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Context: Hip fracture is a common clinical problem that leads to considerable mortality and disability. A need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fracture., Objectives: To identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care., Design: Prospective study with data obtained from medical records and through structured interviews with patients and proxies., Setting and Participants: A total of 571 adults aged 50 years or older with hip fracture who were admitted to 4 New York, NY, metropolitan hospitals between August 1997 and August 1998., Main Outcome Measures: In-hospital and 6-month mortality; locomotion at 6 months; and adverse outcomes at 6 months, defined as death or needing assistance to ambulate, compared by hospital, adjusting for patient risk factors., Results: The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P =.02 for both) but were not significantly associated with mortality. Adjustment for baseline characteristics either substantially augmented or diminished interhospital differences in outcomes. Two hospitals had 1 outcome (functional status or mortality) that was significantly worse than the overall mean while the other outcome was nonsignificantly better than average., Conclusions: Mortality and functional status ideally should be considered both together and individually to distinguish effects limited to one or the other outcome. Hospital performance for these 2 measures may differ substantially after adjustment, probably because different processes of care are important to each outcome.

Objectives: To ascertain the most common causes of delirium, to establish the initiation and timing of delirium, and to determine the duration of delirium in patients with hip fracture., Methods: Five hundred seventy-one (88%) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospectively interviewed on a daily basis, 5 days a week, with the Confusion Assessment Method for the presence of delirium. The patients were enrolled within 48 hours of admission. Their medical charts and the data collected by the study staff were reviewed and summarized. Two of us (R.S.M. and A.L.S.) reviewed the case summaries independently and assigned a cause based on a previously developed classification system, estimated the onset of the delirious episode, and determined whether the delirium had cleared, improved, or persisted at discharge. Subsequently, discrepancies in cause, timing of initiation, and mental status on discharge between the 2 physicians reviewers were discussed until consensus was reached., Results: The prevalence of delirium was 9.5% (54/ 571; 95% confidence interval, 7.0-11.9). Seven percent of episodes were assigned a definite cause, 20% a probable cause, 11% a possible cause, and 61% were attributable to 1 or more comorbid conditions. Twenty-eight (53%) of 54 subjects developed delirium after surgery. The delirium had cleared or improved in 40 (74%) of 54 subjects at the time of discharge., Conclusions: Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill; it also appears to follow a different clinical course. These results have important implications for the management of delirium in patients with hip fracture.

Background: We have observed that many black and Hispanic patients receiving palliative care at a major urban teaching hospital are unable to obtain prescribed opioids from their neighborhood pharmacies. In this study, we investigated the availability of commonly prescribed opioids in New York City pharmacies., Methods: We surveyed a randomly selected sample of 30 percent of New York City pharmacies to obtain information about their stock of opioids. For each pharmacy, U.S. Census estimates for 1997 were used to determine the racial and ethnic composition of the neighborhood (defined as the area within a 0.4-km [0.25-mile] radius of the pharmacy) and the proportion of residents who were more than 65 years old. Data on robberies, burglaries, and arrests involving illicit drugs in 1997 were obtained for the precinct in which each pharmacy was located. We used a generalized linear model to examine the relation between the racial or ethnic composition of neighborhoods and the opioid supplies of pharmacies, while controlling for the proportion of elderly persons at the census-block level and for crime rates at the precinct level., Results: Pharmacists representing 347 of 431 eligible pharmacies (81 percent) responded to the survey. A total of 176 pharmacies (51 percent) did not have sufficient supplies of opioids to treat patients with severe pain. Only 25 percent of pharmacies in predominantly nonwhite neighborhoods (those in which less than 40 percent of residents were white) had opioid supplies that were sufficient to treat patients in severe pain, as compared with 72 percent of pharmacies in predominantly white neighborhoods (those in which at least 80 percent of residents were white) (P<0.001)., Conclusions: Pharmacies in predominantly nonwhite neighborhoods of New York City do not stock sufficient medications to treat patients with severe pain adequately.

Background: To determine the relative impact of five proposed barriers to physician usage of advance directives with the aim of increasing the number of advance directives generated., Methods: Questionnaires were sent to 460 internal medicine resident and attending physicians at a large New York, NY, hospital. Of these, 277 (60%) responded. We used multiple regression to measure the impact of five barriers to physician-initiated discussions of advance directives (time constraints, compensation concerns, discomfort with the subject, beliefs about appropriateness, and lack of understanding) on respondents' estimates of the number of advance directives held by respondents' patients, the number of recent advance directive discussions, and the number of discussions initiated by physicians., Results: Physician lack of understanding and erroneous beliefs about appropriateness had particularly strong effects, serving as barriers to recent advance directive discussions (P < .0001 and P < .0001, respectively) and total number of advance directives held (P < .0001 and P < .02). Physicians' lack of knowledge also served as a barrier to the percentage of discussions that were physician initiated (P < .003 and P < .04). Time constraints and lack of comfort affected only discussions that were physician initiated (P < .001). Compensation concerns did not appear to serve as a barrier. Respondents were supportive of the concept of advance directives but reported minimal use of them in appropriate situations., Conclusions: Attention can now be focused on methods to overcome the five barriers studied and thereby enhance the execution of advance directives.