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Biomedical subjects

J M Gaspoz

Publications and source records attributed to J M Gaspoz.

At least 37 records · Page 2Linked to original sources
PubMed1998

Hospital-acquired pressure ulcers: risk factors and use of preventive devices.

BACKGROUND: Pressure ulcers are a frequent complication of bed rest. We examined risk factors for hospital-acquired pressure ulcers, the use of preventive devices, and the impact of case-mix adjustments on between-ward comparisons. METHODS: We conducted 3 cross-sectional surveys in a teaching hospital of 2373 patients who had no pressure ulcer on admission. We assessed the presence of pressure ulcer, dates of admission and ulcer occurrence, hospital ward, patient age and sex, appetite and route of nutrition, surgery during stay, hospitalization for fracture, comorbidities, use of low-pressure devices (special mattresses, cushions, and pressure-reducing beds), and the Norton Pressure Ulcer Prediction score (physical condition, mental condition, activity, mobility, and incontinence). RESULTS: Two hundred forty-seven new pressure ulcers occurred (5.7 per 1000 person-days). In multivariate analysis, the risk for pressure ulcer increased with age (risk gradient across 5 categories was 1:4.5; P<.001) and Norton score (across 5 categories, risk gradient was 30-fold; P<.001); other risk factors (all relative risks, 1.5-1.8; P<.002) were hospitalization for fracture, surgical intervention, reduced appetite, and nasogastric tube or intravenous nutrition. Adjustment for case mix substantially modified differences between hospital wards. Use of preventive devices was associated with Norton score, but not all high-risk patients benefited. CONCLUSIONS: Pressure ulcers were seen in every 10th hospitalized adult. Patient age and Norton score were the strongest risk factors for pressure ulcers. Use of preventive devices was suboptimal. Adjustment for case mix is essential if pressure ulcer incidence is to be used as an indicator of quality of care.

Adolescent↗
PubMed1998

Do physicians modify their prehospital management of patients in response to a public campaign on chest pain?

The goals of this study were to analyze the impact of a public campaign on chest pain on physicians involved in the prehospital care of patients with this symptom, in terms of physician delay, rates of immediate hospitalization, and of transportation by ambulance. Prehospital delays and decisions for all 866 patients with chest pain managed by the community and generalist physicians or by emergency physicians, who presented to the emergency department of a teaching hospital during the 12 months of the campaign, were compared with those of all 749 patients with similar presentations during the 12 months before it. When community and generalist physicians were involved, median (110 minutes) physician delay did not decrease during the campaign, whereas it decreased from 65 to 56 minutes (p <0.003) when emergency physicians were involved. Rates of immediate hospitalization (73%) and of transportation by ambulance (47%) of patients managed by community and generalist physicians were unaffected by the campaign, whereas they increased from 96% and 89%, respectively, to 98% (p = 0.09) and 94% (p <0.02) when emergency physicians were involved. Similar observations were made in patients with confirmed acute myocardial infarction and unstable angina and remained highly significant after adjustment for differences in clinical characteristics. Thus, community and generalist physicians did not significantly modify their prehospital management of patients with chest pain despite a public campaign. To be successful, guidelines on the matter have to be developed with the active participation of these physicians.

Aged↗
PubMed1998

Use of a short-form screening procedure to detect unrecognized functional disability in the hospitalized elderly.

We performed an observational cohort study to test the ability of a short-form screening procedure to detect unrecognized functional disability, as well as its capacity to predict clinical outcome. This screening procedure was administered to 198 consecutive patients within 48 hours of admission. Clinical outcomes upon discharge from the acute care hospital and at 3 months were analyzed according to the number of functional disabilities present on admission. This brief test identified a mean of 1.8 and a median of 1 previously unrecognized functional disabilities per patient. The presence of two or more functional disabilities on admission (48% of the study population) was significantly associated with a negative outcome upon discharge (relative risk = 1.73; CI, 1.33-2.25; p = 0.0001) and at 3 months after discharge (relative risk = 1.34; CI, 1.10-1.64; p = 0.003) confirming the reliability of the short-form screening procedure.

Activities of Daily Living↗
PubMed1998

Predictors of inappropriate hospital days in a department of internal medicine.

BACKGROUND: This study aimed to identify predictors of inappropriate hospital days in a department of internal medicine, as a basis for quality improvement interventions. METHODS: The appropriateness of 5665 hospital days contributed by 500 patients admitted to the Department of Internal Medicine, Geneva University Hospitals, Switzerland, was assessed by means of the Appropriateness Evaluation Protocol. Predictor variables included patient's age and sex, manner of admission and discharge, and characteristics of hospital days (weekend, holiday, sequence). RESULTS: Overall, 15% of hospital admissions and 28% of hospital days were rated as inappropriate. In multivariate models, inappropriate hospital days were more frequent among patients whose admission was inappropriate (odds ratio [OR] = 5.3, 95% CI: 3.1-8.4) and among older patients (80-95 years: OR = 3.6, 95% CI: 1.7-7.0, versus <50 years). The likelihood of inappropriateness also increased with each subsequent hospital day, culminating on the day of discharge, regardless of the total length of stay. CONCLUSIONS: This study identified both the admission and the discharge processes as important sources of inappropriate hospital use in a department of internal medicine. The oldest patients were also at high risk of remaining in the hospital inappropriately. Surprisingly, long hospital stays did not generate a higher proportion of inappropriate days than short hospital stays. This information proved useful in developing interventions to improve the hospitalization process.

Adolescent↗
PubMed1998

Contribution of individual items to the performance of the Norton pressure ulcer prediction scale.

OBJECTIVES: To assess the specific contribution to overall scale performance of each of the five items that constitute the Norton pressure ulcer prediction scale. DESIGN: A comparison of statistical models based on cross-sectional surveys of hospitalized patients. SETTING: An urban teaching hospital in Geneva, Switzerland. PARTICIPANTS: 2373 hospitalized patients who were free of pressure ulcers on admission. MEASUREMENTS: Norton scale items measuring activity, mobility, physical condition, mental condition, and incontinence on a 4-point scale were examined as predictors of stage 1 or greater pressure ulcers. RESULTS: A total of 245 new pressure ulcers occurred between admission and patient observation. After adjustment for other independent predictors in proportional hazards models, only the activity and mobility items remained associated significantly with the risk of pressure ulcer. A simplified 2-item scale was more strongly associated with pressure ulcer risk than was the classic 5-item Norton scale. CONCLUSIONS: Our study suggests that the activity and mobility items of the Norton scale are sufficient to express the risk of pressure ulcers in hospitalized patients. Confirmation of this finding in prospective studies is warranted.

Adolescent↗
PubMed1997

Accuracy of an automatic and patient-triggered long-term solid memory ambulatory cardiac event recorder.

This study evaluated the R-Test Evolution, a new type of cardiac event recorder bearing both patient-triggered and automatic capabilities. Its 7-day automatic arrhythmia analysis showed promising clinical advantages, especially when investigating patients with unexplained rare events such as syncope, feeling of weakness or faintness, palpitations, stroke, or in patients inconsistent in their use of patient-triggered recordings.

Arrhythmias, Cardiac↗
PubMed1997

[Thrombolysis in acute myocardial infarct in everyday clinical practice].

We prospectively included in a database all thrombolyzed acute transmural myocardial infarction patients admitted to our hospital from November 1986 to September 1995. Six hundred and twenty-seven patients (497 males) with a mean age of 61 +/- 12 years (range 26-88 years) were included. 87% were having their first acute myocardial infarction. Different thrombolytic regimens were applied in the emergency room but the vast majority (92%) received t-PA. The median delay between the onset of pain and admission was 2 h 0 min (10 min-22 h). The median admission to treatment time was 40 min (5 min-6 h 20 min). The latter has been shortened (median 55 min from 1986 to 1989 versus 35 min from 1990 to 1995, p < 0.05) during the study period. The rate of intracerebral hemorrhage was 2.4% (confidence interval 1.1-3.5%) and no significant predictor could be found, although patients with cerebral bleeding tended to be slightly older (66 +/- 9 years vs 61 +/- 13 years, p = ns). The rate of false diagnosis was only 4.6%, even when patients with a final diagnosis of unstable angina and/or aborted acute myocardial infarction were included. The in-hospital mortality was 8.8%, a rate similar to those reported in the literature. Using multivariate analysis, negative prognostic factors were higher age (p < 0.001), advanced Killip class at admission (p < 0.001) and elevated peak CPK levels (p < 0.001). These results confirm that thrombolysis for acute myocardial infarction in the emergency room can be done with a short admission-to-treatment time and with an acceptably low rate of false diagnosis. However, our intracerebral hemorrhage rate was clearly higher than generally reported in the literature and may be explained by a different patient selection from that in large randomized studies.

Adult↗
PubMed1997

Risk factors for a medically inappropriate admission to a Department of Internal Medicine.

OBJECTIVE: To identify patient- and admission-related risk factors for a medically inappropriate admission to a department of internal medicine. METHODS: Cross-sectional study of a systematic sample of 500 admissions to the department of internal medicine of an urban teaching hospital. The appropriateness of each admission and reasons for inappropriate admissions were assessed using the Appropriateness Evaluation Protocol. Risk factors included the time (day of week and holidays) and manner (through emergency department or direct admission) of admission, patient age and sex, health status of patient and spouse, living arrangements, formal home care services, and informal support from family or friends. RESULTS: Overall, 76 (15.2%) hospital admissions were rated as medically inappropriate by the Appropriateness Evaluation Protocol. In multivariate analysis, the likelihood of an inappropriate admission was increased by better physical functioning of the patient (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1 [for 1 SD in Physical Functioning scores]), lower mental health status of the patient's spouse (OR, 2.6; 95% CI, 1.3-5.6), receipt of informal help from family or friends (OR, 3.3; 95% CI, 1.5-7.2), and hospitalization by one's physician (OR, 3.6; 95% CI, 1.7-7.5). Receiving formal adult home care was not associated with inappropriateness of hospitalization. CONCLUSIONS: Inappropriate admissions to internal medicine wards are determined by a mix of factors, including the patient's health and social environment. In addition, the private practitioners' discretionary ability to hospitalize their patients directly may also favor medically inappropriate admissions.

Adolescent↗
PubMed1997

[The prehospital phase of patients with suspected acute myocardial infarct: results of the Oltner Cardiac Emergency Study].

Early reperfusion in acute myocardial infarction has been shown to reduce myocardial damage and to improve prognosis. The goals of this study, the Olten Cardiac Emergency Study, were to identify the factors, related to the patients or to the emergency medical services, which influenced pre-hospital delay in patients with symptoms suggestive of acute myocardial infarction. From November 1, 1992, to June 15, 1993, all the events occurring between symptom onset and hospital discharge where analyzed for 341 such patients who were cared for by the emergency networks connected with the Cantonal Hospital, Olten: in addition, follow-up at 3 months was obtained on all patients discharged alive. Of the 341 patients, 14 (4.1%) died out of the hospital. The final diagnoses of the 327 patients admitted to the emergency department were: acute myocardial infarction 18.3%; unstable angina 10.1%; stable angina 3.4%; non-ischemic cardiac diseases 29.4%; other non-cardiac diseases 38.8%. Mean delay between symptom onset and arrival at the hospital was 8 h 55 min (median delay 4 h 10 min); for patients with a final diagnosis of acute myocardial infarction, mean delay was 9 h 43 min (median delay 5 h 10 min). Patient delay was surprisingly long and represented 70.4% of the total pre-hospital delay; 56.6% of the patients did not realize that their symptoms were serious and only 47.1% (and 68.3% of the patients with acute myocardial infarction) came to the hospital by ambulance. These long pre-hospital delays were responsible for the low (13.3%) thrombolysis rate of patients with acute myocardial infarction. We conclude that pre-hospital delay was much too long in our population. Improvements can only be achieved through patient education and better efficiency of emergency networks. Our findings underline the need for public education campaigns on heart attacks.

Aged↗
PubMed1997

C-reactive protein as a marker for acute coronary syndromes.

BACKGROUND: For several years, acute coronary syndromes have been perceived as causing the most hospital admissions, and even hospital mortality. The syndrome of unstable angina frequently progresses to acute myocardial infarction but its pathogenesis is poorly understood, and prognosis determination is still problematic. We tested the hypothesis that measurement of the C-reactive protein in patients admitted for chest pain could be a marker for acute coronary syndromes. METHODS AND RESULTS: We studied 110 patients admitted with suspected ischaemic heart disease, but without elevated serum creatine-kinase levels at the time of hospital admission. Patients were subsequently divided into two groups based on their final diagnosis: group 1 comprised patients with unstable angina; group 2 patients with acute myocardial infarction. We measured the C-reactive protein at the time of hospital admission. The concentration of C-reactive protein was elevated in 59% of the patients with a final diagnosis of acute myocardial infarction, and in 5% of the patients with a final diagnosis of unstable angina, (P < 0.001). CONCLUSION: This study indicates that C-reactive protein levels measured at the time of admission in patients with suspected ischaemic heart disease could be a marker for acute coronary syndromes, and helpful in identifying patients at high risk for acute myocardial infarction. Measurement of C-reactive protein may have practical clinical significance in the management of patients hospitalized for suspected acute coronary syndromes.

Acute Disease↗
PubMed1996

Maximal blood lactate level acts as a major discriminant variable in exercise testing for coronary artery disease detection in men.

BACKGROUND: The interpretation of exercise stress testing for coronary artery disease detection is affected by the many differences in chosen variables and mathematical methods. We conducted a prospective trial to evaluate a global muscle fatigue parameter--the blood lactate level achieved at maximal exercise--as a method of distinguishing between diseased and nondiseased coronary status. METHODS AND RESULTS: We evaluated 236 consecutive male patients without previous myocardial infarction who had been referred for the diagnosis of coronary artery disease. None of the patients had cardiomyopathy, severe cardiac heart failure, or valvular heart disease. Blood lactate concentration at maximal exercise was measured as well as other classic variables. Correlations between variables and coronary status as assessed by coronary arteriography were described using receiver operating characteristic (ROC) curves and logistic regression analysis. The first four most powerful variables (lactate level, maximal power output, exercise duration, and percentage of maximal predicted heart rate), which are directly representative of the global functional capacity, showed values of 0.777, 0.775, 0.760, and 0.740, respectively, by ROC curve analysis. Mean +/- SD blood lactate level at peak exercise reached 7.68 +/- 2.70 mmol/L in the 153 diseased and 10.56 +/- 2.75 mmol/L in the 83 nondiseased patients (P < .0001). After adjustment for other variables, blood lactate level remained a significant predictor of coronary artery disease by logistic regression analysis (adjusted odds ratio, 1.2; confidence interval, 1.04 to 1.4). CONCLUSIONS: Global muscle fatigue as assessed by lactate levels in the blood at maximal exercise appears to be a powerful distinguisher of diseased and nondiseased coronary status.

Adult↗
PubMed1996

[Current models in health insurance and health care delivery].

Health care organizations similar to American HMOs have recently appeared in Switzerland. They elicit many reactions, both in the general public and among the medical profession. In contrast to traditional health insurance, HMOs organize and actively manage health care delivered to their members. This paper reviews the historical background of similar organizations in Europe and in the United States, and focuses in particular on the recent evolution and fragmentation of the concept of "managed care". Follows a discussion of the mechanisms and the side-effects of various tools used to manage care, both in managed care settings and by traditional health insurance plans. It appears that all of health care is managed, that all management tools have potential side effects, and that use of some management tools implies a redistribution of the respective roles of plan members, administrators, and physicians. The authors suggest that the complexity of health care management requires a more active implication of the health professions in that process.

Delivery of Health Care↗
PubMed1996

Cost-effectiveness of prescription recommendations for cholesterol-lowering drugs: a survey of a representative sample of American cardiologists.

OBJECTIVES: We sought to determine the cost-effectiveness of the recommendations of cardiologists for the pharmacologic treatment of hypercholesterolemia. BACKGROUND: Despite the publication of guidelines such as the report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, little is known about the national prescribing practices of physicians and how they compare with the recommendations of cost-effectiveness analyses. METHODS: Under the auspices of the Cardiovascular Norms Committee of the American College of Cardiology, a nationally representative sample of cardiologists was surveyed, and their recommendations for the pharmacologic treatment of hypercholesterolemia were assessed to determine cost-effectiveness. RESULTS: The 346 responding cardiologists were reasonably representative of the membership of the American College of Cardiology. For the 12 hypothetical patients, the cardiologists recommended pharmacologic treatment more commonly in cases in which previously published studies estimated the treatment to be more cost-effective, although there was a tendency to recommend such treatment for primary prevention even when it was estimated to cost well over $100,000/year of life saved. CONCLUSIONS: These findings suggest that the cardiologists' pharmacologic recommendations for lowering lipids are correlated with published cost-effectiveness analyses. However, substantial variation in their recommendations remains, with somewhat less aggressive treatment for secondary prevention and more aggressive treatment for primary prevention than would be recommended on the basis of cost-effectiveness analyses.

Adult↗
PubMed1996

Detecting acute thoracic aortic dissection in the emergency department: time constraints and choice of the optimal diagnostic test.

STUDY OBJECTIVES: To compare diagnostic strategies for the emergency assessment of patients with suspected acute thoracic aortic dissection and to measure the effect of delays related to the availability of these tests on the selection of the most appropriate one. METHODS: We carried out a decision analysis representing the risks of performing one or two sequential tests, the tests' accuracy, the risks and benefits of treatment, and the time-dependent mortality rate in untreated patients with dissection (1%/hour). Data were drawn from a Medline search. Our subjects were patients who presented to the emergency department with chest pain in whom acute thoracic aortic dissection was suspected. For different clinical probabilities of aortic dissection, we compared the risks and benefits of testing using the following procedures (alone and in combinations): aortography, computed tomography (CT), magnetic resonance imaging (MRI), and both transesophageal (TEE) and transthoracic echocardiography (TTE). We then measured the effect of delays in these tests on the selection of the appropriate procedure. The outcome studied was 30-day survival. RESULTS: We determined that the "threshold" clinical probability of aortic dissection above which the benefits of testing outweigh its risks is low. It ranges from 2% with the most reliable procedure (MRI) to 9% with the least (TTE). At low probability of dissection (< 15%), the accuracy of all tests except TTE is sufficient to rule out dissection. Delays have negligible effect on these results. When the likelihood of dissection is higher, the preferred option is to order a second diagnostic test if the results of the first are negative. The threshold probabilities above which to order a second test range from 15% (CT, then aortography) to 35% (MRI, then aortography). Excessive delays may affect the selection of tests when the likelihood of dissection is high (eg, 50%). Thus, although it is less accurate, a CT scan obtained within 2 hours or a TEE obtained within 6 hours of presentation to the ED yields a higher survival rate than an MRI obtained within 9 hours. Similarly, the benefits of ordering a second test, if the result of the first are negative, outweigh the risks only if the delay in obtaining the test does not exceed 10 hours. CONCLUSION: All patients in whom aortic dissection is suspected, even if the index of suspicion is very low, should undergo one of the available diagnostic procedures (except TTE). A patient with a moderate to high probability of disease should undergo a second investigation if the findings of the first are negative. When the probability of dissection is high, the physician must consider delays in obtaining specific diagnostic tests and order those that will be the most quickly available.

Aortic Dissection↗
PubMed1996

Impact of a public campaign on pre-hospital delay in patients reporting chest pain.

OBJECTIVE: To decrease pre-hospital delay in patients with chest pain. DESIGN: Population based, prospective observational study. SETTING: A province of Switzerland with 380000 inhabitants. SUBJECTS: All 1337 patients who presented with chest pain to the emergency department of the Hôpital Cantonal Universitaire of Geneva during the 12 months of a multimedia public campaign, and the 1140 patients who came with similar symptoms during the 12 months before the campaign started. MAIN OUTCOME MEASURES: Pre-hospital time delay and number of patients admitted to the hospital for acute myocardial infarction (AMI) and unstable angina. RESULTS: Mean pre-hospital delay decreased from 7h 50 min before the campaign to 4 h 54 min during it, and median delay from 180 min to 155 min (P < 0.001). For patients with a final diagnosis of AMI, mean delay decreased from 9 h 10 min to 5 h 10 min and median delay from 195 min to 155 min (P < 0.002). Emergency department visits per week for AMI and unstable angina increased from 11.2 before the campaign to 13.2 during it (P < 0.02), with an increase to 27 (P < 0.01) during the first week of the campaign; visits per week for non-cardiac chest pain increased from 7.6 to 8.1 (P = NS) during the campaign, with an increase to 17 (P < 0.05) during its first week. CONCLUSIONS: Public campaigns may significantly reduce pre-hospital delay in patients with chest pain. Despite transient increases in emergency department visits for non-cardiac chest pain, such campaigns may significantly increase hospital visits for AMI and unstable angina and thus be cost effective.

Angina, Unstable↗
PubMed1995

[Suspicion of unstable angina and myocardial infarct. Evaluation and prehospital management by the practitioner].

When confronted with chest pain, one should above all consider unstable infarction or unstable angina pectoris, because these events necessitate immediate hospitalization in view of intravenous thrombolysis. In this article, published works on estimates for the probability of acute myocardial infarction based on history and ECG are summarized. The different decision-making processes practitioners may become confronted with as well as some diagnostic and therapeutic recommendations are introduced.

Angina, Unstable↗