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Biomedical subjects

Mary Beth Hamel

Publications and source records attributed to Mary Beth Hamel.

At least 19 recordsLinked to original sources
PubMed2006

Understanding patients' value of weight loss and expectations for bariatric surgery.

BACKGROUND: Few studies examine patients' expectations for bariatric surgery or the value patients place on weight loss. METHODS: 44 patients planning to undergo bariatric surgery were surveyed to examine patients' expectations and motivations for surgery. We also quantified how much patients valued different health and weight loss states using the standard gamble, an approach that estimates an outcome's value based on a patient's willingness to risk death to achieve the outcome. Utilities ranging from 0 to 1.00 were calculated where 1.00 represented the most desired state. RESULTS: Mean age of the patients was 42.6 years, and mean body mass index was 47.1 kg/m(2). The majority were women (n=42) and white (n=29), and reported poor quality of life. Most patients considered surgery for health reasons. Patients expected to lose 38% of their total body weight and would be disappointed if they did not lose at least 24% of their body weight. Significantly more patients were willing to risk death to achieve their "dream" weight (n=40) than to lose 20% (n=32) or 10% (n=17) of their total body weight. The respective utilities for these weight states were 0.98, 0.94, and 0.92. More patients were willing to risk death to undergo surgery (n=42) than to achieve a permanent weight loss of 20% (n=32), P<0.004. CONCLUSION: Patients appeared to value weight loss highly but had unrealistic expectations for bariatric surgery. Future studies should examine whether patient expectations, motivations, and value for realistic weight losses might predict outcomes and satisfaction after surgery.

Adult↗
PubMed2005

Cost-effectiveness of full medicare coverage of angiotensin-converting enzyme inhibitors for beneficiaries with diabetes.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors slow renal disease progression and reduce cardiac morbidity and mortality in patients with diabetes. Patients' out-of-pocket costs pose a barrier to using this effective therapy. OBJECTIVE: To estimate the cost-effectiveness to Medicare of first-dollar coverage (no cost sharing) of ACE inhibitors for beneficiaries with diabetes. DESIGN: Markov model with costs and benefits discounted at 3%. DATA SOURCES: Published literature and Medicare claims data. TARGET POPULATION: 65-year-old Medicare beneficiary with diabetes. TIME HORIZON: Lifetime. PERSPECTIVE: Medicare and societal. INTERVENTIONS: We evaluated Medicare first-dollar coverage of ACE inhibitors compared with current practice (no coverage) and the new Medicare drug benefit. OUTCOME MEASURES: Costs (2003 U.S. dollars), quality-adjusted life-years (QALYs), life-years, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Compared with current practice, first-dollar coverage of ACE inhibitors saved both lives and money (0.23 QALYs gained and 1606 USD saved per Medicare beneficiary). Compared with the new Medicare drug benefit, first-dollar coverage remained a dominant strategy (0.15 QALYs gained, 922 USD saved). RESULTS OF SENSITIVITY ANALYSIS: Results were most sensitive to our estimate of increase in ACE inhibitor use; however, if ACE inhibitor use increased by only 7.2% (from 40% to 47.2%), first-dollar coverage would remain life-saving at no net cost to Medicare. In analyses conducted from the societal perspective, benefits were similar and cost savings were larger. LIMITATIONS: Results depend on accuracy of the underlying data and assumptions. The effect of more generous drug coverage on medication adherence is uncertain. CONCLUSIONS: Medicare first-dollar coverage of ACE inhibitors for beneficiaries with diabetes appears to extend life and reduce Medicare program costs. A reduction in program costs may result in more money to spend on other health care needs of the elderly.

Aged↗
PubMed2005

Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery.

OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and 1999. METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older.

Age Distribution↗
PubMed2005

Health care expenditures associated with overweight and obesity among US adults: importance of age and race.

OBJECTIVES: We estimated health care expenditures associated with overweight and obesity and examined the influence of age, race, and gender. METHODS: Using 1998 Medical Expenditure Panel Survey data, we employed 2-stage modeling to estimate annual health care expenditures associated with high body mass index (BMI) and examine interactions between demographic factors and BMI. RESULTS: Overall, the mean per capita annual health care expenditure (converted to December 2003 dollars) was $3338 before adjustment. While the adjusted expenditure was $2127 (90% confidence interval [CI]=$1927, $2362) for a typical normal-weight White woman aged 35 to 44 years, expenditures were $2358 (90% CI=$2128, $2604) for women with BMIs of 25 to 29.9 kg/m(2), $2873 (90% CI=$2530, $3236) for women with BMIs of 30 to 34.9 kg/m(2), $3058 (90% CI=$2529, $3630) for women with BMIs of 35 to 39.9 kg/m(2), and $3506 (90% CI=$2912, $4228) for women with BMIs of 40 kg/m(2) or higher. Expenditures related to higher BMI rose dramatically among White and older adults but not among Blacks or those younger than 35 years. We found no interaction between BMI and gender. CONCLUSIONS: Health care costs associated with overweight and obesity are substantial and vary according to race and age.

Adult↗
PubMed2004

Perspectives, preferences, care practices, and outcomes among older and middle-aged patients with late-stage cancer.

PURPOSE: To evaluate relationships among physician and cancer patient survival estimates, patients' perceived quality of life, care preferences, and outcomes, and how they vary across middle-aged and older patient groups. PATIENTS AND METHODS: Subjects were from the Study to Understand Prognoses and Preferences for Risks of Treatments (SUPPORT) prospective cohort studied in five US teaching hospitals (from 1989 to 1994), and included 720 middle-aged (45 to 64 years) and 696 older (> or = 65 years) patients receiving care for advanced cancer. Perspectives were assessed in physician and patient/surrogate interviews; care practices and outcomes were determined from hospital records and the National Death Index. General linear models were used within age groups to obtain adjusted estimates. RESULTS: Although most patients had treatment goals to relieve pain, treatment preferences and care practices were linked only in the older group. For older patients, preference for life-extending treatment was associated with more therapeutic interventions and more documented discussions; cardiopulmonary resuscitation (CPR) preference was linked to more therapeutic interventions and longer survival. For middle-aged patients, better perceived quality of life was associated with preferring CPR. In both groups, patients' higher survival estimates were associated with preferences for life-prolonging treatment and CPR; physicians' higher survival estimates were associated with patients' preferences for CPR, fewer documented treatment limitation discussions about care, and actual 6-month survival. More discussions were associated with readmissions and earlier death. More aggressive care was not related to outcomes. CONCLUSION: Fewer older patients preferred CPR or life-prolonging treatments. Although older patients' goals for aggressive treatment were related to care, this was not so for middle-aged patients. Aggressive care was not related to prolonged life in either group.

Age Factors↗
PubMed2004

Estimating prognosis for nursing home residents with advanced dementia.

CONTEXT: Survival varies for patients with advanced dementia, and accurate prognostic tools have not been developed. A small proportion of patients admitted to hospice have dementia, in part because of the difficulty in predicting survival. OBJECTIVES: To identify factors associated with 6-month mortality in newly admitted nursing home residents with advanced dementia and to create a practical risk score to predict 6-month mortality in this population. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of data from the Minimum Data Set (MDS). All Medicare or Medicaid licensed nursing homes in New York and Michigan were included. Participants had advanced dementia and were admitted to New York nursing homes between June 1, 1994, and December 30, 1998 (derivation cohort, n = 6799), and to Michigan nursing homes from October 1, 1998, through July 30, 2000 (validation cohort, n = 4631). MAIN OUTCOME MEASURES: MDS factors associated with 6-month mortality were determined in the derivation group, and the resulting mortality risk score was evaluated in the validation cohort. Risk score performance was compared with the cut point of 7c on the Functional Assessment Staging (FAST) scale. RESULTS: Among residents with advanced dementia, 28.3% (n = 1922) died within 6 months of nursing home admission in the derivation cohort; 35.1% (n = 1626) died in the validation cohort. The 6-month mortality rate increased across risk scores (possible range, 0-19): 0 points, 8.9% mortality; 1 to 2, 10.8%; 3 to 5, 23.2%; 6 to 8, 40.4%; 9 to 11, 57.0%; and at least 12, 70.0% in the validation cohort. The area under the receiver operating characteristic (AUROC) curve for predicting 6-month mortality was 0.74 and 0.70 in the derivation and validation cohorts, respectively. Our risk score demonstrated better discrimination to predict 6-month mortality (AUROC, 0.64 for a cutoff of > or =6 points vs 0.51 for FAST stage 7c). CONCLUSION: A risk score based on 12 variables from the MDS estimates 6-month mortality for nursing home residents with advanced dementia with greater accuracy than existing prognostic guidelines.

Aged↗
PubMed2004

Dying with advanced dementia in the nursing home.

BACKGROUND: Nursing homes are important providers of end-of-life care to persons with advanced dementia. METHODS: We used data from the Minimum Data Set (June 1, 1994, to December 31, 1997) to identify persons 65 years and older who died with advanced dementia (n = 1609) and terminal cancer (n = 883) within 1 year of admission to any New York State nursing home. Variables from the Minimum Data Set assessment completed within 120 days of death were used to describe and compare the end-of-life experiences of these 2 groups. RESULTS: At nursing home admission, only 1.1% of residents with advanced dementia were perceived to have a life expectancy of less than 6 months; however, 71.0% died within that period. Before death, 55.1% of demented residents had a do-not-resuscitate order, and 1.4% had a do-not-hospitalize order. Nonpalliative interventions were common among residents dying with advanced dementia: tube feeding, 25.0%; laboratory tests, 49.2%; restraints, 11.2%; and intravenous therapy, 10.1%. Residents with dementia were less likely than those with cancer to have directives limiting care but were more likely to experience burdensome interventions: do-not-resuscitate order (adjusted odds ratio [OR], 0.12; 95% confidence interval [CI], 0.09-0.16), do-not-hospitalize order (adjusted OR, 0.33; 95% CI, 0.16-0.66), tube feeding (adjusted OR, 2.21; 95% CI, 1.51-3.23), laboratory tests (adjusted OR, 2.53; 95% CI, 2.01-3.18), and restraints (adjusted OR, 1.79; 95% CI, 1.23-2.61). Distressing conditions common in advanced dementia included pressure ulcers (14.7%), constipation (13.7%), pain (11.5%), and shortness of breath (8.2%). CONCLUSIONS: Nursing home residents dying with advanced dementia are not perceived as having a terminal condition, and most do not receive optimal palliative care. Management and educational strategies are needed to improve end-of-life care in advanced dementia.

Advance Directives↗
PubMed2003

Diagnosis and management of adults with pharyngitis. A cost-effectiveness analysis.

BACKGROUND: Rheumatic fever has become uncommon in the United States while rapid diagnostic test technology for streptococcal antigens has improved. However, little is known about the effectiveness or cost-effectiveness of various strategies for managing pharyngitis caused by group A beta-hemolytic streptococcus (GAS) in U.S. adults. OBJECTIVE: To examine the cost-effectiveness of several diagnostic and management strategies for patients with suspected GAS pharyngitis. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Published literature, including systematic reviews where possible. When costs were not available in the literature, we estimated them from our institution and Medicare charges. TARGET POPULATION: Adults in the general U.S. population. TIME HORIZON: 1 year. PERSPECTIVE: Societal. INTERVENTIONS: Five strategies for the management of adult patients with pharyngitis: 1) observation without testing or treatment, 2) empirical treatment with penicillin, 3) throat culture using a two-plate selective culture technique, 4) optical immunoassay (OIA) followed by culture to confirm negative OIA test results, or 5) OIA alone. OUTCOME MEASURES: Cost per lost quality-adjusted life-days (converted to life-years where appropriate) and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Empirical treatment was the least effective strategy at a GAS pharyngitis prevalence of 10% (resulting in 0.41 lost quality-adjusted life-day). Although the other four strategies had similar effectiveness (all resulted in about 0.27 lost quality-adjusted life-day), culture was the least expensive strategy. RESULTS OF SENSITIVITY ANALYSES: Results were sensitive to the prevalence of GAS pharyngitis: OIA followed by culture was most effective when GAS pharyngitis prevalence was greater than 20%. Observation was least expensive when prevalence was less than 6%, and empirical treatment was least expensive when prevalence was greater than 71%. The effectiveness of strategies was also very sensitive to the probability of anaphylaxis: When the probability of anaphylaxis was about half the baseline probability, OIA/culture was most effective; when the probability was 1.6 times that of baseline, observation was most effective. Only at an OIA cost less than half of baseline did the OIA alone strategy become less expensive than culture. Results were not sensitive to other variations in probabilities or costs of diagnosis or treatment of GAS pharyngitis. CONCLUSIONS: Observation, culture, and two rapid antigen test strategies for diagnostic testing and treatment of suspected GAS pharyngitis in adults have very similar effectiveness and costs, although culture is the least expensive and most effective strategy when the GAS pharyngitis prevalence is 10%. Empirical treatment was not the most effective or least expensive strategy at any prevalence of GAS pharyngitis in adults, although it may be reasonable for individual patients at very high risk for GAS pharyngitis as assessed by a clinical decision rule.

Adult↗
PubMed2003

Length of stay in home care before and after the 1997 Balanced Budget Act.

CONTEXT: Prior to 1997, home health agencies (HHAs) were reimbursed on a fee-for-service basis and had incentives to provide more services. The 1997 Balanced Budget Act (BBA) reduced payments for home care services to help control Medicare spending. OBJECTIVE: To examine the length of stay in home care before and after the 1997 BBA. DESIGN AND SETTING: Cross-sectional study of home care patients in the 1996 and 1998 National Home and Hospice Care Surveys, which surveyed 1053 HHAs in 1996 and 1088 HHAs in 1998. PATIENTS: Nationally representative random sample of home care patients with Medicare coverage in 1996 (4127 patients) and 1998 (4051 patients). MAIN OUTCOME MEASURE: Length of stay in home care (based on the number of days a patient was enrolled in home care services). RESULTS: From 1996 to 1998, unadjusted median length of stay decreased by 16 days for all home care patients (60-44 days, P =.002). The decrease affected for-profit HHAs more than not-for-profit HHAs (111-55 days [51% decrease, P =.002] vs 46-36 days [22% decrease, P =.042]). In a Cox proportional hazards model of time to discharge from home care, post-BBA year (1998) was associated with a shorter length of stay in home care (adjusted hazard ratio [aHR] for home care discharge, 1.39 [95% confidence interval [CI], 1.19-1.61]), and for-profit status was associated with a longer length of stay in home care (aHR, 0.82 [95% CI, 0.71-0.94]) after adjusting for patient demographics, diagnoses, and functional status. CONCLUSION: After the 1997 BBA, length of stay in home care decreased among Medicare patients, particularly among those receiving care from for-profit HHAs.

Aged↗
PubMed2003

Diagnosis and treatment of osteoporosis in patients with vertebral compression fractures.

OBJECTIVES: To determine whether patients with vertebral compression fractures are diagnosed with or treated for osteoporosis. DESIGN: Retrospective cohort study. SETTING: Two primary care practices in Massachusetts. PARTICIPANTS: Two hundred six patients with vertebral compression fractures noted on routine radiographs in 1997-1998. MEASUREMENTS: Percentage of patients diagnosed with osteoporosis and treated with prescription medications (estrogen, bisphosphonates, raloxifene, or calcitonin). Factors associated with missed osteoporosis diagnosis and treatment, including risk factors for osteoporosis, comorbidities, vertebral fracture severity, and processes of care communication were also examined. RESULTS: The median patient age was 76, 71% of the cohort was female, and 13% of patients had a history of corticosteroid use. Thirty-eight percent of subjects (46% of women and 19% of men) were diagnosed with osteoporosis and 32% (39% of women and 14% of men) received prescription medications for osteoporosis. Of women who were diagnosed with osteoporosis, 69% received prescription medications. In adjusted analyses women younger than 50 (adjusted odds ratio (AOR) = 0.09; 95% confidence interval (CI) = 0.01-0.71) and 90 and older (AOR = 0.27; 95% CI = 0.08-0.98) were less likely to be diagnosed with osteoporosis, whereas women with a prior hip or radial fracture (AOR = 3.65; 95% CI = 1.28-10.38) or back pain (AOR = 2.84; 95% CI = 1.38-5.85) were more likely to be diagnosed with osteoporosis. CONCLUSIONS: Physicians frequently did not diagnose osteoporosis in primary care patients with vertebral fractures, missing an important preventive opportunity for patients at high risk for future fractures. Efforts targeted to improving diagnosis of osteoporosis could improve patient care.

Aged↗
PubMed2002

Medical care inconsistent with patients' treatment goals: association with 1-year Medicare resource use and survival.

OBJECTIVES: To describe how frequently seriously ill persons perceive that the care they receive is inconsistent with treatment preferences and the effect on 1-year resource utilization. SETTING: Five U.S. teaching hospitals. DESIGN: Secondary analysis of interview data. PARTICIPANTS: Seriously ill Medicare beneficiaries. MEASUREMENTS: Interviews about patients' preferred approaches to care and whether they perceived care was consistent with these preferences. Part A and B costs for up to 1 year, adjusted for cost differences across hospitals and over time and for 1-year survival. RESULTS: Forty percent of the 1,185 study patients expressed a preference for treatment to focus on extending life, whereas 60% expressed a preference for comfort care. Eighty-six percent of the patients who wanted aggressive treatment reported that care was consistent with their preferences, but only 41% of those who preferred comfort care reported that care was consistent with their preferences. More than one-third of those with a preference for comfort care (35%) reported that the medical care that they received was inconsistent with their goals; 24% were unsure of treatment goals. Those who preferred comfort care but believed that their care was inconsistent with their wishes had higher estimated mean 1-year costs than those who believed that their care was consistent with their wishes (92,442 US dollars vs 52,098 US dollars, P < .001). Even after adjusting for differences in disease severity, age, gender, race, functional status, income, and years of education, adjusted costs were 1.4 times (95% confidence interval = 1.2-1.6) higher. However, 1-year survival was lower in these patients who stated that care was consistent with their preference to focus on comfort care than for those who wished to receive comfort care and stated that care was not consistent with their preference (38% vs 55% 1-year survival, P < .001). CONCLUSION: More than one in three seriously ill persons who prefer comfort care believe that their medical care is at odds with their preference that treatment focus on palliation. Such discord was associated with higher 1-year healthcare costs and increased survival.

Aged↗
PubMed2002

The use of life-sustaining treatments in hospitalized persons aged 80 and older.

OBJECTIVES: To characterize the use of life-sustaining treatments in hospitalized patients aged 80 and older. DESIGN: A prospective cohort study. SETTING: Four teaching hospitals in the United States that participated in the Hospitalized Elderly Longitudinal Project (HELP). PARTICIPANTS: Hospitalized patients aged 80 and older. MEASUREMENTS: We report the rates of admissions to intensive and coronary care units and the rates of use of cardiopulmonary resuscitation (CPR), ventilators, right heart catheterization, artificial nutrition and hydration, surgical interventions, hemodialysis, and blood transfusions. RESULTS: Of the 1,266 patients enrolled in HELP, 72 died during the enrollment hospitalization. The median age of those who died was 86 (range 83-89). Of the patients who died, the median number of activities of daily living impairments was two (range 1-4) before hospitalization, and 70% reported their baseline quality of life as fair or poor. Most patients who died had stated that they did not want aggressive care; 70% wanted their care focused on comfort rather than prolonging life, and 80% had a do-not-resuscitate order. However, the majority (63%) of the patients received one or more life-sustaining treatments before they died. Fifty-four percent were admitted to intensive or coronary care units, 43% were on a ventilator, 18% received CPR, 18% received tube feeding, 17% underwent surgery, 15% had right heart catheterization, 14% received blood transfusions, and 6% had hemodialysis. Intensive care did not affect survival time. CONCLUSION: The use of life-sustaining treatments was prevalent in very old patients who died in the course of hospitalization, despite the fact that the majority had a preference for comfort care. This lack of congruence warrants further investigation and efforts to provide care that is more consistent with patients' preferences.

Advance Directive Adherence↗
PubMed2002

Cost effectiveness of aggressive care for patients with nontraumatic coma.

OBJECTIVE: To estimate the cost effectiveness of aggressive care for patients with nontraumatic coma. DESIGN: Cost-effectiveness analysis. SETTING: Five academic medical centers. PATIENTS: Patients with nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Patients with reversible metabolic causes of coma such as diabetic ketoacidosis or uremia were excluded. MEASUREMENTS: We calculated the incremental cost effectiveness of continuing aggressive care vs. withholding cardiopulmonary resuscitation and ventilatory support after day 3 of coma. We estimated life expectancy based on up to 4.6 yrs of follow-up. Utilities (quality-of-life weights) were estimated using time-tradeoff questions. Costs were based on hospital fiscal data and Medicare data. Separate analyses were conducted for two prognostic groups based on five risk factors assessed on day 3 of coma: age > or = 70 yrs, abnormal brainstem response, absent verbal response, absent withdrawal to pain, and serum creatinine > or = 132.6 micromol/L (1.5 mg/dL). RESULTS: For the 596 patients studied, the median (25th, 75th percentile) age was 67 yrs (range, 55-77), and 52% were female. By 2 months after enrollment, 69% had died, 19% were severely disabled, 7% had survived without severe disability, and 4% had survived with unknown functional status. The incremental cost effectiveness of the more aggressive care strategy was $140,000 (1998 dollars) per quality-adjusted life year (QALY) for high-risk patients (3-5 risk factors, 93% 2-month mortality) and $87,000/QALY for low-risk patients (0-2 risk factors, 49% mortality). In sensitivity analyses, the incremental cost per QALY did not fall below $50,000/QALY, even with wide variation in our baseline estimates. CONCLUSIONS: Continuing aggressive care after day 3 of nontraumatic coma is associated with a high cost per QALY gained, especially for patients at high risk for poor outcomes. Earlier decisions to withhold life-sustaining treatments for patients with very poor prognoses may yield considerable cost savings.

Activities of Daily Living↗
PubMed2002

Discrepancies between explicit and implicit review: physician and nurse assessments of complications and quality.

OBJECTIVE: To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care. SETTING: Forty-two acute-care hospitals in California and Connecticut in 1994. STUDY DESIGN: In a retrospective chart review of 1,025 Medicare beneficiaries age >65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments. DATA COLLECTION: With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews. PRINCIPAL FINDINGS: Agreement about complications was fair (kappa = 0.36) among surgical and was moderate (kappa = 0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases (kappa = 0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome. CONCLUSIONS: We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality.

Aged↗
PubMed2001

Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile.

A total of 271 patients were prospectively followed up to determine whether patients whose hospital stay is complicated by diarrhea due to Clostridium difficile experience differences in cost and length of stay and survival rates when compared with patients whose stay is not complicated by C. difficile-associated diarrhea. Forty patients (15%) developed nosocomial C. difficile-associated diarrhea. These patients incurred adjusted hospital costs of $3669--that is, 54% (95% confidence interval [CI], 17%-103%)--higher than patients whose course was not complicated by C. difficile-associated diarrhea. The extra length of stay attributable to C. difficile-associated diarrhea was 3.6 days (95% CI, 1.5-6.2). C. difficile-associated diarrhea was not associated with excess 3-month or 1-year mortality after adjustment for age, comorbidity, and disease severity. On the basis of the findings of this study, a conservative estimate of the cost of this disease in the United States exceeds $1.1 billion per year.

Adult↗