Measuring prognosis and case mix in hospitalized elders. The importance of functional status

OBJECTIVE

Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients' activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses.

SETTING

The general medical service of a teaching hospital.

PARTICIPANTS

Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women).

MEASUREMENTS

Independence in ADL function on admission was assessed by interviewing each patient's primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent.

MAIN RESULTS

ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS. Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1-58.8), 1-year mortality (OR 4.4; 2.7-7.4), and 90-day nursing home use (OR 14.9; 6.0-37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both.

CONCLUSIONS

ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case-mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.

Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons

BACKGROUND

Older patients often have poor health status outcomes after hospitalization. Symptoms of depression are common in hospitalized older persons and may be a risk factor for these poor outcomes.

OBJECTIVE

To determine whether symptoms of depression predict worse health status outcomes in acutely ill, older medical patients, independent of health status and severity of illness at hospital admission.

DESIGN

Prospective cohort study.

SETTING

Medical service of a teaching hospital.

PATIENTS

572 hospitalized medical patients older than 70 years of age.

MEASUREMENTS

15 symptoms of depression, health status, and severity of illness were measured at admission. The main outcome was dependence in basic activities of daily living at discharge and 30 and 90 days after discharge. Other outcome measures were dependence in instrumental activities of daily living, fair or poor global health status, and poor global satisfaction with life.

RESULTS

The median number of symptoms of depression on admission was 4. Patients with 6 or more symptoms on admission (n = 196) were more likely than patients with 0 to 2 symptoms (n = 181) to be dependent in basic activities of daily living (odds ratio, 2.47 [95% CI, 1.58 to 3.86]) after controlling for demographic characteristics and severity of illness. At each subsequent time point, patients with more symptoms of depression on admission were more likely to be dependent in basic activities of daily living. This association persisted after adjustment for dependence in basic activities of daily living, severity of illness, and demographic characteristics on admission. The odds ratios comparing patients who had 6 or more symptoms with those who had 0 to 2 symptoms were 3.23 (CI, 1.76 to 5.95) at discharge, 3.45 (CI, 1.81 to 6.60) 30 days after discharge, and 2.15 (CI, 1.15 to 4.03) 90 days after discharge. At each time point, patients with 6 or more symptoms of depression were more likely to have more dependence in instrumental activities of daily living, worse global health status, and less satisfaction with life.

CONCLUSIONS

Symptoms of depression identified a vulnerable group of hospitalized older persons. The health status of patients with more symptoms of depression was more likely to deteriorate and less likely to improve during and after hospitalization. This association was not attributable to health status or severity of illness on admission. The temporal sequence and magnitude of this association, its consistency over time with different measures, and its independence from the severity of the somatic illness strongly support a relation between symptoms of depression on admission and subsequent health status outcomes.

Health services research and the endocrinologist

This article highlights the importance of health services research to endocrinologists. The content and goals of health services research are defined, and, with examples related to endocrinology, the field's focus and key themes are described and its methods and sources of data delineated. Considerations that informed readers should keep in mind when reading this literature are illustrated, with a recent example that has important implications for the role of endocrinologists in the management of diabetic patients.

Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation

OBJECTIVE

To determine how often warfarin was prescribed to patients with nonrheumatic atrial fibrillation in our community in 1992 when randomized trials had demonstrated that warfarin could prevent stroke with little increase in the rate of hemorrhage, and to determine whether warfarin was prescribed less frequently to older patients-the patients at highest risk of stroke but of most concern to physicians in terms of the safety of warfarin.

DESIGN

Cross-sectional study. Appropriateness of warfarin was classified for each patient based on the independent judgments of three physicians applying relevant evidence and guidelines.

SETTING

Two teaching hospitals and five community-based practices.

PATIENTS

Consecutive patients with nonrheumatic atrial fibrillation (n = 189).

MEASUREMENTS AND MAIN RESULTS

Warfarin was prescribed to 44 (23%) of the 189 patients. Warfarin was judged appropriate in 98 patients (52%), of whom 36 (37%) were prescribed warfarin. Warfarin was prescribed to 11 (14%) of 76 patients aged 75 years or older with hypertension, diabetes mellitus, or past stroke, the group at highest risk of stroke. In a multivariable logistic regression model controlling for appropriateness of warfarin and other patient characteristics, patients aged 75 years or older were less likely than younger patients to be treated with warfarin (odds ratio 0.25; 95% confidence interval 0.10, 0.65).

CONCLUSIONS

Warfarin was prescribed infrequently to these patients with nonrheumatic atrial fibrillation, especially the older patients and even the patients for whom warfarin was judged appropriate. These findings indicate a substantial opportunity to prevent stroke.

Why isn't warfarin prescribed to patients with nonrheumatic atrial fibrillation?

OBJECTIVE

To determine the opinions of selected physicians in our community about use of warfarin for patients with nonrheumatic atrial fibrillation, and to determine the relation of the physicians' opinions to their practices.

DESIGN

Survey of physicians, using eight hypothetical clinical vignettes to characterize physicians' opinions about use of warfarin in patients with nonrheumatic atrial fibrillation, according to patient age, risk of bleeding, and risk of stroke.

SETTING

Two teaching hospitals and five community-based practices.

PARTICIPANTS

Eighty physicians who cared for 189 consecutive patients with nonrheumatic atrial fibrillation.

MEASUREMENTS AND MAIN RESULTS

The survey response rate was 73%. Nearly all responding physicians (90%) recommended warfarin for at least one vignette. However, physicians recommended warfarin less often for vignettes depicting 85-year-old patients than for matched vignettes depicting 65-year-old patients (odds ratio [OR] 0.03; 95% confidence interval [CI] 0.01, 0.08), and less often for cases with specified risk factors for bleeding than for matched cases without the risk factors (OR 0.01; 95% CI 0.004, 0.03); warfarin was recommended more often for cases with a recent stroke than for matched cases without this history (OR 8.2; 95% CI 3.6, 18). In practice, warfarin was prescribed more often (p < or = .05) by physicians reporting good personal experience and by those who had favorable opinions about its use. However, even physicians with good experience and favorable opinions did not prescribe warfarin to half of their patents for whom warfarin was independently judged appropriate.

CONCLUSIONS

Physicians' opinions frequently opposed warfarin for older patients with nonrheumatic atrial fibrillation, and for those with bleeding risk factors. Physicians' opinions, as well as other barriers to warfarin therapy, most likely contribute to its infrequent prescription.

Is economic hardship on the families of the seriously ill associated with patient and surrogate care preferences? SUPPORT Investigators

BACKGROUND

Serious illness often causes economic hardship for patients' families. However, it is not known whether this hardship is associated with a preference for the goal of care to focus on maximizing comfort instead of maximizing life expectancy or whether economic hardship might give rise to disagreement between patients and surrogates over the goal of care.

METHODS

We performed a cross-sectional study of 3158 seriously ill patients (median age, 63 years; 44% women) at 5 tertiary medical centers with 1 of 9 diagnoses associated with a high risk of mortality. Two months after their index hospitalization, patients and surrogates were surveyed about patients' preferences for the primary goal of care: either care focused on extending life or care focused on maximizing comfort. Patients and surrogates were also surveyed about the financial impact of the illness on the patient's family.

RESULTS

A report of economic hardship on the family as a result of the illness was associated with a preference for comfort care over life-extending care (odds ratio, 1.26; 95% confidence interval, 1.07-1.48) in an age-stratified bivariate analysis. Similarly, in a multivariable analysis controlling for patient demographics, illness severity, functional dependency, depression, anxiety, and pain, economic hardship on the family remained associated with a preference for comfort care over life-extending care (odds ratio, 1.31; 95% confidence interval, 1.10-1.57). Economic hardship on the family did not affect either the frequency or direction of patient-surrogate disagreements about the goal of care.

CONCLUSIONS

In patients with serious illness, economic hardship on the family is associated with preferences for comfort care over life-extending care. However, economic hardship on the family does not appear to be a factor in patient-surrogate disagreements about the goal of care.

The annual guide to "America's best hospitals". Evidence of influence among health care leaders

To determine health care leaders' opinions about a prominent guide to hospital quality, we surveyed 82 chief executive officers (CEOs) and 80 chiefs of staff of hospitals listed in the 1994 edition of the guide and 50 directors of employer based coalitions. Most of the CEOs (87%) and chiefs of staff (86%) said the guide was used in advertising. More than three quarters of the CEOs, chiefs of staff, and coalition directors who were familiar with the guide thought it was accurate, and most indicated that key constituencies (e.g., physicians, corporate managers) were aware of the guide. Our results demonstrate the likely influence of one prominent guide to health care quality and highlight the need for formal independent assessment of such guides.

Surgery for colorectal cancer: Race-related differences in rates and survival among Medicare beneficiaries

This study examined surgery for colorectal cancer among Medicare beneficiaries 65 years of age or older with an initial diagnosis in 1987 (n = 81 579). Black patients were less likely than White to undergo surgical resection (68% vs 78%), even after age, comorbidity, and location and extent of tumor were controlled for. Among those who underwent resection, Black patients were more likely to die (a 2-year mortality rate of 40.0% vs 33.5% in White patients); this disparity also remained after confounders had been controlled. The disparities were similar in teaching and nonteaching hospitals and in private and public hospitals. These data may indicate racially based differences among Medicare beneficiaries in access to and quality of care for colorectal cancer.

Functional outcomes of acute medical illness and hospitalization in older persons

BACKGROUND

Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization.

METHODS

A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning.

RESULTS

At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized.

CONCLUSION

This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.

Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization

OBJECTIVES

To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization.

DESIGN

Multi-center prospective cohort study.

SETTING

Four university and two private non-federal acute care hospitals.

PATIENTS

The development cohort consists of 448 patients and the validation cohort consists of 379 patients who were aged 70 and older and who were hospitalized for acute medical illness between 1989 and 1992.

MEASUREMENTS

All patients were evaluated on hospital admission to identify baseline demographic and functional characteristics and were then assessed at discharge and 3 months after discharge to determine decline in ADL functioning.

RESULTS

Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL function. A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories. The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively. Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge.

CONCLUSION

Hospital Admission Risk Profile (HARP) is a simple instrument that can be used to identify patients at risk of functional decline following hospitalization. HARP can be used to identify patients who might benefit from comprehensive discharge planning, specialized geriatric care, and experimental interventions designed to prevent/reduce the development of disability in hospitalized older populations.

Nurse practitioners in a teaching hospital

The development of a model of care using acute care nurse practitioners in a teaching hospital and the integration of the nurse practitioner into an alternative model of care delivery are discussed. Issues in implementation include lack of understanding about the nurse practitioner role on the part of other members of the health care team, legislative constraints, and the administrative restrictions of teaching hospitals. Education of nurses and physicians regarding the scope of practice of the nurse practitioner role, departmental policy changes, and the development of protocols facilitate the efficiency and utilization of the nurse practitioner in this setting. Specific concerns surrounding costs of a nurse practitioner service and practice differences between the clinical nurse specialist and the acute care nurse practitioner are addressed. Nurse practitioner models of care delivery, which address quality, cost-effective care are on the forefront of tomorrow's health care.

Long-term outcomes of deep-vein thrombosis

OBJECTIVE

To assess the long-term outcomes of patients with acute deep-vein thrombosis.

METHODS

We followed up 124 patients with deep-vein thrombosis 6 to 8 years after the index thrombosis to determine the frequency of death, recurrent venous thromboembolism, postphlebitic symptoms, and their relationship to three domains of health-related quality of life.

RESULTS

Fifty-two (42%) of the 124 patients died. The cumulative incidence of death was 17% at 1 year and 39% at 5 years. Death was especially common among patients older than 75 years and those with cancer or stroke (5-year cumulative incidence, 66%, compared with 12% among other patients; P < .0001). Most deaths were attributable to cancer or cardiovascular disease. Venous thromboembolism recurred in 18 patients (15%); the cumulative incidence was 6% at 1 year and 13% at 5 years. Recurrence was more common, however, among patients younger than 65 years with a history of recurrent venous thromboembolism (5-year cumulative incidence, 34%, compared with 10% among other patients; P < .01). In interviews with 52 patients 6 to 8 years after the index deep-vein thrombosis, 42% reported pain, swelling, or discoloration in the leg affected by the index thrombosis. Perceptions of health, physical functioning, and role limitations attributed to physical health were worse (P < .01 for each domain) in symptomatic patients than in asymptomatic patients.

CONCLUSIONS

Six to 8 years after deep-vein thrombosis, many patients had died of preexisting cancer or cardiovascular disease. Recurrent venous thromboembolism was uncommon. Symptoms in the leg affected by the index thrombosis were common, however, and were associated with worse health-related quality of life.

A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients

BACKGROUND

Older persons who re hospitalized for acute illnesses often lose their independence and are discharged to institutions for long-term care.

METHODS

We studied 651 patients 70 years of age or older who were admitted for general medical care at a teaching hospital; these patients were randomly assigned to receive usual care or to be cared for in a special unit designed to help older persons maintain or achieve independence in self-care activities. The key elements of this program were a specially prepared environment (with, for example, uncluttered hallways, large clocks and calendars, and handrails); patient-centered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; discharge planning with the goal of returning the patient to his or her home; and intensive review of medical care to minimize the adverse effects of procedures and medications. The main outcome we measured ws the change from admission to discharge in the number of five basic activities of daily living (bathing, getting dressed, using the toilet, moving from a bed to a chair, and eating) that the patient could perform independently.

RESULTS

Twenty-four patients in each group died in the hospital. At the time of discharge, 65 (21 percent) of the 303 surviving patients in the intervention group were classified as much better in terms of their ability to perform basic activities of daily living, 39 (13 percent) as better, 151 (50 percent) as unchanged, 22 (7 percent) as worse, and 26 (9 percent) as much worse. In the usual care group, 40 (13 percent) of the 300 surviving patients were classified as much better, 33 (11 percent) as better, 163 (54 percent) as unchanged, 39 (13 percent) as worse, and 25 (8 percent) as much worse (P = 0.009). The difference between the groups remained significant (P = 0.04) in a multivariable model in which we controlled for potentially confounding base-line characteristics of the patients. Lengths of stay and hospital charges were similar in the two groups. Fewer patients assigned to the intervention group were discharged to long-term care institutions (43 patients [14 percent], as compared with 67 patients [22 percent] in the usual-care group; P = 0.01). Among the 493 patients discharged to private homes, similar proportions (about 10 percent) in the two groups were admitted to long-term care institutions during the three months after discharge.

CONCLUSIONS

Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of acutely ill older patients to perform basic activities of daily living at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care.

Cultures of skin biopsy tissue from immunocompromised patients with cancer and rashes

BACKGROUND AND DESIGN

Microbiological cultures of skin biopsy tissue are often recommended in immunocompromised patients with cancer and rashes, but in a previous study, they were usually sterile or grew clinically insignificant organisms. To examine the use and bacteriological results of these cultures more comprehensively, we reviewed records from all immunocompromised adults with cancer and acute rash on which skin biopsy was performed during 39 months on a bone marrow transplantation/acute leukemia unit of a university hospital (108 episodes of rash in 80 patients).

RESULTS

Of the 158 cultures that were performed, one (1%; 95% confidence interval [CI], 0% to 4%) was a true positive; 11 (7%; 95% CI, 3% to 13%) were false positive; 143 (91%; 95% CI, 87% to 95%) were true negative; and three (2%; 95% CI, 1% to 6%) were false negative. Thus, the sensitivity of culture was 0.25, and the specificity was 0.93. Coagulase-negative Staphylococcus was the single pathogenic organism that grew, yet was judged to be a contaminant in three episodes. Among the 95 rashes in which fewer than four types of culture were performed, viral culture may have been helpful in one case (1%; 95% CI, 0% to 6%).

CONCLUSIONS

Cultures of skin tissue from immunocompromised cancer patients with rashes were often unable to diagnose infection or the absence of infection. Clinical judgement was crucial to the interpretation of culture results.

Predicting future functional status for seriously ill hospitalized adults. The SUPPORT prognostic model

OBJECTIVE

To develop a model estimating the probability of an adult patient having severe functional limitations 2 months after being hospitalized with one of nine serious illnesses.

DESIGN

Prospective cohort study.

SETTING

Five teaching hospitals in the United States.

PARTICIPANTS

1746 patients (model development) who survived 2 months and completed an interview, selected from 4301 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT); independent validation sample of 2478 patients.

MEASUREMENTS AND MAIN OUTCOMES

Patient function 2 months after admission categorized as absence or presence of severe functional limitations (defined as Sickness Impact Profile scores > or = 30 or as activities of daily living scores > or = 4 [levels that require near-constant personal assistance]). A logistic regression model was constructed to predict severe functional limitation.

RESULTS

One third (n = 590) of patients who were interviewed at 2 months had severe functional limitations. Changes in functional status were common: Of those with no baseline dependencies (not dependent on personal assistance), 21% were severely limited at 2 months; of those with 4 or more baseline limitations, 30% had improved. The patient's ability to do activities of daily living was the most important predictor of functional status. Physiologic abnormalities, diagnosis, days in hospital, age, quality of life, and previous exercise capacity also contributed substantially. Model performance, assessed using receiver-operating characteristic curves, was 0.79 for the development sample and 0.75 for the validation sample. The model was well calibrated for the entire risk range.

CONCLUSIONS

Functional outcome varied substantially after hospitalization for a serious illness. A small amount of readily available clinical information can estimate the probability of severe functional limitations.

A national population-based study of incidence of colorectal cancer and age. Implications for screening in older Americans

BACKGROUND

Population-based screening programs with flexible sigmoidoscopy have been advocated as a means to reduce the death rate from colorectal cancer. Because other studies have suggested a greater prevalence of lesions inaccessible to sigmoidoscopy in older patients, the expected yield of this procedure may differ in these subgroups.

METHODS

A 100% sample of Medicare beneficiaries 65 years or older with a first known diagnosis of colorectal cancer in 1987 was studied. Tumor site was divided into rectum, distal colon (distal to splenic flexure) and proximal colon. The analysis was also stratified by sex, race, and presence or absence metastatic disease, and incidence rates at each site by 5-year age group were calculated.

RESULTS

Among the 75,266 patients studied, the incidence of colorectal cancer increased from 1.59 patients/1000 in patients age 65-69 years to 3.87 patients/1000 in patients age 85 years and older. Although the incidence rates at all three sites increased, the increment was greatest for proximal tumors. The incidence trends with age also persisted in an analysis of only metastatic lesions. Moreover, incidence rates were consistently higher in men than in women and higher in whites than in blacks at all sites, though the age-related increase in incidence was consistent among all four groups.

CONCLUSIONS

The proportion of tumors beyond the reach of sigmoidoscopy increased with age, as did the actual incidence of accessible lesions. These patterns were also consistent in subgroup analyses. As the age-related increase in incidence was observed for metastatic tumors at all sites in the colon, age-related differences in screening and diagnostic evaluation alone do not adequately explain the findings. These data underscore the need for further studies of the relative benefits of cancer screening and pathogenic factors in tumor development in different subgroups of the older population.

Predictive validity of the Nursing Severity Index in patients with musculoskeletal disease. Nurses of University Hospitals of Cleveland

Prior studies have not examined the validity of severity of illness instruments in patients at low risk for mortality. We, therefore, examined the predictive validity of a newly developed instrument, the Nursing Severity Index in 5347 adult medical and surgical patients with musculoskeletal diagnoses admitted to an academic medical center in 1985-88. The Index is based on aggregating 34 clinical observations which were recorded by primary nurses during patient care; observations reflect biologic, functional, cognitive and psychosocial abnormalities. Other data, including patient demographic data and outcomes were obtained from hospital data bases. We found that, among all study patients, admission Nursing Severity Index scores were highly related (p < 0.001) to in-hospital death rates-which were 0, 0.4, 0.8, 2.6, 6.7 and 23.5% in six hierarchical strata defined by the Index-and to nursing home discharge rates. In multivariate analyses, adjusting for diagnosis and other important covariates, each strata was associated with a 2.5-fold increased risk of mortality and a 1.6-fold increased risk of nursing home discharge. In addition, the Nursing Severity Index was an independent predictor (p < 0.001) of hospital charges and length of stay. We conclude that the Nursing Severity Index assesses multiple dimensions of illness, can be easily recorded during routine patient care, and accurately predicts hospital outcomes in an important 'low risk' group of patients. The validity of the Nursing Severity Index in other clinical subgroups should be further studied.

Anticoagulants in older patients. A safety perspective

Although anticoagulants are beneficial in the prevention and management of many thromboembolic disorders, they can cause serious bleeding. However, the risk of anticoagulant-related bleeding is not clearly defined for older patients, who are likely to benefit the most from anticoagulant therapy. Older patients may be at increased risk for anticoagulant-related bleeding because of their increased incidence of adverse drug reactions, increased prevalence of comorbidity and polypharmacy and increased vascular and endothelial fragility. Furthermore, the anticoagulant effect of warfarin is increased in older patients. Therefore, it is important to determine whether or not heparin-related and warfarin-related bleeding are more common in older patients. Most studies that have examined age as a risk factor for heparin-related bleeding have found bleeding to be more frequent in older patients: patients 60 years and older were approximately 3 times as likely to develop bleeding during heparin therapy than were younger patients. Studies that have examined age as a risk factor for warfarin-related bleeding have found conflicting results. Seven studies, enrolling a total of 14,388 patients, found that older patients were approximately twice as likely to bleed during warfarin therapy. In contrast, 7 studies, enrolling a total of 2940 patients, found no increase in the frequency of warfarin-related bleeding in older patients. These findings provide a basis for weighing the risks of anticoagulant therapy and for making decisions about the use of anticoagulants in older patients. These findings also indicate the potential value of methods to decrease the frequency of anticoagulant-related bleeding in older patients. Such methods include maintaining the anticoagulant effect within the therapeutic range and recognising other modifiable factors, such as medication use, that may promote bleeding.

A cost analysis of topical drug regimens for dermatophyte infections

OBJECTIVE

To examine the extra cost of using higher-priced drugs as initial therapy for dermatophyte infections, because the many available effective drugs vary considerably in cost.

DESIGN

Cost analysis from the purchaser's perspective, comparing two prototypical regimens to treat tinea pedis: one in which all patients initially receive a lower-priced drug and those with unresponsive infections receive a higher-priced drug at a follow-up office visit, and one in which all patients receive the higher-priced drug from the outset. The reference drug was miconazole, an imidazole available without a prescription, for which reported overall efficacy rates are 70% to 100%.

MAIN OUTCOME MEASURES

The threshold efficacy rate (the efficacy rate of miconazole below which it is always less expensive to use a specific higher-priced drug first) and the extra cost (of beginning therapy with a higher-priced drug).

RESULTS

Assuming the Medicare-approved charge for a follow-up visit ($21.98), it is less expensive to begin therapy with a prescription drug only if the efficacy rate of miconazole is less than 55%; this threshold efficacy rate varied from 26% (for a $0 total cost of the follow-up visit) to 79% (for an $89 total cost of the follow-up visit). If the efficacy rate of miconazole is 70%, the extra cost per patient for all patients to receive the least expensive prescription antifungal drug instead of miconazole first was $15.23 and $8.64 if total visit costs were $0 and $21.98; miconazole remained the less expensive alternative as long as the total cost of the follow-up visit was less than $50.76.

CONCLUSION

For reported efficacy rates and standard costs of a follow-up office visit, using miconazole first and then treating only those patients with unresponsive infections with a higher-priced prescription drug is less expensive than treating all patients with the higher-priced drug.

A medical unit for the acute care of the elderly

Older patients often experience a loss of independent physical functioning during the course of an acute illness requiring hospitalization. This functional decline is associated with serious sequelae including prolonged hospital stay, nursing home placement, and mortality. Elements of hospitalization may contribute to the progression or persistence of functional decline. The Unit for Acute Care of the Elderly (ACE Unit) at University Hospitals of Cleveland is an acute care general medical service that is designed to foster the independent functioning of patients. The Prehab Program of Patient Centered Care on the ACE Unit is a multifaceted intervention that integrates geriatric assessment into the optimal medical and nursing care of patients in an interdisciplinary environment. The Prehab Program has several key elements tailored to each individual patient's needs: a prepared environment, patient-centered care, multidimensional assessment and nonpharmacologic prescriptions, medical care review, and home planning. Standards of care serve to reduce the risk of iatrogenic illness resulting from polypharmacy, use of physical restraints, and diagnostic procedures. Nurse-initiated guidelines contribute to prevention of functional decline and to restoration of independent patient functioning. The effectiveness of the ACE Unit is being evaluated in a randomized clinical trial.