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Purpose To identify variables related to time spent on a waiting list for cataract extraction and the effect of waiting time on some outcomes. Setting Twelve ophthalmology units throughout Spain. Design Cohort study. Methods This study included consecutive patients scheduled to have cataract removal by phacoemulsification. Sociodemographic and clinical data, including visual acuity, and Visual Function Index 14 (VF-14) results were collected before and after cataract extraction. Univariate and multivariate linear regression was performed to identify variables related to time on the waiting list for cataract extraction and the influence of waiting time on postoperative visual acuity, visual function, and complications. Results The study comprised 3787 patients. Patients with social support spent significantly more time (1.04 times) on the waiting list ( P = .0188), while those with contralateral visual acuity better than 0.5 and those with vision-related daily living difficulties spent less time on the waiting list. Patients who waited longer than 5 months for cataract extraction had smaller gains in visual acuity than those who waited fewer than 3 months ( P = .0348). Time on the waiting list did not significantly influence changes in the VF-14 results or complications from surgery. Conclusions The finding that some contradictory sociodemographic factors influence time spent on a waiting list for cataract extraction suggests that rational, explicit, and homogeneous appropriateness and priority criteria are not being applied to these patients. Use of such criteria could improve waiting times and order waiting lists so patients who need cataract extraction the most would receive it soonest. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

EVALUATION OF: Las Hayas C, Quintana JM, Padierna JA, Bilbao A, Muñoz P. Use of Rasch methodology to develop a short version of the Health Related Quality of Life for Eating Disorders questionnaire: a prospective study. Health Qual. Life Outcomes 8, 29 (2010). Quality of life has become of increasing interest for health professionals since the 1980s and is now incorporated into assessment, treatment and evaluation of many health interventions. Within the arena of eating disorders, adequate consideration of quality of life within treatment and research has been slower, but is now coming into line with wider physical and mental health fields. A number of eating disorder-specific measures have been developed that aim to assess perceived quality of life while also minimizing response bias, which can be attributable to the ego-syntonicity of the eating disorders. While these measures are of great importance, further work is still required to assess the reliability and validity of these scales and to adapt the current available measures to increase their suitability for incorporation into clinical and research protocols. The current discussed paper by Las Hayas et al. aims to evaluate the Health Related Quality of Life for the Eating Disorders - version 2 (HeRQoLEDv2) for reliability and validity, to develop a short form of this questionnaire, the Health Related Quality of Life for the Eating disorders - Short form (HeRQoLED-S) using Rasch methodology and to further assess the HeRQoLED-S for reliability and validity. The authors confirm their hypothesized internal structure of the scales and present evidence for the reliability of the short scale. However, the short measure should be subject to more rigorous analysis of its reliability and construct validity in order to provide evidence as to its relationship to quality of life as perceived by eating disorder individuals.

Rationale, aims and objectives Given the increasing prevalence of cataract and demand for cataract extraction surgery, patients must often wait to undergo this procedure. We validated a previously developed priority scoring system in terms of clinical variables, pre-intervention health status, appropriateness of surgery and gain in visual acuity (VA) and health-related quality of life (HRQoL). Methods Explicit prioritization criteria for cataract extraction created by a variation of the Research and Development (RAND) and University of California Los Angeles appropriateness methodology were retrospectively applied to a prospective cohort of 5257 patients on waiting lists to undergo cataract by phacoemulsification at 17 hospitals in Spain. Demographic data, clinical data and data related to surgical technique were collected by trained ophthalmologists. Patients were evaluated by their ophthalmologist before the intervention and 6 weeks afterward. They also completed, by mail, the Visual Function Index (VF-14) before the intervention and 3 months afterward. Results High-priority patients experienced greater improvement in VA and HRQoL than those classified as intermediate or low-priority (P

Background Total joint replacements are interventions with large waiting times from indication to the surgery management. These patients can be managed in two ways; first-in first-out or through a priority tool. The aim of this study was to compare real time on waiting list (TWL) with a priority criteria score, developed by our team, in patients awaiting joint replacement due to osteoarthritis. Methods Consecutive patients placed on waiting list were eligible. Patients fulfilled a questionnaire which included items of our priority tool and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) specific questionnaire. Other priority items were extracted from the clinical history. The priority tool gives a score from 0 to 100 points, and three categories (urgent, preferent and ordinary). We studied the differences among categories and TWL by means of one-way analysis of variance. Correlational analysis was used to evaluate association among priority score and TWL and WOMAC baseline and gains at 6 months with priority score and TWL. Results We have studied 684 patients. Women represented 62% of sample. The mean age was 70 years. There were not association between the categories of priority score and TWL (P = 0.12). The rho correlation coefficient between TWL and priority score was −0.11. Among baseline WOMAC scores and priority score, the rho coefficients were 0.79, 0.7 and 0.52 with function, pain and stiffness dimensions, respectively. There were differences in the mean scores of WOMAC dimensions according to the three priority categories (P

Background: Although patients admitted to hospital for community-acquired pneumonia (CAP) experience substantial short-term mortality following hospital discharge, few studies have focused on identifying factors that predict mortality after admission to hospital in this population. The objective of this study was to develop and validate a prognostic index for 90-day mortality after hospital discharge among patients with CAP. Methods: The prognostic index was derived in 1117 adult patients discharged between 2003 and 2007 from a general hospital following admission for CAP. It was validated in 646 consecutive patients with CAP discharged from three other hospitals between 1 November 2005 and 31 July 2006. Risk factors evaluated included host-related factors, severity upon admission, in-hospital management and bacteriology. Results: In the derivation cohort, three factors were independently associated with 90-day mortality: pre-illness functional status, Charlson index (composite measure of co-morbid illnesses) and severity on admission. Mortality at 90 days was 0.7% in the low-risk group, 3.5% in the intermediate-risk group and 17.2% in the high-risk group. In the validation cohort, 90-day mortality in the three groups was 0.6%, 3.9% and 19.6%, respectively. Compared with the low-risk group, the odds ratio for mortality was 43.5 for the high-risk group. The risk categories showed an area under the receiver operating characteristic curve of 0.79 in the derivation cohort and 0.82 in the validation cohort. Conclusions: The prognostic index accurately stratifies patients admitted to hospital for CAP into low-, intermediate- and high-risk groups for 90-day mortality on discharge. The use of this index could help clinicians improve outcomes in this vulnerable population by targeting specific interventions to each group.

Background and aims: The prevalence of knee and hip symptoms varies from study to study, or is unknown. The goals of this study were to determine the prevalence of these symptoms, of diagnosed osteoarthritis and the use of prostheses, by age and gender, in a sample of the general older population. Methods: We mailed a questionnaire to 11,002 people aged 60 to 90 years who were selected by stratified random sampling. The questionnaire included questions on pain, functional limitations, diagnosed osteoarthritis, previous operations on either or both joints, and sociodemographic data. Descriptive statistics were performed. Results: From 10,150 people who fulfilled the selection criteria, 74.6% answered the questionnaire. Up to 49.2% of the subjects reported pain in either knee or hip or both, with pain in the knee reported more frequently (38.3%) than the hip (23.8%). Functional limitations were present in 51.6% of respondents, with 42.5% having limitations in the knees and 27.7% in the hips. The symptoms increased with age and were more prevalent in women. About 6.6% of respondents reported that they had already had prosthesis implant (hip 3.9%; knee 2.6%). The presence of a hip prosthesis was slightly lower in women than in men and more women had a knee prosthesis. Physicians had already diagnosed osteoarthritis in 38.5% of the sample, 19.4% of the hip and 31% of the knee. Conclusions: The prevalence of pain symptoms is relatively high among older people, more often in the knee and, in both pints, more often in women, but the rate of prosthetic surgeries was low, which means that additional studies are necessary to gain insight into the healthcare needs of the population.

To compare patient satisfaction in 4 acute hospitals.The sample was composed of individuals admitted to 4 hospitals in the Basque Health Service (Osakidetza, Spain) in January and February 2002. Six hundred and fifty patients were selected from each hospital and were sent a satisfaction questionnaire composed of 34 items summarized in 6 factors. Independent scores for each factor were created. Sociodemographic variables, those related to admission, as well as some global questions and the average scores of the factors were compared among the 4 hospitals.Differences between the 4 hospitals were found in age, the number of previous admissions, type of service, length of hospital stay, and the questions evaluating satisfaction with waiting time between users' arrival at the hospital and admission. Although the degree of satisfaction was high, differences were detected depending on the factor and the hospital. Thus, "information", "dealings with staff" and "comfort" were rated more highly by users of hospital 3 than by those of hospital 1. The results observed in the univariate analysis changed only slightly in the multivariate models.The questionnaire used allowed comparable results to be obtained among the 4 hospitals participating in this study and identified areas of excellence and areas requiring improvement in each of the centers.

A study was undertaken to identify and weigh at the time of hospital discharge simple clinical variables that could predict short-term outcomes in patients with pneumonia.In a prospective observational cohort study of 870 patients discharged alive after hospitalization for pneumonia, we collected oxygenation and vital signs on discharge and assessed mortality and readmission within 30 days. From the beta-parameter obtained in a multivariate Cox proportional hazard regression model, a score was assigned to each predictive variable. The effects of instability at discharge on outcomes within 30 days thereafter were examined by adjusted models with use of the pneumonia severity index at hospital admission, the length of stay, the Charlson comorbidity index, or the preillness functional status.Four variables related to a 30-day mortality rate from all causes were identified in the multivariate model; these included one major criterion (temperature37.5 degrees C) and three minor criteria (systolic BP90 mm Hg or diastolic BP60 mm Hg, respiratory rate24 breaths/min, and oxygen saturation90%). The developed score remained significantly associated with a higher risk-adjusted rate of death. Patients with a scoreor = 2 (one major criterion or two minor criteria) had a sixfold-greater risk-adjusted hazard ratio (HR) of death (HR, 5.8; 95% confidence interval, 2.5 to 13.1).Four criteria of instability on discharge seem to be related to the mortality rate after discharge, but each of the factors must be weighed differently. The resulting score is a simple alternative that can be used by clinicians in the discharge process.

This study was designed to assess 8-year trends in the duration of hospitalization for community-acquired pneumonia and to evaluate the impact of declining length of stay on postdischarge short-term readmission and mortality.We conducted a prospective observational cohort study of 1886 patients with community-acquired pneumonia who were discharged from a single hospital between March 1, 2000, and June 30, 2007. The main outcomes measured were all-cause mortality and hospital readmission during the 30-day period after discharge. Regression models were used to identify risk factors associated with hospital length of stay and the adjusted associations between length of stay and mortality and readmission.Factors associated with a longer hospital stay included the number of comorbid conditions, high risk classification on the Pneumonia Severity Index, bilateral or multilobe radiographic involvement, and treatment failure. Patients treated with an appropriate antibiotic were less likely to have an increased length of stay. The mean length of stay was significantly shorter during the 2006 to 2007 period (3.6 days) than during the 2000 to 2001 period (5.6 days, P.001). Despite the reduction in length of stay, there were no significant differences in the likelihood of death or readmission at 30 days between the 2 time periods. Adjusted multivariate analysis showed that patients with hospital stays less than 3 days did not have significant increases in postdischarge outcomes.The marked decreased in the length of stay for patients hospitalized with community-acquired pneumonia since 2000 has not been accompanied by an increase in short-term mortality or hospital readmission.

Objective The introduction of phacoemulsification in the early 1990s significantly changed the treatment of cataract. It is possible that appropriateness criteria for cataract extraction developed before the widespread adoption of phacoemulsification no longer is as accurate or valid as possible. The objective of this study was to validate newly developed explicit appropriateness criteria. Design Prospective, observational cohort study. Participants Consecutive patients with a diagnosis of cataract who were on waiting lists to undergo cataract extraction by phacoemulsification were recruited. Methods Newly developed explicit appropriateness criteria for cataract extraction, following Research and Development methodology, were applied in this study conducted in 17 public teaching hospitals. Data necessary to classify the appropriateness of the intervention, including demographic and clinical data and that related to the surgery and complications, were recorded by previously trained ophthalmologists in all centers before the intervention and at the 6-week visit afterward. Main Outcome Measures Subjects completed 2 questionnaires that measure health-related quality of life—the Short Form 36 and the Visual Function Index 14 (VF-14)—before the procedure and 3 months afterward. Also, visual acuity was recorded by ophthalmologists previous to the intervention and at 6 weeks after. Results Five thousand two hundred fifty-seven cases were included in the study. At 3 months after cataract extraction, 4335 (82.5%) patients had responded to the questionnaires. Patients whose procedures were classified as necessary or appropriate by the new appropriateness criteria had greater improvements in visual acuity and VF-14 scores than those undergoing procedures classified as inappropriate. These differences seemed to be clinically relevant by measures such as the minimal clinically important difference and minimal detectable change. Complications rates were similar among all appropriateness categories, except for complications occurring in the peri-intervention period. Conclusions These results suggest a direct relationship between the newly developed explicit appropriateness criteria for cataract extraction and outcomes, as measured by clinical evaluation and health-related quality-of-life instruments. The results support the use of these criteria for clinical evaluation or the development of clinical guidelines. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

[Objective]: To study three molecular parameters (number of CGG repeats, X-inactivation ratio, and expression of FMR1 mRNA) in premutation carriers of fragile X syndrome with and without premature ovarian failure (POF) to find differences between these two groups that could be useful in reproductive counseling. [Design]: A retrospective clinical and molecular genetic study of 42 known premutation carriers of fragile X syndrome aged 40 years or older, 25 with POF and 17 without. A blood sample to obtain mRNA was taken from all of them. They all lived in five autonomous communities in northern Spain. [Results]: Although the relationship among mRNA levels, X-inactivation ratio, and CGG repeats seems to be similar both in women with POF and in those without: in women with POF, the effect of the CGG repeats on the mRNA levels was statistically significant (P = 0.0437), but in women without POF, it was not (P = 0.0724). Moreover, we confirmed previous results on the nonlinear association between CGG repeat number and the manifestation of POF, showing that the likelihood of having POF was significantly higher with fewer than 100 CGG repeats compared with 100 or more CGG repeats (odds ratio = 13.09, P = 0.0240). [Conclusions]: Our present work suggests that mRNA and X-inactivation studies in blood are not relevant in predicting POF in female premutation carriers of fragile X syndrome. However, having a permutation of fewer than 100 repeats could represent a significant risk of POF. © 2008 by The North American Menopause Society.

Objective: To assess health-related quality of life (HRQoL) in patients following liver transplantation and the factors associated with HRQoL variation. Methods and Materials: Sociodemographic and clinical data were collected for 60 consecutive patients activated for liver transplantation in a single hospital. Patients were classified according to the severity of the cirrhosis (Child–Pugh class) and disease etiology (alcoholic cirrhosis, viral cirrhosis, cholestatic diseases, and hepatocarcinoma). HRQoL was assessed by three different questionnaires: the Health Survey Short Form 36 (SF-36), the Hospital Anxiety and Depression Scale (HAD), and a specific-symptom questionnaire. Questionnaires were completed during the pre-operative period and six months after transplantation. Results: In the pre-operative period, patients with Child A had higher mean levels of HRQoL than did those in other groups. At six months following transplantation, there were no significant differences among the groups, largely because gains obtained by patients with Child B and C were much greater than those attained by patients with Child A. Across the four etiological groups, there were significant differences in all domains of the three questionnaires, except SF-36-bodily pain and HAD-anxiety, prior to transplantation, because patients with hepatocarcinoma had much better HRQoL. After transplantation, there were no differences because patients with viral and alcohol-induced cirrhosis achieved greater gains with respect to the neoplastic group. During the pre-operative period, the scores for all areas of the SF-36 and for all groups were below the general population normalized score of 50 (except for patients with Child class A and those affected with hepatocarcinoma). Six-months post-transplantation, the scores on most of the domains remained below 50, except for certain mental areas in which higher scores were attained. Conclusions: Health-related quality of life is influenced by the severity and etiology of cirrhosis—patients with Child class C and those with alcoholic or viral cirrhosis have the poorest quality of life. There were no differences observed among the groups after the transplantation, as the patients with the lowest HRQoLs prior to surgery demonstrated greater gains in HRQoL associated with liver transplantation.

Objectives Motor skill learning involves both practice and a latent, sleep-dependent process of consolidation that develops after training (“off-line” learning). Sleep consolidation is linked to reduced brain activation in prefrontal areas, along with strong involvement of parietal regions. The objective in this study was to investigate the influence of sleep on the consolidation process of a motor task in patients with prefrontal damage. Patients and methods For that purpose 14 patients with acquired focal prefrontal lesions, 15 age-matched healthy controls, and five patients with parietal lesions were evaluated on a serial reaction time task, SRTT, before and after a night of monitored sleep. Verbal and working memory was also tested. We anticipated that patients with prefrontal lesions, who are impaired in the acquisition of motor tasks, would benefit greater from sleep than the other two groups, since consolidation does not depend on prefrontal regions. Results Prefrontal patients showed an erratic learning curve at night, with great inter- and intrasubject variability that normalized after sleep. They also showed higher overnight learning of the motor skill and improvement on speed performance on the SRTT. No differences in the other memory tests were found between sessions. Conclusion Prefrontal-injured patients benefit from night sleep in terms of motor task learning and performance, likely related to an advantageous off-line learning. Sleep could play a role in motor rehabilitation programs in prefrontal patients.

Objetivo: traducir y evaluar las propiedades psicométricas de un cuestionario de calidad de vida específico para pacientes sometidos a trasplante hepático. Material y métodos: el cuestionario fue administrado a 60 pacientes en lista de espera de trasplante hepático de la Unidad de Trasplante del Hospital de Cruces, y a los 6 meses tras la intervención. Se estudió la fiabilidad, la validez, la sensibilidad al cambio y el mínimo cambio detectable (MCD). Para evaluar la validez convergente se utilizaron dos cuestionarios, SF-36 (Health Survey Short Form 36) y el HAD (Hospital Anxiety and Depression Scale). Resultados: el cuestionario específico presenta un coeficiente alfa de Cronbach superior a 0,7. El análisis factorial demuestra una única dimensión. Las correlaciones con las áreas del SF-36 oscilaron entre -0,34 y -0,71 en el preoperatorio, y entre -0,21 y -0,67 a los 6 meses. Respecto al HAD-ansiedad, los coeficientes eran 0,44 en el preoperatorio y 0,51 a los 6 meses, y para HAD-depresión de 0,64 y 0,39 respectivamente. Los estudios de validez discriminante confirman que el cuestionario muestra diferencias entre pacientes con cirrosis de diversas etiologías o gravedad. En el estudio de la sensibilidad al cambio se obtuvieron unos valores para los índices TEE (tamaño del efecto estandarizado) y MRE (media de respuesta estandarizada) de 0,92 y 0,99 respectivamente. Además, un 58,33% de los pacientes superaba el MCD. Conclusiones: el cuestionario específico posee adecuadas propiedades psicométricas, lo cual puede aconsejar su utilización en estos pacientes, como otra medida más para evaluar los resultados de esta intervención.

Objective strategies are needed to improve the diagnosis of severe community-acquired pneumonia in the emergency department setting.To develop and validate a clinical prediction rule for identifying patients with severe community-acquired pneumonia, comparing it with other prognostic rules.Data collected from clinical information and physical examination of 1,057 patients visiting the emergency department of a hospital were used to derive a clinical prediction rule, which was then validated in two different populations: 719 patients from the same center and 1,121 patients from four other hospitals.In the multivariate analyses, eight independent predictive factors were correlated with severe community-acquired pneumonia: arterial pH7.30, systolic blood pressure90 mm Hg, respiratory rate30 breaths/min, altered mental status, blood urea nitrogen30 mg/dl, oxygen arterial pressure54 mm Hg or ratio of arterial oxygen tension to fraction of inspired oxygen250 mm Hg, ageor = 80 yr, and multilobar/bilateral lung affectation. From the beta parameter obtained in the multivariate model, a score was assigned to each predictive variable. The model shows an area under the curve of 0.92. This rule proved better at identifying patients evolving toward severe community-acquired pneumonia than either the modified American Thoracic Society rule, the British Thoracic Society's CURB-65, or the Pneumonia Severity Index.A simple score using clinical data available at the time of the emergency department visit provides a practical diagnostic decision aid, and predicts the development of severe community-acquired pneumonia.

Background We used a validated inpatient satisfaction questionnaire to evaluate the health care received by patients admitted to several hospitals. This questionnaire was factored into distinct domains, creating a score for each to assist in the analysis. We evaluated possible predictors of patient satisfaction in relation to socio-demographic variables, history of admission, and survey logistics. Methods Cross-sectional study of patients discharged from four acute care general hospitals. Random sample of 650 discharged patients from the medical and surgical wards of each hospital during February and March 2002. A total of 1,910 patients responded to the questionnaire (73.5%). Patient satisfaction was measured by a validated questionnaire with six domains: information, human care, comfort, visiting, intimacy, and cleanliness. Each domain was scored from 0 to 100, with higher scores indicating higher levels of patient satisfaction. Results In the univariate analysis, age was related to all domains except visiting; gender to comfort, visiting, and intimacy; level of education to comfort and cleanliness; marital status to information, human care, intimacy, and cleanliness; length of hospital stay to visiting and cleanliness, and previous admissions to human care, comfort, and cleanliness. The timing of the response to the mailing and who completed the questionnaire were related to all variables except visiting and cleanliness. Multivariate analysis confirmed in most cases the previous findings and added additional correlations for level of education (visiting and intimacy) and marital status (comfort and visiting). Conclusion These results confirm the varying importance of some socio-demographic variables and length of stay, previous admission, the timing of response to the questionnaire, and who completed the questionnaire on some aspects of patient satisfaction after hospitalization. All these variables should be considered when evaluating patient satisfaction.

Background: We studied the association between explicit appropriateness criteria for total hip joint replacement (THR) and total knee replacement (TKR) with changes in health-related quality of life of patients undergoing these procedures. Methods: Prospective observational study of 1576 consecutive patients with diagnoses of osteoarthritis on waiting lists to undergo THR or TKR. Explicit appropriateness criteria using the RAND appropriateness method were applied. Patients completed 2 questionnaires that measured health-related quality of life, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), before the procedure and 6 months afterward. Results: Patients who were considered appropriate candidates for these procedures had greater improvements than those who were considered inappropriate candidates in all 3 WOMAC domains (pain, functional limitation, and stiffness; THR: 43.0, 40.6, and 40.4 vs 14.7, 19.1, and 15.9; TKR: 34.9, 32.5, and 30.2 vs 23.2, 18.9, and 17.1;P.001 for all comparisons). Patients who underwent THR and were judged to be appropriate candidates had greater improvements in the physical function, role–physical, bodily pain, and social function domains of the SF-36 than those judged to be inappropriate candidates (34.4, 35.1, 33.1, and 26.6 vs 19.6, 9.2, 5.7, and 7.0; P=.04, P=.03, P.001, and P.001, respectively). Appropriate candidates for TKR demonstrated greater improvement in the social function domain of the SF-36 after the procedure than those deemed inappropriate candidates (19.9 vs 7.9; P=.004) but not in the other domains of functional status. Conclusions: These results suggest a direct relationship between explicit appropriateness criteria and better health-related quality-of-life outcomes after THR and TKR surgery. Our results support the use of these criteria for clinical guidelines or evaluation purposes. Arch Intern Med. 2006;166:220-226

The CURB-65 score (Confusion, Urea > 7 mmol x L(-1), Respiratory rate > or = 30 x min(-1), low Blood pressure, and age > or = 65 yrs) has been proposed as a tool for augmenting clinical judgement for stratifying patients with community-acquired pneumonia (CAP) into different management groups. The six-point CURB-65 score was retrospectively applied in a prospective, consecutive cohort of adult patients with a diagnosis of CAP seen in the emergency department of a 400-bed teaching hospital from March 1, 2000 to February 29, 2004. A total of 1,100 inpatients and 676 outpatients were included. The 30-day mortality rate in the entire cohort increased directly with increasing CURB-65 score: 0, 1.1, 7.6, 21, 41.9 and 60% for CURB-65 scores of 0, 1, 2, 3, 4, and 5, respectively. The score was also significantly associated with the need for mechanical ventilation and rate of hospital admission in the entire cohort, and with duration of hospital stay among inpatients. The CURB-65 score (Confusion, Urea > 7 mmol x L(-1), Respiratory rate > or = 30 x min(-1), low Blood pressure, and age > or = 65 yrs), and a simpler CRB-65 score that omits the blood urea measurement, helps classify patients with community-acquired pneumonia into different groups according to the mortality risk and significantly correlates with community-acquired pneumonia management key points. The new score can also be used as a severity adjustment measure.

Objectives To assess the responsiveness of the Health-Related Quality of Life for Eating Disorders questionnaire version-2 (HeRQoLEDv2) and present the psychometric characteristics of a new binge domain. Study Design and Setting Patients with an eating disorder completed the HeRQoLEDv2, the Eating Attitudes Test-26, Short Form Health Survey-12, and two items from the Eating Disorder Inventory-2, at baseline and after 1 year. At the second assessment, patients completed the HeRQoLEDv2, as part of the battery of tests, along with health transitional questions. Validity and reliability analyses of the new binge domain were performed. Responsiveness was evaluated using distributional and anchor-based approaches, comparison of mean changes, mean change correlations, the minimal detectable change (MDC) at the individual and group level, and the minimal important difference (MID). Results Items in the binge domain loaded above 0.40. Cronbach alpha was 0.82. Regarding responsiveness, the mean changes detected by the HeRQoLEDv2 correlated above 0.30 with the criterion measures. Patients who reported improvement showed significant changes, and effect sizes above 0.30. The MDC90%ind was larger than the MID. Conclusion The HeRQoLEDv2 includes the new binge domain. It responded to change at the group level. Further research regarding the MID is needed.

Objective. To develop a psychometrically sound, hospital patient satisfaction questionnaire to be administered to patients discharged from medical and surgical services. Design. Cross-sectional survey in Spanish. Setting. Four acute care general hospitals of the Basque Health Service. Study participants. Random samples of 650 discharged patients from each hospital during February and March 2002. A total of 1910 patients responded to the questionnaire (73.5%). Main outcome measures. Overall perceived quality of health care and perceived health improvement. Results. No sociodemographic differences were found between respondents and non-respondents. Six dimensions were identified from the factor analysis, explaining 50% of the variance. All items, except two, revealed loadings above 0.4. Cronbach’s alpha exceeded 0.7 for all dimensions, except privacy. Comfort was the dimension with the lowest level of patient satisfaction, whereas privacy was the most satisfactory. The interscale correlations never exceeded the internal consistency of each scale. The analysis of the dimensions with two items of global assessment showed a positive correlation. Conclusions. The results obtained from the development and validation of the questionnaire provide evidence of its psychometric properties, although it would be useful to carry out further analyses to assess time-based properties of reliability. We found a positive relation between the degree of patient satisfaction and overall evaluation of the quality of health care, providing evidence of the ability of the questionnaire to correlate with other concepts. The in-patient satisfaction questionnaire could become a useful instrument in quality-of-care assessment.

Variability in the management of patients hospitalized with community-acquired pneumonia (CAP) is attributable to many factors. The objective of this study was to determine whether such variability is influenced by the medical specialty area where the patient is treated.The treatment and outcomes for a random sample of patients with CAP admitted to 4 hospitals over 2 periods (1 year starting March 1, 1998, and 1.5 years starting March 1, 2000) were compared by medical specialty department. Multiple linear and logistic regression models were used to analyze differences.Differences were found between departments in the coverage of atypical pathogens (P.001). The adjusted mean length of stay in hospital varied between 6.8 and 9.1 days (P.01), and the duration of intravenous treatment varied between 4.6 and 7.3 days (P.05). Adjusted models showed that mortality in hospital and at 30 days was significantly higher for patients treated in internal medicine departments (odds ratios, 2.1 and 2, respectively) than for those treated in pulmonology departments.Interdepartmental differences were observed in how patients hospitalized with CAP were treated and in the outcomes achieved. This variation is probably influenced by the differences that were found in the use of antibiotics.

Background: Cholecystectomy use varies moderately across regions and countries. The purpose of this study was to evaluate the appropriateness of the use of cholecystectomy in patients with nonmalignant diseases in different hospitals using explicit criteria developed by an expert panel. Methods: Patients on waiting lists to undergo a cholecystectomy for nonmalignant diseases in six public hospitals in Spain were included in this prospective observational study over a 1-year period. Appropriateness criteria were first developed by a panel of experts using the RAND appropriateness method. The appropriateness of the indication was judged by applying explicit criteria developed previously. Complications were recorded 3 months after surgery. Results: After evaluation of 960 patients, 7 (0.7%) were considered to have undergone inappropriate procedures and 76 (7.9%) were judged to be uncertain. Differences were found in the rate of appropriateness among some centres (inappropriateness rate ranging from to 0 to 2.6%). No differences were found among the appropriateness categories for length of stay or complications, mortality, or readmission up to the third month after discharge. Conclusions: This study identified a low percentage of inappropriately performed cholecystectomies in our area. Even so, appropriateness differences among hospitals were found.

Summary Study objetives : The goal of this study was to assess variability in the management of patients admitted to hospitals with community-acquired pneumonia (CAP), and changes in secular trends of this condition. Methods : Observational study carried out, in 5 teaching hospitals, in northern Spain of patients admitted with CAP between March 1,1998 and March 1,1999 (baseline period), and between March 1, 2000 and September 30, 2001 (follow-up period). Clinical histories were analyzed retrospectively for relevant parameters for process-of-care and outcome performance. Those parameters among hospitals during the baseline period were compared. For each hospital, changes in these parameters between baseline and follow-up were also measured. All parameters were adjusted for disease severity. Results : A total of 844 patients were included in the baseline period, and 654 in the follow-up period. During the baseline period, adjusted analyses revealed statistically significant differences in all process-of-care parameters except the coverage of atypical pathogens. With regard to clinical outcomes, however, only the 30-day readmission rate was significantly different ( P = 0.03 ). Adjusted mean length of stay ranged from 6.3 to 9.2 days ( P 0.0001 ). In adjusted analyses of temporal changes within hospitals for process-of-care and outcome performance, revealed few statistically significant differences. Conclusions : Variability discovered between hospitals in the management of patients in the absence of relevant secular changes in each hospital points out the necessity to implement measures designed to reduce such variability between hospitals and to improve the quality of medical treatment.

Background: Few studies have assessed the health outcomes of patients who underwent cholecystectomy. The goal of this study was to evaluate the health-related quality-of-life (HRQoL) improvement of patients undergoing laparoscopic versus open cholecystectomy. Methods: A prospective observational study was performed of consecutive patients on waiting lists to undergo cholecystectomy for nonmalignant disease in six hospitals. Patients were asked to complete two questionnaires that measure (HRQoL)—the SF-36 and the Gastrointestinal Quality of Life Index (GIQLI)—before the intervention and 3 months later. Results: Improvement after surgery, measured by the SF-36 and GIQLI, was similar for both surgical techniques. The SF-health transition item showed a perception of worse health, compared to 1 year previously, for those who underwent open surgery and complications were also higher. Conclusions: HRQoL improvement at 3 months was relevant and similar for both surgical techniques, although the health transition perception was worse for those who underwent open surgery.

Background Bacteremia by Streptococcus pneumoniae has been traditionally associated with poor outcomes in patients with pneumonia; however, data on its impact on outcomes are limited and are sometimes contradictory. Methods We performed a prospective study in two hospitals in northern Spain in which cases diagnosed with pneumococcal pneumonia were selected from a cohort of hospitalized patients with pneumonia between January 2001 and July 2009. We compared patients with pneumococcal bacteremic pneumonia with those with pneumococcal non-bacteremic pneumonia. Results We compared 492 patients with negative blood culture and 399 with positive culture results. Host related factors were very similar in both groups. Severity of illness on admission measured by CURB-65 score was similar in both groups. Adjusted analysis showed a greater likelihood of septic shock during in-hospital course among patients with pneumococcal bacteremia (OR, 2.1; 95% CI, 1.2–3.5; P = 0.006). Likewise, patients with positive blood culture had greater in-hospital mortality (OR 2.1; 95% CI, 1.1 - -3.9; P = 0.02), 15-day mortality (OR 3.6; 95% CI, 1.7 - 7.4; P = 0.0006), and 30-day mortality (OR, 2.7; 95% CI, 1.5 - 5; P = 0.002). Conclusions Although host related factors and severity on admission were very similar in the two groups, bacteremic patients had worse in-hospital course and outcomes. Bacteraemia in pneumococcal pneumonia is of prognostic significance.

Background The adequate information about the functional capacity of elderly populations is a key for the comprehensive assessment of their health status and autonomy. The Lawton IADL (instrumental activities of daily living) Scale is a very often used scale to assess independent living skills, but has never been validated for its use in Spanish-speaking populations. The purpose of this study was to assess the validity, the reliability, and responsiveness of this widely used scale. Methods The validation was based on a prospective cohort of 1,965 patients aged 65 or over who suffered an accidental fall with a hip or wrist fracture as a result. These patients were followed up six months after the production of the fracture. Cronbach’s alpha was used to assess reliability, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) for the construct validity. Convergent and discriminant validity were examined by the correlation of the IADL Scale with the Barthel Index, SF-12, WOMAC short form, and QuickDASH questionnaires. Known-groups validity was also studied comparing IADL Scale according to different groups, and responsiveness was assessed by means of effect sizes. Results The mean age was 80.04 years (SD 8.04). The Cronbach alpha coefficient was 0.94. In the EFA, factor loadings ranged from 0.67 to 0.90, and CFA confirmed the homogeneity of the construct. Regarding the convergent validity, all correlation coefficients were higher than 0.40. Significant differences were found according to different groups, supporting known-groups validity. Responsiveness parameters showed moderate to large changes (effect sizes, 0.79 and 0.84 among patients classified as worsened). Conclusions These results confirm that the Spanish version of the Lawton IADL Scale has excellent reliability and validity and a moderate to large sensitivity to change. This study provides a proper validation, not only of the Spanish version of the Lawton IADL Scale, but also of the original instrument.

Introduction Falls with hip or wrist fractures in elderly people are common situations. The goal of this study was to determine the joint function and which clinical and social factors predict change after those fractures, measured by the short-WOMAC or QuickDASH questionnaires. Methods Patients older than 65 years who attended the emergency room (ER) of seven acute hospitals with a hip or wrist fracture due to a fortuity fall were recruited. Patients fulfilled the QuickDASH or short WOMAC specific questionnaires at the time of the fall, as how they were before the fall, and 6 months later, and some other questions on sociodemographic issues. Clinical parameters from the ER and admission to the hospital were also recorded. Univariate and multivariate regression analysis were performed, considering the changes on the QuickDASH or short WOMAC specific questionnaires as dependent variables. Results Preliminary analysis of our data (recruitment: 343 hip; 412 wrist fracture patients) showed an important decline in both specific questionnaires (hip-limitation domain of short-WOMAC-26.2; wrist-QuickDASH:20.3) at 6 months after the fracture. Older patients and lower socioeconomic status were those with greater worsening on WOMAC limitation domain on hip fracture, after adjusting by baseline scores. On wrist fractures, patients receiving rehabilitation and those who did not receive social support had greater worsening on QuickDASH scores. Conclusion Specific changes in the function of the joint affected were determined by the socioeconomic level on hip fractures while in wrist fractures the presence of social support provided benefit for these patients.

Introduction Hip fractures are one of the most severe fractures that elderly patients may suffer while wrist fractures are among the most common. The goal of this study was to determine which clinical and social factors predict a better recovery of functionality, as measured by the Barthel questionnaire, after those fractures. Methods Patients older than 65 years who attended the emergency room (ER) of 7 acute hospitals with a hip or wrist fracture due to a fortuity fall were recruited. Patients fulfilled the Barthel questionnaire at the time of the fall, as how they were before the fall, and 6 months later, as well as some other questions on sociodemographic parameters. Clinical parameters from the ER and admission to the hospital were also recorded. Univariate and multivariate regression analysis were performed, considering the change on Barthel as dependent variable. Results Preliminary analysis of our data (recruitment of 343 patients with hip and 412 wrist fractureS) showed an important decline in Barthel scores (hip: 23.2; wrist fractures: 5.4 points) at 6 months after the fracture. Patients who were older, who did not receive social support and not living alone were those with higher losses on hip fracture, after adjusting by baseline scores. In the case of wrist fractures, older patients and those not living alone had higher losses in the Barthel. Conclusion Providing support through social services as well as the living status of the patient diminished the losses in general function perception due to those fractures.

Introduction Falls with fractures in elderly people are common situations. Wrist and hip fractures are the most common or severe respectively. The goal of this study was to determine the Health Related Quality of Life (HRQoL) evolution, and which clinical and social factors predict its change after those fractures, by measuring HRQoL by the SF-12 questionnaire. Methods Patients older than 65 years who attended the emergency room (ER) of seven acute hospitals with a hip or wrist fracture due to a fortuity fall were recruited. Patients fulfilled the SF-12 questionnaire at the time of the fall, as how they were before the fall, and 6 months later, as well as some other questions on sociodemographic issues. Clinical parameters from the ER and admission to the hospital were also recorded. Univariate and multivariate regression analysis were performed, considering the changes on the physical component score (PCS) domain of the SF-12 as dependent variable. Results Analysis of our data with a recruitment of 343 hip and 412 wrist fracture patients showed an important decline in PCS (hip:10.8; wrist:8.9) at 6 months after the fracture. Older patients and lower socioeconomic status were those with greater worsening on PCS on hip fracture, after adjusting by baseline scores. On wrist fractures, older patients, women and not having social support were predictors of greater worsening. Conclusion HRQoL physical changes in hip fractures were not influenced by socio-sanitary services while in wrist fractures social support provided benefit while it was found gender differences.

Objective To develop decision trees based on prospectively collected data for determining the appropriateness of cataract extraction. Design Prospective observational cohort study. Participants Consecutive patients with a diagnosis of cataract who are on waiting lists to undergo cataract extraction by phacoemulsification. Methods Patients were randomly assigned to 1 of 2 independent cohorts: The derivation cohort included 3691 patients, and the validation cohort included 2416 patients. Sociodemographic and clinical data, including visual acuity (VA) and the Visual Function Index 14 (VF-14), were collected before and after cataract extraction. Univariate and multivariate linear regression, and regression trees analysis were performed in the derivation cohort. Decision trees obtained in the derivation cohort were validated in the validation cohort. Final results were divided into appropriate or inappropriate indications and compared with a previously established benchmark of desirable VA and VF-14 gain in relation to preintervention VA classes. Main Outcome Measures Preintervention VA and changes 6 weeks after the intervention. Results Among patients with simple cataract, predictors of significant improvement in VA after cataract extraction were preintervention VA and negative surgical complexity. Among patients with cataract and other ocular comorbidity, preintervention visual function and expected postintervention VA also predicted change in VA. When compared with a benchmark based on the minimal clinically important difference in VA after cataract extraction, sensitivity for the decision trees was 83% for both diagnostic groups and specificities ranged from 36.2 to 54.8. Conclusions A simple decision tree based on changes in VA can help identify appropriate patients for cataract extraction and be used to evaluate clinical practice or for quality control. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Objective To assess visual acuity (VA) and 2 questionnaires of health-related quality of life—the Visual Function 14 (VF-14) index and the Medical Outcomes Study Short Form 36 Health Survey (SF-36)—as instruments for capturing clinically important changes after cataract surgery. Design Prospective, observational study. Participants Four thousand three hundred fifty-six consecutive patients attending ophthalmologic clinics in 17 hospitals in preparation for cataract surgery were recruited. Methods Clinical data were collected in the visit before the intervention and 6 weeks after surgery by ophthalmologists. Patients completed the questionnaires before surgery and 3 months after surgery. Main Outcome Measures The VF-14 and SF-36 questionnaire results obtained before surgery and 3 months after the procedure and VA before the procedure and 6 weeks afterward. Results Positive mean changes in VA (+0.47) and VF-14 results (+24.03) indicated significant improvements after cataract surgery that were not reflected in changes in SF-36 domains (from 1.86 to 5.62). Responsiveness parameters demonstrated large changes in VA and VF-14 scores but not in SF-36 domains. The minimal clinically important differences (MCID) after surgery were 0.41 for VA and 15.57 for VF-14 results; the minimal detectable change (MDC) for VF-14 was 10.81. Conclusions Visual acuity and VF-14 scores, but not SF-36 scores, are appropriate instruments for capturing clinically important changes after cataract surgery. The MCID and MDC values obtained herein, although not absolute thresholds, may aid in the interpretation of changes in VA and VF-14 scores. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

In the “Materials and methods” section, under the subheading “Statistical analysis,” it was stated that just patients with ASA IV were in the high surgical risk group, whereas the high surgical risk group included patients with ASA III and ASA IV.

ResumenObjetivosEl objetivo del estudio fue evaluar la validez, la fiabilidad y la sensibilidad al cambio de la versión española de la dimensión reducida de 7 ítems de capacidad funcional del Western Ontario McMaster Universities Osteoarthritis Index (WOMAC).MétodosEstudio prospectivo con seguimiento de 1 año realizado con 459 pacientes en lista de espera para prótesis de cadera o rodilla. Se enviaron los cuestionarios WOMAC y EQ-5D en cuatro tiempos: basal, 3, 6 y 12 meses postintervencion. Se realizó el proceso de validación, análisis Rasch y acuerdo medido por el gráfico de Bland-Altman.ResultadosLos valores de los coeficientes rho de Spearman y de concordancia de Lin entre la versión completa y la reducida estuvieron entre 0,96 y 0,98. Se encontraron diferencias estadísticamente significativas (p

Background The aim of this study was to validate the Quality of Life in Adult Cancer Survivors (QLACS) in short-term Spanish cancer survivor’s patients. Methods Patients with breast, colorectal or prostate cancer that had finished their initial cancer treatment 3 years before the beginning of this study completed QLACS, WHOQOL, Short Form-36, Hospital Anxiety and Depression Scale, EORTC-QLQ-BR23 and EQ-5D. Cultural adaptation was made based on established guidelines. Reliability was evaluated using internal consistency and test-retest. Convergent validity was studied by mean of Pearson’s correlation coefficient. Structural validity was determined by a second-order confirmatory factor analysis (CFA) and Rasch analysis was used to assess the unidimensionality of the Generic and Cancer-specific scales. Results Cronbach’s alpha were above 0.7 in all domains and summary scales. Test-retest coefficients were 0.88 for Generic and 0.82 for Cancer-specific summary scales. QLACS generic summary scale was correlated with other generic criterion measures, SF-36 MCS (r = − 0.74) and EQ-VAS (r = − 0.63). QLACS cancer-specific scale had lower values with the same constructs. CFA provided satisfactory fit indices in all cases. The RMSEA value was 0.061 and CFI and TLI values were 0.929 and 0.925, respectively. All factor loadings were higher than 0.40 and statistically significant (P

Background Consensus techniques have been used previously to create explicit criteria to prioritize cataract extraction; however, the appropriateness of the intervention was not included explicitly in previous studies. We developed a prioritization tool for cataract extraction according to the RAND method. Methods Criteria were developed using a modified Delphi panel judgment process. A panel of 11 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the effect of all variables on the final panel score using general linear and logistic regression models. Priority scoring systems were developed by means of optimal scaling and general linear models. The explicit criteria developed were summarized by means of regression tree analysis. Results Eight variables were considered to create the indications. Of the 310 indications that the panel evaluated, 22.6% were considered high priority, 52.3% intermediate priority, and 25.2% low priority. Agreement was reached for 31.9% of the indications and disagreement for 0.3%. Logistic regression and general linear models showed that the preoperative visual acuity of the cataractous eye, visual function, and anticipated visual acuity postoperatively were the most influential variables. Alternative and simple scoring systems were obtained by optimal scaling and general linear models where the previous variables were also the most important. The decision tree also shows the importance of the previous variables and the appropriateness of the intervention. Conclusion Our results showed acceptable validity as an evaluation and management tool for prioritizing cataract extraction. It also provides easy algorithms for use in clinical practice.