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Sixty-three subjects with DSM-III-R major depression with melancholia or psychosis were followed up 2-4 years after index treatment with electroconvulsive therapy. There was a twofold increase in likelihood of improved outcome with an additional 20 years of age.
OBJECTIVE: To determine whether patients with knee or hip osteoarthritis (OA) who have worse physical function preoperatively achieve a postoperative status that is similar to that of patients with better preoperative function. METHODS: This study surveyed an observational cohort of 379 consecutive patients with definite OA who were without other inflammatory joint diseases and were undergoing either total hip or knee replacement in a US (Boston) and a Canadian (Montreal) referral center. Questionnaires on health status (the Short Form 36 and Western Ontario and McMaster Universities Osteoarthritis Index) were administered preoperatively and at 3 and 6 months postoperatively. Physical function and pain due to OA were deemed the most significant outcomes to study. RESULTS: Two hundred twenty-two patients returned their questionnaires. Patients in the 2 centers were comparable in age, sex, time to surgery, and proportion of hip/knee surgery. The Boston group had more education, lower comorbidity, and more cemented knee prostheses. Patients undergoing hip or knee replacement in Montreal had lower preoperative physical function and more pain than their Boston counterparts. In patients with lower preoperative physical function, function and pain were not improved postoperatively to the level achieved by those with higher preoperative function. This was most striking in patients undergoing total knee replacement. CONCLUSION: Surgery performed later in the natural history of functional decline due to OA of the knee, and possibly of the hip, results in worse postoperative functional status.
OBJECTIVE: To explore the physiometric and psychometric properties of clinical, generic, and condition-specific assessment instruments. To describe patients' outcome after total shoulder arthroplasty. METHODS: Forty-three patients were assessed in a 5-6-year cross-sectional catamnesis. RESULTS: With regard to shoulder joint stability, pain, general physical health, and mental health, the patients showed scores comparative to normative scores. Significant functional limitation was evidenced by low mean scores on the specific function scales (e.g., Disability of the Arm, Shoulder and Hand questionnaire score = 64.0, normative score = 86.6). There were high correlations among the joint-specific scales (up to 0.93) and moderate correlations between these and the generic and clinical scales. Factor analysis identified 3 different assessment domains. CONCLUSION: The patients' quality of life (QOL) was high and not affected by impairment in some specific functional abilities. Physical QOL, mental QOL, clinical assessment, condition-specific measures, and generic measures were identified as separate domains, all of which are required for a comprehensive and sophisticated assessment in practical clinical routine.
Assessment of disease consequences (outcome) requires reliable, valid, and sensitive instruments. Psychometrically sound generic health-status instruments such as the SF-36 have been validated for many languages and are available in German. Instead, most disease specific instruments have been developed in English and need to be adapted for the German language. To allow for cross-cultural comparisons and use of results across cultures, for instance, in international multicenter studies, instruments need to have both content and metric equivalence. Thus, adaptation of health-status instruments requires a standarized process including translation, backtranslation, review and assessment of metric properties (reliability, internal consistency, factors), and validity. Developments of new instruments from scratch are time and cost intensive and should only be considered if no current instrument is available. Ideally, newly developed instruments have interval-scale properties.
We tested the usability, sensitivity and validity of the Health of the Nation Outcome Scales (HoNOS) in routine clinical practice in North America. Three pilot sites provided ratings on all inpatient and outpatient referrals over 4 months using versions covering children and adolescents (HoNOSCA), working-age adults and the over-65s. Data were entered using the routine administrative data system. Sixty-one percent of eligible patients had at least one HoNOS rating (n = 485). Following the initial rating, subsequent completion rates reached 80%. Ratings were sensitive to time and setting, with significantly higher scores in inpatients than outpatients. Individual diagnoses had different patterns of scores, further supporting validity.
The Schwartz Outcomes Scale-10 (SOS-10) is a 10-item scale developed to measure the effectiveness of psychiatric treatments. Using standard methodology, we translated the scale into Czech and examined the psychometric properties of the Czech version. 207 in-patients admitted to Prague Psychiatric Center were included in the study. All patients completed the SOS at admission and discharge. The SOS-10 scale was also administered to 170 persons from the general population. Reliability, validity and sensitivity to treatment change of the Czech SOS-10 were analyzed. The Cronbach's alpha coefficient was 0.92. The item-total correlation coefficients varied from 0.56 to 0.82. The SOS-10 correlated well with condition-specific measures including depression (BDI) and anxiety (BAI) and a global self-rated symptom severity scale (CGI). The SOS-10 also had significant correlations with the Health, Basic needs, Relationship, and Leisure time domains of the Czech version of the Subjective Quality of Life Analysis (SQUALA-CZ). The scale discriminated well between patients and controls, with patients scoring significantly lower on all SOS items. The patient sample's admission and discharge scores were significantly different, indicating that the scale is sensitive to treatment changes. We concluded that the Czech SOS-10 is valid with reliability and factor structure similar to the American language version.
In this review, the historical process leading to the current status of outcome measurements will be discussed and the recent quality-of-life instruments to explore the mental, emotional, and social "hidden morbidity" of children with juvenile arthritis will be analyzed.
The recently concluded Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) was a randomized clinical trial of percutaneous coronary intervention versus coronary bypass graft surgery among patients with medically refractory ischemia who were at high risk for coronary bypass graft surgery because of > or =1 risk factors that included severely reduced left ventricular (LV) function, defined as LV ejection fraction <35%. This study reports the outcome of patients with LV ejection fraction <35% in the randomized clinical trial and the physician-directed and patient choice registries of the AWESOME study.
A cohort comprising 495 heroin users were interviewed for the Australian Treatment Outcome Study and were re-interviewed at 12-month follow-up. The rate of current major depression declined significantly from 26% to 11% for the follow-up period. Those with current major depression on follow-up experienced fewer total days in treatment, but engaged in more treatment episodes. In comparison to those without depression, depressed individuals had less exposure to methadone/buprenorphine maintenance and residential rehabilitation for the follow-up period, but spent more time in detoxification. Those with current major depression on follow-up also reported heavier heroin and other drug use, more risk-taking behaviors, poorer physical health, and greater psychopathology than those without a diagnosis of current major depression. Although caution in interpreting these relationships is advised given the potential for confounding by client characteristics, the findings of this study illustrate the need to consider depression in the treatment of heroin dependence.
PURPOSE: For patients hospitalized with serious illnesses, we identified factors associated with a stated preference to forgo cardiopulmonary resuscitation (CPR), examined physician-patient communication about these issues, and determined the relationship of patients' preferences to intensity of care and survival. PATIENTS AND METHODS: The study was a cross-sectional evaluation of patient preferences. The setting was five geographically diverse academic acute-care medical centers participating in the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) project. Study participants were hospitalized patients > or = 18 years of age with 1 of 9 serious illnesses who were interviewed between days 3 and 6 after qualifying for the study. Using standardized interviews, patients provided information on demographics, preferences for CPR and other treatments, quality of life, functional status, perceptions of prognosis, and whether the patient had discussed CPR preferences with his or her physician. Data abstracted from the medical record included physiologic measures, therapeutic intensity, whether CPR was provided, and whether there was a do-not-resuscitate order. RESULTS: Of 1,995 eligible patients, 84% were interviewed (mean age 62 years, 58% men, inhospital mortality 7%, 6-month mortality 33%). Of the respondents, 28% did not want CPR. Factors associated independently with not wanting CPR included: hospital site; diagnosis; being older; being more functionally impaired; and patient perception of a worse prognosis. Only 29% of patients had discussed their preferences with their physician; 48% of those who did not want CPR reported such discussions. After adjusting for illness severity and factors associated with CPR preferences, patients not wanting CPR had lower intensity of care; similar inhospital mortality; and higher mortality at 2 and 6 months following study entry. CONCLUSIONS: The diagnosis, patients' perception of the prognosis, and hospital site were significantly associated with patients' resuscitation preferences after adjusting for patient demographics, severity of illness, and functional status. The rate of discussing CPR was low even for patients who did not want CPR. Patient preferences not to receive CPR were associated with a small decrease in intensity of care but no difference in hospital survival.
OBJECTIVES: The purpose of this study was to examine the epidemiology of transurethral resection of the prostate (TURP) and associated risks among Medicare beneficiaries during the period of 1984 to 1990. METHODS: Medicare hospital claims for a 20% national sample of Medicare beneficiaries were used to identify TURPs performed during the study period. All reported rates were adjusted to the composition of the 1990 Medicare population. Risks of mortality and reoperation were evaluated using life-table methods. RESULTS: The age-adjusted rate of TURP reached a peak in 1987 and declined thereafter. Similar trends were observed for all age groups. In 1990, the rates of TURP (including all indications) were approximately 25, 19, and 13 per 1000 for men over the age of 75, 70 to 74, and 65 to 69, respectively. The 30-day mortality following TURP for the treatment of benign prostatic hyperplasia (BPH) decreased from 1.20% in 1984 to 0.77% in 1990 (linear trend, p = 0.0001). The cumulative incidence of a second TURP among men with BPH has likewise decreased steadily over time; in this study, the average was 7.2% over 7 years (5.5% when the indication for the second TURP was restricted to BPH only). CONCLUSIONS: The rate of TURP has been declining since 1987, conceivably due to increasing availability of alternative treatments or changes in treatment preferences of patients and physicians. Over the same period, the outcomes following TURPs have improved, perhaps due to improved surgical care and changes in patient selection.
What is the National Cancer Institute (NCI) doing to enhance the state of the science for measuring and understanding patient-centered outcomes of cancer care and to make this information useful for improved decision making? The NCI has a new focus on research that describes, interprets, and predicts the impact of various influences, especially interventions, on end points that matter to decision makers. The research includes end points such as survival, health-related quality of life, satisfaction and patient experience, and economic burden. To further this work, NCI supports and conducts research to (1) identify valid, reliable, responsive, and feasible end-point measures; (2) collect high-quality evidence about the impact of interventions on the end points of interest; (3) improve our understanding of the effects of other factors that shape this interaction; and (4) expand our capacity to translate research findings into information that is useful to patients, clinical policy makers, payers, regulators, standard setters, and providers of cancer care.
BACKGROUND: A near-total shift to cataract extraction on an outpatient basis occurred as a result of an administrative ruling by the Health Care Financing Administration. No national study has been conducted to assess the possible effects of that decision on clinical outcomes of surgery. The authors compared the rates of retinal detachment (RD) repair and hospitalization for endophthalmitis after extracapsular cataract extraction (ECCE) (including phacoemulsification) in 1986 and 1987 with those following inpatient cataract extraction in 1984. METHODS: Using the 5% random sample of Medicare beneficiaries, we analyzed the claims of all individuals 66 years of age or older who underwent ECCE by nuclear expression or phacoemulsification in 1986 and 1987. A total of 57,103 patients were identified and followed to the end of 1988. Cumulative probability of RD repair and hospitalization for endophthalmitis was calculated by standard lifetable methods. These findings were compared with the cumulative probability of the same complications in a cohort of 330,000 patients who underwent cataract extraction on an inpatient basis in 1984. RESULTS: In the 1986-to-1987 cohort, the cumulative probability of RD within 3 years after cataract surgery was 0.81% and the cumulative probability of endophthalmitis within 1 year was 0.08%. The rate of RD is similar to that which we previously reported for 330,000 patients who underwent inpatient surgery in 1984, but the rate of endophthalmitis is significantly lower in the 1986-to-1987 outpatient cohort (0.08% versus 0.12%; z = 2.42; P = 0.01). CONCLUSIONS: The shift to outpatient cataract surgery was accompanied by no significant increase in the probability of RD repair and possibly a significant decrease in the rate of hospitalization for endophthalmitis.
A prospective cohort study was undertaken to observe the long-term outcome of different treatments for palmar wrist ganglia. One hundred and eighty-two patients agreed to participate in the study. One hundred and fifty-five patients (88%) responded at 2 or 5 years. Seventy-nine had been treated by surgical excision, 39 by aspiration and 38 by reassurance alone. At 5 years no significant differences were observed in the recurrence rates which were 42% after excision of a palmar wrist ganglion and 47% (19 of 39) after aspiration. Twenty of the 39 untreated ganglia had disappeared spontaneously. Eighty-five per cent of the patients were satisfied irrespective of treatment. Patients having surgery had a complication rate of 20% and took more time off work (14 days). Significantly more patients in the untreated group felt the persistent ganglion was unsightly. The patient evaluation measure scores were similar. At 2 and 5 year follow-up, regardless of treatment, no difference in symptoms was found, regardless of whether the palmar wrist ganglion was excised, aspirated or left alone. One in four wrists remained weak regardless of treatment or disappearance of the ganglion.
OBJECTIVE: Because difficult vaginal delivery is more frequent with macrosomic fetuses, some authors recommend routine caesarean section for the delivery of fetuses >4500 g. The purpose of this study was to evaluate the appropriateness of this recommendation, in particular, to analyze maternal and fetal complications according to the mode of delivery. METHOD: Maternal and neonatal records of 100 infants with weights of at least 4500 g were identified retrospectively from January 1991 to December 1996. Outcome variables included the mode of delivery and the incidence of maternal and perinatal complications. RESULTS: The study sample consisted of 100 infant and mother pairs. Macrosomic fetuses represented 0.95% of all deliveries during this period and only ten were >5000 g. Mean birth weight was 4730 g (maximum, 5780 g). Gestational diabetes was present in nineteen patients. Diabetes was present in three patients. A trial of labour was allowed in 87 women, and elective caesarean delivery was performed in thirteen patients. The overall cesarean rate, including elective caesarean delivery and failed trial of labour, was 36%. Of those undergoing a trial of labour, 73% (64/87) delivered vaginally. Shoulder dystocia occurred fourteen times (22% of vaginal deliveries) and it was the most frequent complication in our series. There were five cases of Erb's palsy, one of which was associated with humeral fracture, and four cases of clavicular fracture. By three months of age, all affected infants were without sequelae. There was no related perinatal mortality and only two cases of birth asphyxia. Maternal complications with vaginal delivery of macrosomic infants included a high incidence of lacerations requiring repair (eleven cases). No complications were noticed in the patients who had a caesarean section. CONCLUSION: Vaginal delivery is a reasonable alternative to elective cesarean section for infants with estimated birth weights of less than 5000 g and a trial of labour can be offered. For the fetuses with estimated birth weight >5000 g, an elective caesarean section should be recommended, especially in primiparous women.
The purpose of this study was to examine the relationship between the Harris Hip Score (HHS), a traditional method of patient assessment of a total hip arthroplasty (THA), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), a commonly used health-related quality-of-life survey. One hundred forty patients returning for routine clinical follow-up evaluation of a primary THA were asked to fill out the SF-36 quality-of-life survey, as well as questions concerning their perceptions of their THA. The patient's surgeon assessed the THA with the traditional HHS. The correlations between the HHS and the SF-36 domains were highest in the physical component summary scores for male patients of all ages and female patients 65 years of age or older. The correlations were lower for the mental component summary scores of all patients, but particularly in female patients younger than 65. When the SF-36 scores were compared with age and sex-matched population norms, both age and sex were found to be important. Men younger than 65 had scores lower than norms in the physical function domains, but were comparable in the mental health domains. The older men had scores comparable to the norms in all domains. Female patients of all ages, however, had lower scores in the physical function domains. The greatest differences were noted in the female patients younger than 65. The HHS is commonly used to assess disease-specific pain and function in THA patients; however, the results of this study suggest that the SF-36 health survey can capture additional important quality-of-life domains that are influenced by a THA and that these domains are influenced by the age and sex of the patient. The combination of a disease-specific scoring system and a quality-of-life survey would allow a more global assessment of a THA in all patients. Studies evaluating the results of THAs should either assess the results of male and female patients separately when sample size is sufficiently large or use sex as a possible covariate in a multivariate analysis.
Scientific evidence shows that correct contraceptive use will prevent unintended pregnancy and the provision of contraceptives is recognized as a cost-effective intervention. This could encourage health authorities to keep investing more resources in family planning until the target rate of unintended pregnancies is reached, but if this was the only approach taken, the target rate never would be reached. Clinicians and their public health colleagues need to examine their practice in the light of all available evidence. Once desirable changes of practice are identified, local relevant health outcome measures need to be used to assess the effectiveness of the chosen approaches. Blunt factors, such as the unintended pregnancy rate in a city or region, will not suffice to inform individuals whether they are contributing to the overall picture.
BACKGROUND: Anemia is common in hemodialysis (HD) patients. METHODS: Data collected from nationally representative samples of HD patients (n = 11,041) in 2002 to 2003 were used to describe current anemia management for long-term HD patients at 309 dialysis units in 12 countries. Analyses of associations and outcomes were adjusted for demographics, 15 comorbid classes, laboratory values, country, and facility clustering. RESULTS: For patients on dialysis therapy for longer than 180 days, 23% to 77% had a hemoglobin (Hgb) concentration less than 11 g/dL (<110 g/L), depending on country; 83% to 94% were administered erythropoietin (EPO). Mean Hgb levels were 12 g/dL (120 g/L) in Sweden; 11.6 to 11.7 g/dL (116 to 117 g/L) in the United States, Spain, Belgium, and Canada; 11.1 to 11.5 g/dL (111 to 115 g/L) in Australia/New Zealand, Germany, Italy, the United Kingdom, and France; and 10.1 g/dL (101 g/L) in Japan. Hgb levels were substantially lower for new patients with end-stage renal disease, and EPO use before ESRD ranged from 27% (United States) to 65% (Sweden). By patient, EPO use significantly declined with greater Hgb concentration (adjusted odds ratio, 0.61 per 1-g/dL [10-g/L] greater Hgb level; P < 0.0001), as did EPO dosage. Case-mix-adjusted mortality and hospitalization risk declined by 5% and 6% per 1-g/dL greater patient baseline Hgb level (P < or = 0.003 each), respectively. Furthermore, patient mortality and hospitalization risks were 10% to 12% lower for every 1-g/dL greater facility mean Hgb level. Patients were significantly more likely to have Hgb levels of 11 g/dL or greater (> or =110 g/L) if they were older; were men; had polycystic kidney disease; had greater albumin, transferrin saturation, or calcium levels; were not dialyzing with a catheter; or had lower ferritin levels. Facilities with greater intravenous iron use showed significantly greater facility mean Hgb concentrations. Mean EPO dose varied from 5,297 (Japan) to 17,360 U/wk (United States). Greater country mean EPO doses were significantly associated with greater country mean Hgb concentrations. Several patient characteristics were associated with greater EPO doses. Even in some countries with high intravenous iron use, 35% to 40% of patients had a transferrin saturation less than 20% (below guidelines). CONCLUSION: These findings indicate large international variations in anemia management, with significant improvements during the last 5 years, although many patients remain below current anemia guidelines, suggesting large and specific opportunities for improvement.