1.17 to 19.41), signs of heart failure on the preoperative examination (adjusted odds ratio, 3.31; CI, 0.96 to 11.38), coronary disease (adjusted odds ratio, 10.39; CI, 2.27 to 47.46), and a planned vascular operation (adjusted odds ratio, 3.72; CI, 1.12 to 12.37).Coronary artery disease is the major risk factor for perioperative infarction. The stratification scheme identifies subsets of patients with different risks, and finer within-stratum distinctions can be made using additional variables.

Although many clinicians routinely recommend a base-line preoperative electrocardiogram (ECG) and obtain frequent postoperative ECGs to screen for myocardial infarction or ischemia, the diagnostic utility of screening perioperative ECGs is unknown. The present analysis evaluates the sensitivity and specificity of the perioperative ECG and examines its value as a predictor of early postoperative cardiac events and outcomes during the postoperative year. ECGs obtained preoperatively and on the first 3 postoperative days in 206 men undergoing transurethral prostate resection were analyzed using the Minnesota Code. The occurrence of cardiac events during the operative stay was assessed by measurement of the cardiospecific MB creatine kinase isoenzyme on the first 3 postoperative days and review of the entire clinical course. Twenty-one percent of patients developed postoperative ECG changes, mostly involving the T wave; none had cardiac symptoms or sustained creatine kinase MB elevation. Changes were not significantly more common in men known to have coronary disease. The single patient who had a perioperative myocardial infarction confirmed by enzymes had no codable ECG changes. The specificity of any ECG change for perioperative infarction was 78%; of ST segment changes only, 95%. Only one of the patients (2%) who had postoperative ECG changes had a cardiac event in the year after surgery. Routine perioperative ECGs is of little diagnostic/predictive utility in situations in which the incidence of perioperative myocardial infarction is low.

• A case of Legionella pneumophila infection complicated by thrombotic thrombocytopenic purpura (TTP) was confirmed at autopsy by the demonstration of the organism in lung tissue, and by the finding of widespread intravascular and subendothelial thrombi associated with microinfarctions in all major organs examined. In addition to the typical hematologic abnormalities of TTP, the patient was found to have a low serum C3 level and elevated levels of immune complexes as measured by the liquid phase C1q binding assay. We suggest that the L pneumophila infection caused endothelial damage and/or platelet aggregation, perhaps as a consequence of complement activation, thus initiating the sequence of events leading to extensive microvascular thromboses.

Aryl hydrocarbon hydroxylase (AHH) activity was measured in pulmonary alveolar macrophages (PAMs) and peripheral blood lymphocytes from cigarette smokers with and without primary lung cancer. Frequency distribution analysis of AHH induction ratios for the two groups revealed an increased number of individuals in the lung cancer patient group with high lymphocyte induction values (P less than 0.05). A similar increase was not shown for high-PAM AHH values in lung cancer patients (P greater than 0.2). When individual PAM and lymphocyte AHH values were compared between noncancer and lung cancer patients, a positive correlation was observed for noncancer patients (r=0.195, P less than 0.001), but no correlation of these values was noted for lung cancer patients. The lung cancer patients were divided into three subgroups of patients showing (I) high PAM and low lymphocyte AHH levels, (II) low PAM and low lymphocyte AHH levels, and (III) low PAM and high lymphocyte AHH levels. When the incidence of family history of cancer was compared for these subgroups, no family cancer history was recorded for persons in subgroup II; however, individuals in subgroups I and III presented family cancer history incidence of 9.5% and 39.3%, respectively. Patients in group III averaged 6 years younger than those in group I. These data suggest that familial factors may be identified among lung cancer patients and that these factors appear to associate as either a cause of an effect with the capacity of pulmonary alveolar macrophages and lymphocytes to be induced for AHH. The data support the hypothesis that high AHH values may be characteristic of lung cancer patients but show that enzyme values determined from a single tissue, either PAMs or lymphocytes, may not be appropriate for showing whether high AHH inducibility is correlated with lung cancer.

We performed a prospective study of 250 men undergoing transurethral resection of the prostate to determine the incidence of perioperative myocardial infarction. The prevalence of coronary artery disease in the study group was 27%. Patients had measurement of total creatine kinase and its MB isoenzyme and electrocardiography preoperatively and on the first three postoperative days. Only one myocardial infarction was diagnosed, an incidence rate of 0.4%. The overall rate of serious post-operative complications was 3.6%. No deaths occurred during the operative hospitalization. We conclude that with transurethral resection perioperative myocardial infarction is a rare event despite the high prevalence of coronary artery disease in this surgical population. Routine postoperative surveillance with electrocardiograms and creatine kinase determinations in asymptomatic patients is not warranted.

A significant portion of internal medicine residency training in the United States today occurs in general medicine sections of Veterans Administration hospitals. The authors studied the demographic, diagnostic, and prognostic characteristics of the patients treated by house staff members rotating through the general medical wards of the Houston, Texas, Veterans Administration (VA) Medical Center. In 2,131 admissions over 13 months, the most frequent primary causes of admissions included congestive heart failure, pneumonia, exacerbation of chronic obstructive lung disease, and malignancy. In 85 percent of the admissions, two or more chronic diseases were present. In 53 percent of admissions, the patients were deemed to be moderately or severely ill on admission. The data indicate that the residents' experience is representative of problems encountered by practicing internists and that VA hospitals make a significant contribution to internal medicine training and thus to the provision of health care for the nation.