Biomedical subjects

M R London

Publications and source records attributed to M R London.

12 recordsLinked to original sources

PubMed2000

Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly.

OBJECTIVES: To evaluate whether terminal care was consistent with Physician Orders for Life-Sustaining Treatment (POLST), a preprinted and signed doctor's order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes. DESIGN: Retrospective chart review. SETTING: ElderPlace, a Program of All-Inclusive Care for the Elderly (PACE) site in Portland, Oregon. PARTICIPANTS: All ElderPlace participants who died in 1997 were eligible (n = 58). Reasons for exclusion were no POLST (1), missing POLST (1), and insufficient documentation of care (2). MEASUREMENTS: POLST instructions for each participant and whether or not each of the treatments addressed by the POLST was administered in the final 2 weeks of life. RESULTS: The POLST specified "do not resuscitate" for 50 participants (93%); CPR use was consistent with these instructions for 49 participants (91%). "Comfort care" was the designated level of medical intervention in 13 cases, "limited interventions" in 18, "advanced interventions" in 18, and "full interventions" in 5. Interventions administered were at the level specified in 25 cases (46%); at a less invasive level in 18 (33%), and at a more invasive level in 11 (20%). Antibiotic administration was consistent with POLST instructions for 86% of 28 subjects who had infections in the last 2 weeks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for IV fluids and 94% for feeding tubes. CONCLUSIONS: POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life-sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.

Advance Directives↗

PubMed2000

Assessment of pain in cognitively impaired older adults: a comparison of pain assessment tools and their use by nonprofessional caregivers.

OBJECTIVES: To compare self-reporting of pain by cognitively impaired (CI) older adults living in the community with reports of their caregivers; to identify the factors associated with differences in agreement; and to identify those pain assessment tools that are most useful to nonprofessional caregivers. DESIGN: Prospective observational cohort of patients with dementia and their caregivers. SETTING: In-home assessments of community-dwelling CI older adults and family members, adult foster care providers, or aides in residential care facilities. All CI subjects were enrolled in a Program for All-inclusive Care of the Elderly program (ElderPlace) in Portland, Oregon. PARTICIPANTS: A total of 156 CI adults and their caregivers. METHODS: Standardized pain assessment instruments were administered to the CI subjects and their caregivers in the subject's home by trained research assistants between June and October 1998. CI subjects were assessed with the Nonverbal Visual Analog scale ("line"), the Faces Pain Scale ("faces"), and the Philadelphia Pain Intensity Scale (PIS). Research assistants observed pain behaviors in the CI subjects using the Hospice Approach Discomfort Scale. The CI subject's caregivers completed the "line," "faces," PIS, and Cornell Scale for Depression in Dementia. A baseline Mini-Mental State Exam, Functional Assessment Stage Test, and Geriatric Depression Scale were performed on all CI subjects by ElderPlace medical, nursing, or social work staff. RESULTS: The mean age of the CI subjects was 83, and 83% were women. The mean Mini-Mental State Exam score was 15.7. One-third of the CI subjects were unable to complete any of the three pain assessment tools. Of the 104 subjects completing at least one tool, 13 (12.5%) reported no pain and 91 (87.5%) reported some pain. Sixteen (10%) of the subjects were depressed as measured with the GDS or Cornell instrument. In 70 of the 104 subjects (67%) able to complete any tool, the caregiver and CI subject agreed as to the level of pain experienced by the CI subject. The number of tools completed by the CI subjects decreased with increased cognitive impairment. The Pain Intensity Scale was the tool most likely to be completed by both CI subjects and caregivers. The means of test scores were not significantly different for the paired groups of CI subject and caregiver, and the nonparametric correlation of each tool was significant: "faces" (Spearman's rho (p) = .417); "line" (p = .420); and PIS (p = .452). The Hospice Approach Discomfort Scale did not correlate well with other tools. The Pain Intensity Scale seems to be more useful than other pain assessment tools in assessing pain in cognitively impaired patients and can be used by nonprofessional caregivers in a community-based care setting.

Aged↗

PubMed1998

Correlation between health outcome and length of hospital stay in lumbar microdiscectomy.

STUDY DESIGN: Prospective observational trial in a community hospital setting. OBJECTIVES: To examine the effect on patient-reported outcome of a clinical practice, namely, decrease in hospital length of stay for single-level lumbar microdiscectomy. SUMMARY OF BACKGROUND DATA: Health care reform and the economic demands of managed care have created increasing pressure to manage health care resources more effectively. Spine surgery is one of the most common surgeries. METHODS: Starting in October 1993, length of stay for patients undergoing lumbar microdiscectomy was decreased at the study institution. Patients completed questionnaires (SF-36) before surgery and 3 months after surgery that assessed health status, back-related functional status, and treatment satisfaction. Comparisons were made between the intervention group and a historical control group and between 1-day and 2-day patients. RESULTS: SF-36 scores 3 months after surgery approximated age and sex norms of five of the eight SF-36 scales and improved significantly on the remaining three scales. The physical functioning and general health scores were significantly better for the 1-day than the 2-day patients. Patient satisfaction was similar in all groups. Hospital charges for the 1-day patients were $781 less per patient than for the 2-day patients. CONCLUSIONS: Hospital length of stay for lumbar microdiscectomy can be decreased without adverse effect on short-term patient self-reported health status or satisfaction and with lower hospital charges. This model assesses the effect of efficient management of health care resources on patient-perceived quality and satisfaction.

Adult↗

PubMed1998

Insights into asthma prevalence in Oregon.

Asthma is one of the most common chronic diseases. The prevalence of asthma appears to be increasing. National data have suggested that Oregon's asthma mortality rate has been twice as high as the national average. The prevalence and impact of asthma are not systematically assessed or tracked within Oregon. We estimated the current asthma prevalence and mortality using data from statewide hospital discharge data, the 1995 Behavioral Risk Factor Surveillance Survey, and school registration data from the Portland area. A conservative estimate of Oregon's current asthma prevalence is 6-7% and lifetime asthma prevalence is estimated at 6-11% for both adults and children. It appears that current asthma prevalence increases during adolescence. The Willamette Valley, an area known for high pollen counts, does not have a higher rate of hospital discharges per capita than other areas within the state. Oregon's apparent higher asthma mortality may be the result of the Oregon State Health Division's aggressive policies toward accurate reporting on death certificates. Oregon's age distribution may also contribute to the apparent higher asthma mortality rate.

Adolescent↗

PubMed1996

Clinical practice evaluation at Providence Health System.

Over the past seven years, Providence Health System (PHS) in Portland, Oregon, has used an outcomes research paradigm to study treatment of back pain, coronary artery disease, total joint replacement, and cancer. In presenting case studies of each of these areas, the authors chronicle the evolution of clinical practice evaluation at PHS, beginning with early studies in the 1960s, to the establishment of the Center for Outcomes Research and Education (CORE), to the formation of a new systemwide strategy that is responsive to the evolving health care marketplace.

Back Pain↗

PubMed1995

Long-term survival of vascular accesses in a large chronic hemodialysis population.

Complications associated with vascular accesses account for approximately 30% of hospital admissions for chronic hemodialysis patients. Long-term patency of access was evaluated in 76 patients, without diabetes mellitus, who had been on dialysis for at least 3 years and 41 patients, with diabetes mellitus, who had been on dialysis for over 2 years. Fistulas functioned longer than grafts (58 vs. 22 months, p < 0.01, in nondiabetics and 70 vs 22 months, p < 0.01, in patients with diabetes). Declotting or revision of restored graft function for short periods of time (< 6-10 months) and subsequent declotting was ineffective. Infections were uncommon in grafts (1 per 13.5 years of dialysis) and in fistulas (1 in 200 years of dialysis).

Adolescent↗

PubMed1995

Measuring the success of treatment in patient terms.

Measuring the success of major surgeries such as total hip and total knee replacement is important for both case selection and public policy. Patients, purchasers, and practitioners must choose among clinical scoring systems, health status measures, and patient satisfaction ratings to monitor performance and ensure appropriate use of costly procedures. The present study compares results from the Medical Outcomes Study Short Form 36 (SF-36) Health Status Survey and clinical scoring systems to direct patient ratings of success. Data come from a study of 128 total knee-replacement procedure and 211 total hip replacements. Analyses indicate that for both hip and knee patients, success is related closely to posttreatment physical function and bodily pain. Patient ratings of success also are related to the clinical scores used by physicians. Success is related less to change from pretreatment function for knee patients than for hip patients. Although patient ratings of success are generally consistent with other outcome measures, their relationship to patient expectations, satisfaction, and attributions need to be understood before they can become a useful tool for performance monitoring and case selection.

Activities of Daily Living↗

PubMed1994

Renal osteodystrophy and dialysis artifacts as indicators of identification.

Evidence of rare disease may be useful in the identification of unknown remains. Osteodystrophy is a condition commonly associated with chronic renal failure. The presence of renal osteodystrophy and medical artifacts associated with the treatment of kidney failure in human remains may provide information about the individual's medical history. Currently, there are more than 100,000 patients with end stage renal disease in the United States receiving dialysis treatments to replace kidney function, and hundreds of thousands more who have significant chronic kidney failure and are not yet treated with dialysis. Chronic renal failure frequently leads to disorders in the metabolism of vitamin D, calcium, and parathyroid hormone which are extremely difficult to correct. At least three patterns of skeletal change may result: osteitis fibrosa, characterized by increased bone remodelling, increased osteoclastic activity, peritrabecular fibrosis, and a normal mineralization pattern; osteomalacia, with a markedly increased osteoid surface and volume, and impaired mineralization; and mixed osteodystrophy, with increased bone remodelling and moderately impaired mineralization. While these bone changes may not have any clinical manifestations in most patients, they can been seen radiographically and histologically. This evidence may be useful in identifying remains which have been skeletonized, burned, decomposed, or dismembered. Medical artifacts associated with dialysis treatment, such as catheters, polytetrafluoroethylene grafts, and evidence of surgical procedures, are also useful for identification.

Adult↗

PubMed1993

The relevance of mineralization lag time in the evaluation of histologic changes in renal osteodystrophy.

We examined bone biopsies from 47 patients on chronic hemodialysis, and analyzed the histomorphometric and biochemical findings and histologic quantitation of bone aluminium, looking primarily at mineralization lag time (Mlt) to evaluate its usefulness in categorization of renal osteodystrophy (ROD). The patients were categorized as having either relatively normal Mlt (< 35 days, n = 21 patients), moderately prolonged Mlt (35-100 days, n = 13 patients) or markedly prolonged Mlt (> 100 days, n = 13 patients). The group with relatively normal Mlt showed significantly higher C-terminal parathyroid hormone (PTHc) levels (26,141 +/- 19,270 vs 7,226 +/- 6,073 and 4,434 +/- 4,000 pg/ml) than the moderately or markedly prolonged Mlt groups (p < .01) and was associated with histologic characteristics of osteitis fibrosa or mild hyperparathyroidism (BFR/BS range 0.146-0.947 mcm3/mcm2/d). The group with markedly prolonged Mlt included one patient with classic and 11 with adynamic osteomalacia (BFR/BS range 0.009-0.099) and had greater bone aluminum (Al.S/OS 35.3 +/- 26.7% vs 7.2 +/- 9.0%) than the normal Mlt group (p < .01). The group with moderately prolonged Mlt included two patients with aplastic bone disease (Mlt 80.0 and 84.6 days, and Al.S/OS 100.0 and 72.3%) and 11 patients with features of hyperparathyroidism and osteomalacia (BFR/BS range 0.068-0.243) with variable but generally intermediate bone aluminum deposition (Al.S/OS 22.5 +/- 19.9%). Like BFR/BS and other dynamic parameters Mlt correlates with morphologic types of ROD which primarily reflect bone turnover, but it may also suggest varying degrees of mineralization impairment in a spectrum ranging from high to low turnover types of ROD. Its usefulness in this respect should not be overlooked.

Bone Density↗

PubMed1992

The impact of diagnosis-related groups on the cost of hospitalization for end-stage renal disease patients at Rhode Island Hospital from 1987 to 1990.

The introduction of diagnosis-related groups (DRGs) for the reimbursement of hospital costs in the Medicare population made no provisions to identify end-stage renal disease (ESRD) patients. To assess the impact of the DRGs on ESRD patients, we prospectively evaluated all hospitalizations (901) at the Rhode Island Hospital from July 1987 through April 1990 among a chronic hemodialysis population of 587 patients. The complied data on length of hospital stay, cost per day, and total cost were compared with the accepted allowances as defined by the DRG codes assigned to the admissions. The mean values and comparisons were length of stay, 10.2 +/- 21 days (ESRD) versus 9.7 +/- 3.6 days (DRGs), P = 0.44; cost per day, $1,240 +/- $685 (ESRD) versus $671 +/- $897 (DRGs), P = 0.0001; and total cost, $9,660 +/- $17,170 (ESRD) versus $6,815 +/- $8,872 (DRGs), P = 0.0001, a difference of $2,275 per admission. The increase in daily, and thus total, costs was primarily due to the use of supplies, medications, laboratory procedures, and transfusion services. It appears from our data that the DRGs do not adequately reflect the cost of caring for ESRD patients with the same DRGs as non-ESRD patients because of increased demand for ancillary services. If these observations are confirmed, a reevaluation of the DRG process as it relates to ESRD patients is warranted.

Diagnosis-Related Groups↗

PubMed1991

The clinical spectrum of renal osteodystrophy in 57 chronic hemodialysis patients: a correlation between biochemical parameters and bone pathology findings.

Fifty-nine chronic hemodialysis patients who had been on dialysis for an average of 77 months underwent bone biopsies and the pathologic findings were correlated with biochemical and demographic data. All but two had evidence of renal osteodystrophy, 23 with osteitis fibrosa (OF), 19 with osteomalacia and/or adynamic disease (OM/AD), and 15 with mixed osteodystrophy (MOD). Patients in each group were similar with regard to age, sex distribution, duration of dialysis, unstimulated serum aluminum, calcium and phosphorus. Patients with osteitis fibrosa (OF) had statistically higher DFO stimulated aluminum, alkaline phosphatase and PTHC levels than the other two groups although there was marked individual variation. The bone biopsies were also evaluated for the amount of aluminum deposited in the osteoid seam. All 23 of the patients with OF and 11 of the 15 patients with MOD had no, mild, or minimal aluminum deposition but 12 of the 19 patients with OM/AD had moderate to marked aluminum deposition. Patients with minimal to mild aluminum deposition were similar in age, duration of dialysis, sex distribution, unstimulated and DFO stimulated aluminum levels, calcium, phosphorus, alkaline phosphatase to those with moderate to marked deposition but had significantly higher parathormone levels. All patients had been treated in a similar fashion regarding diet, oral phosphate binders and vitamin D; therefore, the observed differences in bone pathology were not readily explicable. However, patients who were found to have osteitis fibrosa and those with minimal to mild aluminum deposition had significantly higher parathormone levels when compared with patients in the other groups at the inception of dialysis.

Adult↗

PubMedDate not supplied

A framework for improving quality. Using project study teams, Providence Health System tackles problem areas.

To identify issues for quality improvement and monitoring, an organization first articulates its service mission and objectives. The organization uses internal measurements and self-examination with external accountability and benchmarks to select a manageable number of projects for study. Supported by collected evidence, published data, and broad-based approval, projects focus on the process or outcomes of care, frequency of services, or patient populations. An accountable leader selects team members from the affected disciplines, who review evidence, agree on what and how to measure, determine implementation strategies, and develop an evaluation plan. The team meets established targets to track the project's progress and shares results with other teams. Providence Health System (PHS) his integrated its continuum of care through quality study groups (e.g., CORE) and improved communication systems. The Guideline Evaluation and Redesign (GEAR) projects compare PHS performance against outside standards, studying eight patient conditions (e.g., geriatric depression, hysterectomy) to decrease hospital days without compromising care. Each team is encouraged to develop guidelines for admission, discharge, and hospital care in their specialty areas. These projects are balanced between surgical and nonsurgical conditions and across clinical programs to engage different staffs. The PHS Population Health Improvement (PHI) teams used feasibility studies of eight patient populations to identify ways to improve quality of care based on internal and external evidence. The high-risk pregnancy team has redesigned staffing and implemented case management, and the Medicare and Medicaid projects have developed risk screens for new patient members.

Benchmarking↗