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Biomedical subjects

E F Philbin

Publications and source records attributed to E F Philbin.

36 records · Page 2Linked to original sources
PubMed1998

Influence of race and gender on care process, resource use, and hospital-based outcomes in congestive heart failure.

Race and gender are important determinants of certain clinical outcomes in cardiovascular disease. To examine the influence of race and gender on care process, resource use, and hospital-based case outcomes for patients with congestive heart failure (CHF), we obtained administrative records on all 1995 New York State hospital discharges assigned ICD-9-CM codes indicative of this diagnosis. The following were compared among black and white women and men: demographics, comorbid illness, care processes, length of stay (LOS), hospital charges, mortality rate, and CHF readmission rate. We identified 45,894 patients (black women, 4,750; black men, 3,370; white women, 21,165; white men, 16,609). Blacks underwent noninvasive cardiac procedures more often than whites; procedure and specialty use rates were lower among women than among men. After adjusting for other patient characteristics and hospital type and location, we found race to be an important determinant of LOS (black, 10.4 days; white, 9.3 days; p = 0.0001), hospital charges (black, $13,711; white, $11,074; p = 0.0001), mortality (black-to-white odds ratio = 0.832; p = 0.003), and readmission (black-to-white odds ratio = 1.301; p = 0.0001). Gender was an important determinant of LOS (women, 9.8 days; men, 9.2 days; p = 0.0001), hospital charges (women, $11,690; men, $11,348; p = 0.02), and mortality (women-to-men odds ratio = 0.878; p = 0.0008). We conclude that race and gender influence care process and hospital-based case outcomes for patients with CHF.

Adult↗
PubMed1998

The relationship between cardiothoracic ratio and left ventricular ejection fraction in congestive heart failure. Digitalis Investigation Group.

BACKGROUND: Left ventricular ejection fraction (EF) is a valuable prognostic index in patients with congestive heart failure (CHF). Although EF can be readily measured, many clinicians use roentgenographic heart size as a clue to differentiate systolic from diastolic dysfunction, even in the absence of solid supportive data. OBJECTIVE: To test the hypothesis that the cardiothoracic ratio (CTR) measured from the chest roentgenogram can be used to estimate left ventricular EF in individuals with CHF. METHODS: To answer this question, the database of the Digitalis Investigation Group trial was used. The CTR, determined using the Danzer method, and quantitative EF, measured locally using angiographic, radionuclide, or 2-dimensional echocardiographic techniques, were compared in 7476 patients with clinical CHF (New York Heart Association functional classes I-IV) due to acquired left-sided cardiac disease of ischemic, hypertensive, idiopathic, and alcohol-related causes. RESULTS: Mean (+/-SD) CTR for the cohort was 0.53+/-.07. Mean (+/-SD) EF was 31.7%+/-12.2%. A weak, negative correlation between CTR and EF was observed (r=-0.176). Similar findings were obtained when the results were stratified by cause of CHF, presence of clinically defined right ventricular dysfunction, and method of EF measurement. Categorical analysis failed to yield a CTR cutoff point that facilitated useful segregation of individuals with an EF greater than 35% or 35% and below; greater than 40% or 40% and below; and greater than 45% or 45% and below in any patient group. CONCLUSIONS: Although a weak, negative correlation exists between CTR and EF, this relationship does not allow for accurate determination of systolic function in individual patients with CHF. Considering the morbidity and mortality associated with CHF, and the clinical implications of systolic function in this syndrome, direct measurement of EF is recommended.

Aged↗
PubMed1998

Factors determining angiotensin-converting enzyme inhibitor underutilization in heart failure in a community setting.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors were underprescribed for patients with congestive heart failure (CHF) treated in the community setting in the early 1990s despite convincing evidence of benefit. HYPOTHESIS: We postulated that (1) the prevalence of ACE inhibitor use has increased, and (2) prescribing biases have narrowed, as community physicians have gained additional clinical experience with these drugs for treatment of CHF. METHODS: We examined rates of ACE inhibitor use among 1,150 patients with CHF hospitalized at 10 community hospitals in 1995, evaluated determinants of ACE inhibitor prescription, and compared the results with survey data gathered among similar patients during 1992. RESULTS: Compared with 1992, ACE inhibitor use prior to hospital admission was increased among all patients (42 vs. 33%, p < 0.001) and the subset with a history of CHF (53 vs. 39%, p < 0.0005). Angiotensin-converting enzyme inhibitor prescription at hospital discharge also increased among all survivors (64 vs. 51%, p < 0.00005) and the subset eligible for ACE inhibitor treatment based on clinical trial criteria (77 vs. 66%, p = 0.04). Multivariate analysis suggested no change in the prescribing biases previously observed; ACE inhibitor use was related to lower ejection fraction, lower serum creatinine, documentation of left ventricular systolic function, younger patient age, prescription of any diuretic drug, and nonprescription of alternate vasodilators and calcium blockers. In multivariate analyses, physician specialty did not predict ACE inhibitor use. CONCLUSIONS: Angiotensin-converting enzyme inhibitor use among patients with CHF is increasing but remains below the 80-90% rates of drug tolerance documented in randomized clinical trials. This discrepancy is partially explained by the prevalence of renal impairment and "diastolic" heart failure in the community setting. However, age bias, use of alternative vasodilators, and substandard quality of care may also play a role.

Aged↗
PubMed1998

Managed care for congestive heart failure: influence of payer status on process of care, resource utilization, and short-term outcomes.

BACKGROUND: Although health maintenance organizations (HMO) are insuring an increasing number of Americans, there are concerns that cost-reduction strategies may limit access to medical care or jeopardize its quality. This study was conducted to examine the influence of insurance payer status on the process of care and resource utilization among patients hospitalized for congestive heart failure (CHF). METHODS AND RESULTS: Administrative information on all 1995 New York State hospital discharges assigned ICD-9-CM codes indicative of CHF in the principal diagnosis position were obtained from the Statewide Planning and Research Cooperative System database. The following were compared among patients with HMO, indemnity, Medicaid fee-for-service, and Medicare fee-for-service insurance coverage: demographics, comorbid illness, process of care, length of stay, hospital charges, mortality rate, and CHF readmission rate. A total of 43,157 patients were identified (HMO, 1322; indemnity, 4350; Medicaid, 3878; Medicare, 33 607). Noninvasive procedures were used with similar frequency, whereas greater use of invasive techniques was observed among HMO and indemnity patients. After adjustment for patient characteristics and hospital type and location, HMO care was associated with shorter length of stay and lower hospital charges, the latter partially explained by fewer hospital days. Medicaid patients had the longest length of stay, greatest hospital charges, and highest CHF readmission rate. The adjusted risk of death during the index hospitalization did not vary among insurance groups. CONCLUSIONS: Though insuring only a small proportion of New Yorkers hospitalized for CHF, managed care plans provide similar access to clinical services while generating fewer charges. Whether these observed differences in short-term outcomes derive from patient mix or quality of care is uncertain and deserves wider prospective study.

Adolescent↗
PubMed1997

Association between diuretic use, clinical response, and death in acute heart failure.

Because the impact of diuretic use on mortality in acute congestive heart failure (CHF) is not known, we examined the association between drug use, fluid balance, and death among 1,150 patients hospitalized for evaluation and treatment of CHF. After adjusting for other relevant intergroup differences, we observed that less net weight loss and a greater number of intravenous drug doses retained significant predictive value for death, suggesting that more frequent diuretic dosing or diuretic resistance may be related to mortality in acute CHF.

Acute Disease↗
PubMed1997

Use of angiotensin-converting enzyme inhibitors in heart failure with preserved left ventricular systolic function.

This study was conducted to provide evidence of an association between angiotensin-converting enzyme (ACE) inhibitor use and clinical outcomes among patients with congestive heart failure (CHF) and preserved left ventricular (LV) systolic function who are treated in the community setting, and to compare the magnitude and direction of these associations among the subset with preserved function to the subset with LV contractile dysfunction. Seven hundred sixty-three hospital survivors who had measurement of systolic function were identified from among a series of consecutive patients with CHF admitted to 10 community hospitals. They were prospectively followed-up for 6 months after discharge to track death, hospital readmission, and quality of life. Outcomes were stratified by ACE inhibitor use among those with preserved systolic function, defined as an LV ejection fraction (EF) > or = 40% or qualitatively normal contractility, and among those with systolic dysfunction, defined as an EF < or = 39% or qualitatively abnormal contractility. ACE inhibitor prescription rates were higher among the 413 patients with LV contractile dysfunction than among the 350 with preserved function (77% vs 54%, p < 0.0001). Drug-treated and untreated patients were similar in many ways, although lower serum creatinine levels, lower EF, and a higher prevelance of high blood pressure characterized those receiving ACE inhibitors. After adjusting for these and other covariables, ACE inhibitor use among the group with normal function was associated with a trend for a lower risk of death and delayed time to hospital readmission but not absolute rates of rehospitalization. By comparison, ACE inhibition among those with impaired systolic function was associated with trends for lower risk of death and rehospitalization. These data suggest that ACE inhibition may be of benefit when CHF occurs in the context of preserved or normal LV systolic function. Large, multicenter, prospective randomized trials to better test this hypothesis are warranted.

Aged↗
PubMed1997

Effect of total hip arthroplasty on cardiovascular fitness.

Thirty patients who underwent total hip arthroplasty and 18 patients with medically treated arthritis participated in this study. Both groups of patients underwent a cardiovascular fitness exercise test on entering the study and 6 months, 1 year, and 2 years later. Fitness was assessed by patient performance on a graded maximal exercise test using a bicycle ergometer and metabolic cart. In the group of total hip arthroplasty patients, significant improvements in exercise duration (P = .011), maximum workload (P = .0013), peak oxygen consumption (P = .0036), and percentage of predicted maximum oxygen uptake achieved (P = .0002) were observed during the follow-up evaluation. In the group of control patients, decreases in exercise duration (P = .0001), maximum workload (P = .0001), and workload at anaerobic threshold (P = .0108) occurred without a significant change in the other measures of cardiovascular fitness. The results indicate that resumption of routine physical activities after total hip arthroplasty is associated with a corresponding improvement in cardiovascular fitness.

Activities of Daily Living↗
PubMed1997

Longer hospital length of stay is not related to better clinical outcomes in congestive heart failure.

Efforts to reduce hospital lengths of stay (LOS) are prevalent, despite limited understanding of the clinical impact of duration of hospitalization. Thus, we sought to evaluate the clinical relevance of LOS in congestive heart failure (CHF) by studying its relationship to inpatient and post-discharge outcomes among individuals with this disorder. Ten acute care community hospitals in New York State participated in this investigation. The study population consisted of 1,402 consecutive patients, predominantly elderly, who were hospitalized for evaluation and treatment of moderately severe or severe CHF. The patients' medical records were abstracted by trained personnel immediately after hospital discharge. Patients were followed forward for six month's time to track death and readmission rates, as well as functional status, quality of life, and satisfaction. Mean LOS for the group was 7.9 +/- 9.2 days. Longer LOS had a neutral or negative association with patient outcomes. Specifically, longer LOS was linked to a higher adjusted mortality rate during the index hospitalization, as well as a greater adjusted risk of death during the post-discharge period. Moreover, longer LOS was associated with worse post-discharge functional class and a trend for less patient satisfaction with their physicians' care. We conclude that death becomes more prevalent and functional measures decline in association with prolonged hospital stays for heart failure. Although these findings may be of use in planning management strategies, they offer no proof that reducing the costs of care will improve clinical outcomes in CHF.

Aged↗
PubMed1997

Predictors and determinants of hospital length of stay in congestive heart failure in ten community hospitals.

BACKGROUND: Little is known about the actual determinants of hospital length of stay (LOS) among patients admitted with congestive heart failure (CHF), in spite of its economic impact. To increase understanding of these factors, we examined the demographic, clinical, laboratory, and treatment characteristics of patients hospitalized with decompensated CHF. METHODS: The charts of consecutive patients admitted to 10 acute care community hospitals during 1995 were reviewed. The relationship between LOS and more than 140 patient-specific variables were examined. First, patient characteristics identifiable within the first 24 hours of hospitalization were examined for their relationship with LOS. Then, variables indicative of the processes of care and response to treatment were studied. Finally, administrative data were added to yield the final model for LOS. RESULTS: During the study period 1402 patients were admitted to the participating centers. The patients were predominantly elderly with moderately severe or severe CHF. With stepwise multiple linear regression, 5% of the variation in LOS could be explained by baseline characteristics alone (r = 0.22, p < 0.0001). When treatment and response variables were added to this model, 15% of the variation in LOS could be explained (r = 0.39, p < 0.0001). When administrative data were added, the final model explained 31% of the variation in LOS (r = 0.56, p < 0.0001). CONCLUSIONS: We conclude that LOS among patients hospitalized with decompensated CHF is partially related to patient demographics, severity of illness, management modalities, response to treatment, and administrative data. However, significant residual variation in LOS exists, which cannot be explained by these factors. These observations may be of value in the design and implementation of initiatives aimed at reducing resource utilization and improving quality of care in CHF.

Age Factors↗
PubMed1996

Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals.

Because they provide relief of symptoms and reduce mortality, angiotensin-converting enzyme (ACE) inhibitors have become a highly recommended part of the pharmacologic treatment of patients with congestive heart failure (CHF). Although clinical trials suggest that 80% to 90% of patients with CHF tolerate ACE inhibitors, recent surveys reveal that for fewer than this number of patients are actually receiving these drugs. The reasons for this discrepancy are not known. To better understand physician-prescribing behavior, the current study examined the demographic, clinical, laboratory, and medical care characteristics of patients treated and not treated with ACE inhibitors during hospitalization for decompensated CHF. The charts of a consecutive series of patients admitted to 2 acute care hospitals during 1992 (n = 424) were reviewed and comparisons made between those receiving and not receiving ACE inhibitors at the time of hospital admission and hospital discharge. In addition, measures of in-hospital and postdischarge outcome were compared between the groups. The results revealed significant differences in certain demographic variables (e.g., patient age), clinical measures (e.g., left ventricular ejection fraction and serum creatinine), management issues (e.g., documentation of left ventricular function and documentation of etiology of CHF), and treatment strategies (e.g., ancillary drug use). Few differences were noted in measures of severity of CHF (e.g., New York Heart Association functional class and serum sodium level). Death rates were significantly higher for those not receiving ACE inhibitors. Patterns that emerged that could explain under-prescription ACE inhibitors included older age, worse renal function, left ventricular diastolic dysfunction, use of alternate vasodilators, and overall less intense medical management. Programs to educate care providers regarding the proper use of ACE inhibitors in CHF are recommended.

Aged↗
PubMed1996

Does QI work? The Management to Improve Survival in Congestive Heart Failure (MISCHF) study.

BACKGROUND: In an ongoing study, a randomized, controlled trial is being conducted on the effects of a collaborative quality improvement program on practice patterns and patient outcomes regarding congestive heart failure (CHF) in community hospitals in upstate New York. CHF is associated with severe morbidity and mortality, with annual rates of death exceeding 50% among patients with the most severe disease. PHASE I: Phase I of the study was designed to model the processes of care and outcomes, develop valid disease-specific risk adjustment techniques, and target areas for quality improvement (QI) intervention. Beginning April 1, 1995, and ending December 31, 1995, baseline data were collected during hospitalization and for six months postdischarge for all 1,402 consecutive patients assigned diagnosis-related groups (DRGs) 127 and 124. Preliminary analyses revealed high rates of hospital readmission (46%) and postdischarge death (18%), with significant interhospital variation. QI INITIATIVES: Initiatives include educational programs on CHF, feedback of Phase I data to clinicians and administrators, design and implementation of a clinical care pathway, improvement of the emergency department (prehospital) phase of CHF management, and improvement in patient education and discharge planning. SUMMARY AND CONCLUSIONS: The study suggests that community hospitals, many without extensive experience in clinical investigation, can voluntarily collaborate to design and implement a timely QI initiative that is evidence based, clinically relevant, and scientifically sound. Preliminary results have led to better understanding of the processes of care and determinants of outcome for patients with heart failure. Phase II of the study should yield insights into the providers' response to a locally derived intervention and the effects of such a program on patient outcomes.

Cardiology Service, Hospital↗
PubMed1996

Improvement in cardiovascular fitness after total knee arthroplasty.

Patients who have osteoarthrosis involving weight-bearing joints typically have a gradual decline in physical activity, which is often associated with cardiovascular deconditioning. After joint replacement, many patients resume routine walking and recreational activities, which may improve aerobic capacity. The purpose of the present study was to determine the effect of total knee arthroplasty on cardiovascular fitness. Nineteen patients who had had total knee arthroplasty (the arthroplasty group) performed an exercise test for cardiovascular fitness preoperatively. Sixteen of these patients were tested again at one year postoperatively and thirteen, at two years postoperatively. Sixteen patients in whom osteoarthrosis of the knee was being treated medically (the control group) were tested at the time of enrollment in the study and one year later. Nine of these patients also were tested two years after enrollment. All of the patients completed the Arthritis Impact-Measurement Scales (AIMS) at each examination. Fitness was assessed by the performance of a progressive maximum exercise test with use of a bicycle ergometer and a metabolic cart. All patients achieved the anaerobic threshold. One year postoperatively, the patients in the arthroplasty group demonstrated an increase, which approached significance, in maximum oxygen consumption (measured in milliliters of oxygen per minute) (p = 0.07), maximum oxygen consumption corrected for body weight (p = 0.08), and percentage of predicted maximum uptake of oxygen (p = 0.06). Two years after the total knee arthroplasty, the patients had a significant improvement with regard to all three parameters (p = 0.008, 0.005, and 0.005, respectively). The patients in the control group demonstrated a significant decrease in duration of exercise and in maximum workload at one year (p = 0.003 and 0.005, respectively) and at two years (p = 0.008 for both parameters). Physical activity had increased in the arthroplasty group but not in the control group, as demonstrated by the results of the Arthritis Impact-Measurement Scales. These findings demonstrate a trend toward improvement in cardiovascular fitness one year after total knee arthroplasty and a significant improvement two years postoperatively for patients who had been able to resume routine functional activities because of the arthroplasty. These improvements compared favorably with the static pattern or the decline in the measures of fitness that were observed in the control group. Our results should be considered preliminary because of the relatively small number of patients who were studied.

Aged↗
PubMed1996

Osteoarthritis as a determinant of an adverse coronary heart disease risk profile.

BACKGROUND: Osteoarthritis is associated with obesity, sedentary behavior and poor fitness. This study was conducted to test the hypothesis that risk factors for coronary heart disease (CHD) are more prevalent among patients with osteoarthritis than among non-arthritic adults of the same age and sex. METHODS: Forty-six patients with osteoarthritis of the hip and/or knee were evaluated; 23 non-arthritic subjects served as control group. A panel of metabolic risk factors were measured including body mass index (BMI), waist-hip ratio (WHR), blood pressure, fasting blood glucose, and serum lipids and apoproteins. RESULTS: Measures of arthritis severity confirmed marked disability and deformity in the arthritis group. Patients reported the performance of less aerobic exercise than controls. Compared with controls, patients were noted to have greater mean BMI (31.2 +/0- 5.9 versus 24.6 +/- 3.2 kg/m2, P < 0.000005), WHR (0.88 +/- 0.07 versus 0.83 +/- 0.08, P < 0.05), systolic blood pressure (140.8 +/- 17.9 versus 131.3 +/- 15.3 mmHg, P < 0.05) and fasting blood glucose (105.0 +/- 24.6 versus 93.2 +/- 7.0 mg/dl, P < 0.01), and lower mean high-density-lipoprotein cholesterol (47.9 +/- 10.9 versus 56.7 +/- 17.1 mg/dl, P < 0.05). Nonsignificant trends for higher mean diastolic blood pressure and serum triglycerides were also noted in the arthritic group. Mean estimated risk for development of CHD within 10 years of evaluation was greater in the arthritic than in the control group (21.6 +/- 14.4% versus 15.2 +/- 11.7%, P < 0.05). CONCLUSION: Patients with moderately severe to end-stage lower extremity osteoarthritis may be at advanced risk for the development of CHD by virtue of their unfavorable risk factor profile.

Aged↗
PubMed1995

Cardiovascular fitness and health in patients with end-stage osteoarthritis.

OBJECTIVE: To evaluate the cardiovascular fitness of a group of patients with severe osteoarthritis (OA). METHODS: Thirty-seven patients with end-stage OA were evaluated just before hip or knee replacement surgery. Severity of arthritis was evaluated using standardized techniques. Patients and age- and sex-matched controls underwent a single, maximal, symptom-limited, cardiopulmonary exercise test using arm or leg ergometry and a metabolic cart to measure expired respiratory gases. RESULTS: Severe musculoskeletal disability and deformity was confirmed in the OA patient group. During exercise testing, OA patients were able to perform physiologically maximal cardiopulmonary exercise. Arthritis patients were noted to be severely deconditioned, with reduced peak oxygen consumption (OA hips mean +/- SD 14.9 +/- 4.2 versus control hips 19.0 +/- 4.6, P < 0.0001; OA knees 12.8 +/- 3.7 versus control knees 17.6 +/- 5.2 ml/kg/minute, P < 0.0005). A trend for more frequent manifestations of coronary heart disease in OA patients than in controls (27% versus 13%; P > 0.05) was also noted. CONCLUSION: Patients with end-stage lower extremity OA are severely deconditioned. This may place them at incremental risk for the development of coronary heart disease.

Aged↗
PubMed1995

Feasibility of maximal cardiopulmonary exercise testing in patients with end-stage arthritis of the hip and knee prior to total joint arthroplasty.

STUDY OBJECTIVE: Although no studies exist, to our knowledge, that examine the feasibility and safety of stress testing in a consecutive series of patients with severe arthritis, musculoskeletal conditions are often listed as relative contraindications to graded exercise testing. The current study was designed to examine the feasibility of maximal exercise testing in patients with end-stage arthritis prior to total joint arthroplasty. DESIGN: An observational and descriptive study in a consecutive series of patients with severe arthritis. SETTING: This study was conducted in the outpatient clinics and cardiopulmonary exercise physiology laboratory of a rural teaching hospital. PARTICIPANTS: Sixty-one patients with severe osteoarthritis and rheumatoid arthritis were recruited from the orthopedic surgical service immediately before total joint arthroplasty of the hip, knee, or both. A reference group of 23 nonarthritic control patients were recruited from the general medical population of the same hospital and subjected to measures of arthritis severity. MEASUREMENTS AND RESULTS: The severity of arthritis was graded by assessment of variables reflective of subjective symptoms, lifestyle impact, joint deformity, and radiographic abnormality. Arthritic subjects underwent a single graded, maximal, symptom-limited, cardiopulmonary exercise test using an electronically braked ergometer and a metabolic cart. Subjects were first asked to pedal with their legs; those apparently incapable performed the same task using their arms. Ninety-five percent of subjects who presented for an exercise test were capable of symptom-limited exercise. Of 29 patients evaluated before hip replacement, 66% completed leg tests, 31% completed arm tests, and 3% were incapable of symptom-limited exercise. Of 30 patients evaluated before knee replacement, 57% completed leg tests and 37% completed arm tests, while 7% were incapable of symptom-limited exercise. Two patients were evaluated before hip and knee surgery; one completed a leg study and one completed an arm study. Among the 37 subjects completing leg tests, a mean percentage of age-predicted maximum heart rate (APMHR) of 92 +/- 11% and a mean respiratory exchange ratio (RER) of 1.15 +/- 0.13 were noted. Among the 21 completing arm tests, a mean percentage of APMHR of 87 +/- 11% and a mean RER of 1.10 +/- 0.10 were observed. High rates of achievement of physiologic values indicative of maximal exercise (80% or more of APMHR and RER > or = 1.0) were noted in individuals in both exercise groups. Similar findings were noted regardless of the patient's subjective symptomatic limitation to exercise and the presence or absence of documented or suspected coronary heart disease. CONCLUSIONS: Most patients with severe arthritis are capable of maximal, symptom-limited exercise using ergometry methods. Ergometry stress testing may be a viable, low-cost alternative to dipyramidole-thallium testing or cardiac catheterization in some patients with arthritis warranting objective assessment of known or suspected cardiac disease.

Aged↗
PubMed1995

Relationship between severity of gonarthrosis and cardiovascular fitness.

Cardiovascular fitness was assessed in 3 groups of patients having varying severity of gonarthrosis. Group I consisted of 16 patients with severe knee symptoms scheduled for total knee arthroplasty. Group II included 17 patients with medically treated osteoarthrosis who were not considered surgical candidates because knee symptoms were not severe. Group III consisted of 14 healthy control patients with no lower extremity arthritis. All patients were evaluated with Hospital for Special Surgery knee scores, Arthritis Impact Measurement Scale questionnaires, and a cardiopulmonary exercise test using semi-upright bicycle ergometry. All patients achieved anaerobic threshold during exercise. Mean (+/- standard deviation) maximum oxygen consumption (VO2) at peak exercise was 13.9 +/- 3.3 for Group I, 16.2 +/- 4.1 for Group II, and 21.5 +/- 3.9 for Group III. Mean (+/- standard deviation) Hospital for Special Surgery score was 55 +/- 7 for Group I, 70 +/- 14 for Group II, and 100 +/- 1 for Group III. Lower Hospital for Special Surgery score was associated with lower VO2 at peak exercise, suggesting that inactivity secondary to more severe arthritic symptoms can result in cardiovascular deconditioning. The association between severity of gonarthrosis and cardiovascular deconditioning supports the concept that a regular exercise program should be recommended for patients with arthritis. Also, for patients who are surgical candidates, the practice of delaying total knee arthroplasty may be associated with worsening cardiovascular fitness, particularly when physical activity becomes more limited. The expected longevity of implant function as well as the effect of continued arthritic symptoms on cardiovascular fitness should be considered when determining the optimal time for a patient to undergo total knee arthroplasty.

Activities of Daily Living↗
PubMedDate not supplied

The relationship between hospital length of stay and rate of death in heart failure.

OBJECTIVE: To study the relationship between length of stay (LOS) and the rate of death among patients hospitalized with congestive heart failure (CHF). DESIGN: A retrospective, observational study. SETTING: Fifteen acute care community hospitals in upstate New York. PATIENTS: Three thousand nine hundred fourteen patients whose principal billing diagnosis was diagnosis-related group number 127 (CHF and shock). OUTCOME MEASURES: Mean total LOS and hospital death rate. VARIABLES: Mean number of nonacute care hospital days per patient, mean number of acute care days (acute LOS) per patient, cases per hospital, hospital bed capacity, and the presence of a cardiac catheterization laboratory, cardiac surgical services, or a medical residency training program. An index of severity of illness and a severity-weighted expected LOS were calculated for each patient as well. RESULTS: Significant variability in mean total LOS (7.6 to 12.7 days), mean acute LOS (7.1 to 10.3 days), and death rates (4.3 to 12.0%) was noted among the centers. Minimal variation in mean expected LOS (5.2 to 6.1 days) and mean severity score (2.8 to 3.3) was observed. Mean total LOS (r = 0.14, p = 0.61) and acute LOS (r = 0.11, p = 0.69) were not related significantly to death rate for the 15 centers. When the hospitals were separated into tertiles based on rank order of total LOS and acute LOS, no differences among the subgroups were noted in the number of cases per hospital, deaths per hospital, death rates, expected LOS, and severity scores, Interhospital variation in total LOS was partially explained by the care of patients who did not require acute hospitalization. CONCLUSIONS: Significant interhospital variation exists in LOS and death rates for patients admitted with CHF; these two measures are not related to each another. This variability in outcome cannot be explained by severity of illness case-mix alone; significant variation in the processes and effectiveness of patient care may exist.

Aged↗