PubMed · 8188207
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J R Reynolds. 1994. The PACT model.. https://doi.org/10.1176/ps.45.3.281
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OBJECTIVE: To show the influence of variations in case mix on clinical outcome indicators for patients admitted to hospital with acute stroke. DESIGN: "Before and after" cohort study, with prospective, consecutive identification of patients and prospective follow up; multiple logistic regression analyses to correct for case mix variations. SETTING: University teaching hospital. SUBJECTS: 216 patients with stroke identified before the introduction of an organised stroke service, and 252 patients with stroke identified after its introduction. MAIN OUTCOME MEASURES: Case fatality at 30 days and 12 months; for survivors at 12 months, proportions of patients who were independent (according to the Oxford handicap scale) and of those living at home. RESULTS: Crude outcome data suggested that patients in the cohort identified after the introduction of the stroke service were significantly more likely to be alive, independent, and living at home than patients managed before the stroke service. After adjustment for age and sex these "improvements" were less impressive but still significant. After adjustment for many other possible prognostic indicators, however, the differences between the two groups for all four outcomes were non-significant, suggesting that the "improvements" may have been entirely due to differences in case mix between the two cohorts, rather than the new stroke service. CONCLUSIONS: Variations in case mix have a crucial influence on the interpretation of outcome data, and this is particularly important in non-randomised comparative studies. Such studies, comparing performance within and between different provider units, are likely to become increasingly common in the new reformed NHS. To allow meaningful interpretation, these studies must try to correct for case mix.
The term "failure to thrive" is frequently used to describe older adults whose independence is declining. The term was exported from pediatrics in the 1970s and is used to describe older adults with various concurrent chronic diseases, functional impairments, or both. Despite this heterogeneity, failure to thrive has had its own international Classification of Diseases, Ninth Revision (ICD-9) code since 1979 and has been approached as a clinically meaningful diagnosis in many review articles. This conceptual framework, however, can create barriers to proper evaluation and management. The most worrisome of these barriers is the reinforcement of both fatalism and intellectual laziness, which need to be balanced with a deconstructionist approach, wherein the major areas of impairment are identified and quantified and have their interactions considered. Four syndromes known to be individually predictive of adverse outcomes in older adults are repeatedly cited as prevalent in patients with failure to thrive: impaired physical functioning, malnutrition, depression, and cognitive impairment. The differential diagnosis of contributors to each of these syndromes includes the other three syndromes, and multiple contributors often exist concurrently. Some of these contributors are unmodifiable, some are easily modifiable, and some are potentially modifiable but only with the use of resource-intensive strategies, initial interventions should be directed at easily remediable contributors in the hope of improving overall functional status, because a single contributor may simultaneously influence several other syndromes that conspire to create the phenotype of failure to thrive. How aggressively should more resource-intensive strategies for less easily modifiable contributors be pursued? This is a central clinical, ethical, and policy issue in geriatric medicine that cannot be settled without better process and outcome data. This paper examines the medical etymology of failure to thrive and proposes a rational approach to evaluation and management that is based on the limited medical literature.