Validation of a combined comorbidity index

Assessment of mortality after long-term follow-up of patients with community-acquired pneumonia

Although studies have assessed short-term mortality among patients with community-acquired pneumonia, there is limited data on prognosis and risk factors that affect long-term mortality. The mortality among patients enrolled at 4 sites of the Pneumonia Patient Outcome Research Team cohort study who survived at least 90 days after presentation to the hospital was compared with that among age-matched control subjects. Overall, 1419 of 1555 patients survived for >90 days, with a mean follow-up period of 5.9 years. There was significantly higher long-term mortality among patients with pneumonia than among age-matched controls. Factors significantly associated with long-term mortality were age (stratified by decade), do-not-resuscitate status, poor nutritional status, pleural effusion, glucocorticoid use, nursing home residence, high school graduation level or less, male sex, preexisting comorbid illnesses, and the lack of feverishness. This study demonstrates that there is significantly higher long-term mortality among patients with pneumonia than among age-matched controls and that long-term mortality largely is not affected by acute physiologic derangements.

End-stage renal disease in Scotland: Outcomes and standards of care

BACKGROUND

The number of patients starting renal replacement therapy (RRT) for end-stage renal disease (ESRD) in the United Kingdom rises annually. Patients are increasingly elderly with a greater prevalence of comorbid illness. Unadjusted survival, from the time of starting RRT, is not improving. The United Kingdom Renal Association has published recommended standards of treatment, which all United Kingdom nephrologists strive to attain. This study was devised to define the impact of attaining recommended treatment standards, adjusting for patient age and comorbid illnesses, upon survival on RRT in the United Kingdom population.

METHODS

A prospective, registry based, observational study of all patients starting RRT in Scotland over a 1-year period, followed for the first 2 years of RRT.

RESULTS

Of the 523 patients who were studied, 217 (41.5%) had died by 2 years of follow-up, 32% excluding deaths within the first 90 days. Age, comorbidity, weight when starting RRT, and attaining the recommended standards for albumin and hemoglobin had a significant impact upon survival.

CONCLUSION

This study has emphasized the very high mortality of patients starting RRT in Scotland. By paying close attention to the attainment of recommended standards of care for patients with ESRD, it may be possible to improve upon current mortality figures. The monitoring of such success is only possible if correction is made for age and comorbidity.

Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly?

This prospective randomized trial compared the efficacy of unipolar versus bipolar hemiarthroplasty in elderly patients (> or = 65 years) with displaced femoral neck fractures in terms of quality of life and functional outcomes. One hundred fifteen patients with a mean age of 82.1 years were enrolled in this study and randomized to either unipolar or bipolar hemiarthroplasty. Quality of life and functional outcomes were assessed using the Musculoskeletal Functional Assessment instrument and Short Form-36 health survey. Seventy-eight patients completed 1 year of followup. There were no differences between the groups in estimated blood loss, length of hospital stay, mortality rate, number of dislocations, postoperative complications, or ambulatory status at 1 year. There also were no significant differences between the two groups at either point in postoperative Short Form-36 or Musculoskeletal Functional Assessment instrument scores. Results of this prospective randomized study suggest that the bipolar endoprosthesis provides no advantage in the treatment of displaced femoral neck fractures in elderly patients regarding quality of life and functional outcomes.

Tooth retention as an indicator of quality dental care: development of a risk adjustment model

BACKGROUND

Retaining teeth improves oral health and quality of life. Thus, receipt of a root canal (vs. a tooth extraction) is a useful indicator of the quality of dental care. However, use of this quality measure without adjusting for the severity of oral disease could lead to spurious conclusions.

OBJECTIVES

This paper describes the development of a dental severity adjustment methodology.

RESEARCH DESIGN

Retrospective study.

SUBJECTS

54,423 users of Department of Veterans Affairs (VA) dental care who had either root canal therapy or a tooth extraction at a VA facility in Fiscal year 1998.

MEASURES

International Classification of Disease Clinical Modification codes for dental diagnoses and comorbid medical conditions. We modeled the effects of dental disease severity in logistic regression models of the probability of receiving a root canal, using both conceptual and Modified Delphi-Panel derived models, adjusting for age, and medical comorbidities.

RESULTS

Conceptual and Modified Delphi models performed similarly. The dental disease severity adjustments increased the fit in models of the probability of receiving a root canal (C-statistic = 0.822 for the conceptual model and 0.804 for the Modified Delphi Panel model) compared with the model including comorbid medical conditions alone (C-statistic = 0.561).

CONCLUSIONS

Risk adjustment for dental disease severity improves the fit of models of the probability of receiving a root canal. Studies of the quality of dental care should consider employing risk-adjusted models.

The effect of dyadic intervention on self-efficacy, social support, and depression for men with prostate cancer

Urinary and sexual dysfunctions are side effects of radical prostatectomy (RP) for prostate cancer (PC) that contribute to depression. Despite the effectiveness of support groups at reducing depression in cancer patients, men typically do not participate in them. The purpose of this pilot study was to test the effects of a dyadic intervention (one-to-one support) on social support (Modified Inventory of Socially Supportive Behaviors), self-efficacy (Stanford Inventory of Cancer Patient Adjustment), and depression (Geriatric Depression Scale). Subjects were randomized to group. Controls (N=15; Mage=59.7) received usual care. Experimentals were paired with long-term survivors (LTS) who had RP and who had treatment side effects in common. Experimentals (N=15; Mage=57.5) met with a LTS 8 times in 8 weeks to discuss concerns associated with survivorship. No significant differences were detected on social support, but after 4 weeks, significant differences were present on depression between controls and experimentals, however these differences were not seen at 8 weeks. After 8 weeks, there were also significant differences on self-efficacy between controls and experimentals. Weekly anecdotal data supported the feasibility and acceptance of the intervention that was a low cost strategy effective at reducing depression and increasing self-efficacy in men treated by RP. Future research directions and clinical application is presented.

Five-year outcomes for dementia defined solely by neuropsychological test performance

Cognitive impairment that does not meet criteria for dementia is common and progresses to dementia at a high rate. It is not clear how best to define this type of cognitive impairment. We assessed the predictive validity of different case definitions for cognitive impairment and dementia by comparing rates of adverse outcomes for individuals who did not meet dementia criteria but had neuropsychological test results indicating dementia (NPDementia), those who had traditional dementia diagnoses (mild and moderate-severe severity), those who had other cognitive impairment but no dementia (CIND), and those with no cognitive impairment (NCI). Our sample comprised 1,659 participants who had completed a neuropsychological assessment in the Canadian Study of Health and Aging, a prospective, cohort study of 10,263 randomly selected persons aged 65 years or older. Outcomes were determined after 5 years. Institutionalization and death rates for the NPDementia and CIND groups were higher than for the NCI group. Both groups had lower institutionalization rates than the two Dementia groups and lower death rates than the Moderate-Severe Dementia group. Rates of progression to dementia were increased in NPDementia and CIND groups, relative to the NCI group, and the NPDementia group was less likely than the CIND group to revert to a diagnosis of NCI at the 5-year follow-up. Thus, individuals with NPDementia and CIND have substantially worse outcomes over 5 years than those with NCI. The case definition of NPDementia identified individuals with cognitive impairment that is unlikely to resolve and likely to progress to dementia.

Factors influencing the length of hospital stay of patients with heart failure

INTRODUCTION

Heart failure (HF) is characterised by frequent hospital admissions and prolonged length of hospital stay. Admissions for HF have increased over the last decade while length of stay has decreased; the reasons for this change in length of stay are uncertain. This study investigates the effect of patient-related variables, in-hospital progress and complications on length of stay.

METHODS

Patients admitted to Auckland Hospital general medical service and randomised into the Auckland Heart Failure Management Programme were included in this study.

RESULTS

One hundred and ninety-seven patients were included in this study. Mean age 73 years, mean left ventricular ejection fraction 32%; 52% had one or more previous HF admissions and 75% were New York Heart Association class IV at admission. Median length of hospital stay was 6 days (IQR 4, 9) which is comparable to the national average from New Zealand admission databases. Longer than average length of stay, defined as >6 days, was associated with the presence of peripheral congestion, duration of treatment with intravenous diuretic, the development of renal impairment, other acute medical problems at admission, iatrogenic complications during hospital stay, and social problems requiring intervention. Factors independently associated with length of stay in the top quartile (>10 days) on logistic regression included the presence of oedema at admission (OR 10.5), change in weight during stay (OR 1.3), duration of treatment with iv diuretic (OR 7.5), the development of renal impairment (OR 9.8), concurrent respiratory problems requiring specific treatment (OR 3.8), and social problems requiring intervention (OR 6.8).

CONCLUSIONS

Peripheral congestion, concomitant acute medical problems requiring specific treatment, the development of renal impairment and the presence of social problems were related to a longer than average length of hospital stay. Multivariate models only partly explained variance in hospital stay, suggesting the importance of pre-admission and post-discharge factors, including the healthcare environment, the availability of primary and secondary care resources, and the threshold for hospital admission.

Evaluation of Charlson's comorbidity index in elderly living in nursing homes

The object of this article was to validate the predictive value of Charlson's comorbidity index for the prediction of short-term mortality or morbidity in elderly people. The design was a cohort study comparing survival and hospitalization in institutionalized elderly people with different levels of comorbidity at baseline. The setting was 16 Flemish nursing homes for the elderly. The subjects were 2,727 inhabitants of which full data were available for 2,624. The outcome measures were hazard ratios resulting from Cox regression analysis, comparing 6 months survival in patients with moderate and a high level to low level of comorbidity. Odds ratios resulting from multiple logistic regression analysis comparing the occurrence of at least one hospitalization during the follow-up period in surviving patients of the same groups. Mortality adjusted for age group was significantly increased in patients with a moderate (HR = 2.00) and even more in those with a high level (HR = 3.62) of comorbidity. Hospitalization was more frequent in both groups (OR = 1.54 and 2.19, respectively), with statistical significance only being reached for the highest group. Adjustment for age, gender, mobility status, and disorientation did not change the general picture. Charlson's comorbidity index is a predictor of short-term mortality in institutionalized elderly patients and, to a lesser extend, also of hospitalization. These results support its use as a measure for introducing comorbidity as a covariable in longitudinal studies with a geriatric population.

[Prevalence and effects of depressive and anxiety symptoms in internal medicine inpatients during the first year after hospital discharge]

In a prospective follow-up study the German version of the Hospital Anxiety and Depression Scale (HADS) was used to determine the prevalence of anxiety and depressive symptoms in internal medicine inpatients. From a total cohort of 376 admitted study patients questionnaires were completed at admission and after one year follow-up. The data demonstrated that the mean HADS score on the anxiety subscale decreased significantly from 6.7 3.5 at study inclusion to 5.8 3.8 after one year (p < 0.0005) while the mean HADS score on the depression subscale was relatively stable (5.3 3.6 versus 5.4 4.3, p = n.s.). Odds ratios for the prediction of positive HADS results at follow-up were 4.1 (95%-CI 2.0-8.4) for anxiety symptoms and 8.2 (95%-CI 4.6-14.6) for depressive symptoms. Patients with abnormal HADS anxiety scores were significantly more frequently rehospitalized (Odds ratio 1.9; p = 0.028) and also more frequently reported pain symptoms (Odds ratio 2.0; p = 0.019). These results demonstrate the persistence of depressive symptoms and the frequent utilization of health care in internal medicine inpatients with psychiatric disorders in the first year after hospital discharge.

Resources and use of the intensive care unit in patients who undergo surgery for ovarian carcinoma

BACKGROUND

The objective of the current study was to determine the association of age, comorbid illness, and length of stay (LOS) in the intensive care unit (ICU) in women who underwent oophorectomy for ovarian carcinoma.

METHODS

The authors conducted a population-based analysis of all women with a primary or secondary diagnosis of ovarian carcinoma who underwent oophorectomy between 1994-1999. Chi-square tests and Student t tests were used to determined differences in means or proportions. Multivariate regression methods were used to build predictive models.

RESULTS

Of 8109 women who were admitted, 1412 women underwent oophorectomy, 1045 of 1412 women (74%) underwent hysterectomy, 325 of 1412 women (23%) underwent intestinal surgery, and 296 of 1412 women (21%) were admitted to the ICU. Overall (+/- standard deviation) LOS was 8.3 days +/- 6.90 days, and the total charges were $16,675 +/- $15,590 (1999 dollars). Patients who underwent intestinal surgery were older (62.5 years vs. 57.1 years; P = 0.01), had a longer LOS (11.62 days vs. 7.33 days; P = 0.01), had a longer ICU stay (1.15 days vs. 0.58 days; P = 0.01), and had a higher mean Charlson Comorbidity Index (CCI) (16.01 vs. 8.73; P = 0.01) compared with patients who did not undergo intestinal surgery. Multivariate regression analysis revealed that age, intestinal surgery, CCI, ICU stay, and African-American race were associated with LOS and contributed indirectly to total charges, whereas age and ICU say were the two most important direct determinants of total charges.

CONCLUSIONS

Advancing age, ICU stay, intestinal surgery, African-American race, and comorbid illness were the most prominent predictors of LOS, whereas age and ICU stay were the most important factors predicting total charges in women who underwent oophorectomy for ovarian carcinoma.

Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study

The purpose of this retrospective cohort study was to examine the associations among chronic kidney disease, anemia, and risk of death among patients with heart failure. Retrospective cohort study. Patients with a principal diagnosis of heart failure (ICD9 codes 402.01, 402.11, 402.91, 404.01, 404.11, 404.91, and 428.xx) were included. Chronic kidney disease (CKD) was defined as a serum creatinine >1.4 mg/dl for women and >1.5 mg/dl for men. There were 665 eligible patients in the sample with a mean (SD) age of 75.7 (10.9) yr; 60% were women, 71% were white, and 38% had CKD. On admission, a hematocrit > or =40% was found for 30.3% of the patients; 22.9% had a hematocrit between 36% and 40%, 33.2% between 30% and 35%, and 13.6% had a hematocrit of <30%. The 1-yr death rates among individuals with and without CKD were 44.9% and 31.4%, respectively (relative risk [RR], 1.43; 95% confidence interval [CI], 1.17 to 1.75). The mortality at 1 yr was 31.2% for individuals with a hematocrit > or =40%; 33.8% (RR, 1.08; 95% CI. 0.79 to 1.47) for hematocrit 36 to 39%; 36.7% (RR, 1.17; 95% CI, 0.89 to 1.54) for hematocrit between 30 and 35%; and 50.0% (RR, 1.60; 95% CI, 1.19 to 2.16) for those with a hematocrit <30% (chi(2) for trend was 7.37; P = 0.007). Both hematocrit and serum creatinine were independently associated with increased risk of death during follow-up after controlling for other patient risk factors. In conclusion, CKD and anemia are frequent among older patients with heart failure and are independent predictors of subsequent risk of death.

Resource utilization for patients undergoing hysterectomy with or without lymph node dissection for endometrial cancer

OBJECTIVE

The objective was to study the association of age, comorbid illness, race, and type of hospital with resource use in patients undergoing hysterectomy and lymph node dissection for endometrial cancer.

METHODS

The study was a population-based analysis of patients undergoing hysterectomy with a diagnosis of endometrial cancer in Maryland 1994-1996. Chi-square and t tests determined differences in means or proportions. Multivariate logistic regression methods were used to build predictive models.

RESULTS

The 1281 women underwent total abdominal hysterectomy, 91%; total vaginal hysterectomy, 6%; radical hysterectomy, 2.5%, laparoscopically assisted total vaginal hysterectomy, 0.3%; 32% also underwent lymph node dissection. Neither age, nor race, nor comorbid illness influenced admission to teaching hospitals. Co-morbidity was documented in 56% of cases. African Americans were more likely to have one (P = 0.002) or >1 co-morbid illness (P = 0.045) than Caucasians. The most common complications were anemia (13.6%), infection/fever (12%), cardiac (9.4%), pneumonia (8%), ileus (5%), and bowel obstruction (5%). These complications occurred with higher frequency in teaching hospitals (P = 0.0001), In large hospitals (P = 0.0001), and in African American patients compared to Caucasians (P = 0.028). Multivariate regression analysis revealed that older age, admission to teaching or large hospitals, lymph node dissection, heart disease, and African American race were associated with significantly higher resource use.

CONCLUSION

We documented age and racial/ethnic differences in comorbid illness, complications, and resource utilization for patients undergoing hysterectomy for endometrial cancer. The differences in resource use for teaching hospitals may be reflective of the severity of complications, which are indirectly determined by length of stay. Given the higher costs and skills required to care for elderly women with comorbid disease and complications, quantification of the complexity of care is of utmost importance for allocation of sufficient resources for the care of women with endometrial cancer.

Validation of case-mix measures derived from self-reports of diagnoses and health

Self-reported chronic diseases and health status are associated with resource use. However, few data exist regarding their ability to predict mortality or hospitalizations. We sought to determine whether self-reported chronic medical conditions and the SF-36 could be used individually or in combination to assess co-morbidity in the outpatient setting. The study was designed as a prospective cohort study. Patients were enrolled in the primary care clinics at seven Veterans Affairs (VA) medical centers participating in the Ambulatory Care Quality Improvement Project (ACQUIP). 10,947 patients, > or = 50 years of age, enrolled in general internal medicine clinics who returned both a baseline health inventory checklist and the baseline SF-36 who were followed for a mean of 722.5 (+/-84.3) days. The primary outcome was all-cause mortality, with a secondary outcome of hospitalization within the VA system. Using a Cox proportional hazards model in a development set of 5,469 patients, a co-morbidity index [Seattle Index of Co-morbidity (SIC)] was constructed using information about age, smoking status and seven of 25 self-reported medical conditions that were associated with increased mortality. In the validation set of 5,478 patients, the SIC was predictive of both mortality and hospitalizations within the VA system. A separate model was constructed in which only age and the PCS and MCS scores of the SF-36 were entered to predict mortality. The SF-36 component scores and the SIC had comparable discriminatory ability (AUC for discrimination of death within 2 y 0.71 for both models). When combined, the SIC and SF-36 together had improved discrimination for mortality (AUC = 0.74, p-value for difference in AUC < 0.005). A new outpatient co-morbidity score developed using self-identified chronic medical conditions on a baseline health inventory checklist was predictive of 2-y mortality and hospitalization within the VA system in general internal medicine patients.

A prospective evaluation of the Charlson Comorbidity Index for use in long-term care patients

OBJECTIVES

Because of the high prevalence of coexisting medical conditions in frail older adults, clinical investigators often need to adjust for comorbidity when assessing the effect of long-term care (LTC) on patient outcomes. This study examined the prognostic value of the Charlson Comorbidity Index (CCI) in predicting 3-year mortality and functional decline in the LTC setting and compared its prognostic value to that of two data-derived comorbidity indices.

DESIGN

Longitudinal cohort study.

SETTING

Eighty-eight residential care facilities from Quebec, Canada.

PARTICIPANTS

Two hundred ninety-one dependent older adults aged 65 and older.

MEASUREMENTS

Subjects' functional abilities were assessed at baseline and 3 years later with the revised version of the Functional Autonomy Measurement System(SMAF). Comorbidity data and the exact date of death for those who had died were collected retrospectively from the subjects' medical files. Subjects were classified as functional decliners if they died or gained 5 points or more on the SMAF between the two assessments.

RESULTS

Multivariate Cox and logistic regressions were used to derive two new comorbidity indices, one for predicting mortality and the other for identifying functional decliners. Although the CCI performed well in predicting these two outcomes, its performance was generally inferior to that of the two newly proposed indices.

CONCLUSIONS

Findings suggest that the CCI can be improved upon when used to measure comorbidity in LTC patients.

Comorbidity in operable lung cancer: a multicenter descriptive study on 2992 patients

STUDY OBJECTIVES

To ascertain the frequency of diseases associated (comorbidity) with operable lung cancer (LC) globally, in relation to the presence of neoplastic clinical symptoms and age.

DESIGN

Prospective; multi-institutional of 19 Spanish hospitals.

PATIENTS

Two thousand nine hundred and ninety two consecutive cases of LC, treated surgically by the Bronchogenic Carcinoma Co-operative Group of the Spanish Society of Pneumology and Thoracic Surgery (GCCB-S) between 1993 and 1997, are analysed.

METHODS

At time of treatment, data on the presence or absence of different specific comorbidities in all consecutive patients operated on for LC were entered on identical forms at all hospitals of the GCCB-S.

RESULTS

In 2189 patients (73%) there was one or several comorbidities (chronic obstructive pulmonary disease [COPD], systemic arterial hypertension, previous tumour, cardiac disease, peripheral vascular disease or diabetes). Fifty percent of the LC was associated to COPD; in 32% of these patients with COPD, preoperative measurement of FEV1 was 70% below the theoretical value. In comparing the cases with symptoms ascribable to LC, it was found that in asymptomatic patients the presence of a previous tumour, arterial hypertension or cardiac disease was significantly more frequent. Conversely, in symptomatic patients, COPD was significantly more frequent. The frequency of all evaluated comorbidities is significantly higher in the older age groups.

CONCLUSIONS

In this multicenter study encompassing 2992 patients with operable LC, a high frequency of comorbidity has been found, COPD occurring most frequently. Certain diseases are more prevalent in asymptomatic patients, probably due to a screening bias. In older patients, there was a significant increase of all comorbidities.

A comparison of three comorbidity indexes in a head and neck cancer population

We explored differences in prognostic ability for mortality of the established and validated Charlson comorbidity index with two other comorbidity indexes developed for this study. Our study was limited to persons diagnosed with HNCA between 1985 and 1993 in a database formed by a linkage of files from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program with Health Care Finance Administration Medicare files (n=9386). Adjusted relative risks (RR) and 95% confidence intervals (95%CI) for comorbidity index scores of 1 or more compared to 0 were (RR=1.50, 95% CI 1.43-1.68) Charlson index, (RR=1.53 95% CI 1.42-1.66) HNCA index, and (RR=1.49, 95% CI 1.32-1.68) ATC index, respectively. The Charlson and HNCA indexes displayed dose-response patterns (P-value for trend <0.0001). Although the ATC index appears promising, the HNCA and Charlson indexes had similar adjusted RR's, dose-response patterns, P-values, and chi-square scores and appear particularly well-suited to the measurement of comorbidity.

The American Society of Anesthesiologists' class as a comorbidity index in a cohort of head and neck cancer surgical patients

BACKGROUND

We assessed the American Society of Anesthesiologists' (ASA) class, as a measure of comorbidity in comparison to the commonly used Charlson index for prognostic ability in a HNCA population.

METHODS

Proportional hazards methods were applied to head and neck cancer patients whose treatment included surgery by the Johns Hopkins Otolaryngology service (n = 388).

RESULTS

The Charlson index and ASA class were modestly correlated (Spearman 0.36, p <.001). Compared with patients with ASA class 1 or 2, those with ASA class 3 or 4 had a two-fold elevated mortality rate (Relative Hazard (RH) = 2.00, 95% CI, 1.38-2.89). This association was stronger than observed for a Charlson index score of 1 or more compared with 0 (RH = 1.59, 95% CI, 1.17-2.17). Both the Charlson index and ASA class adjusted RHs displayed dose-response patterns (p value for trend <.001).

CONCLUSIONS

Compared with the Charlson index, the ASA class had comparable if not greater prognostic ability for mortality in this elderly HNCA population.

Cholesterol and other lipids predict coronary heart disease and ischaemic stroke in the elderly, but only in those below 70 years

The prediction of coronary heart disease (CHD) and stroke by total and low density lipoprotein (LDL) cholesterol in older persons remains problematical. This study tests the hypothesis that cholesterol and other risk factors may be differentially predictive of CHD and ischaemic stroke in older persons when they are segregated into different age groups. CHD and ischaemic stroke outcomes were recorded during 129 months follow-up in a cohort of 2805 men and women of 60 years and older. There were 899 CHD events (32/100) and 326 stroke events (12/100). Using Cox proportional hazards, outcomes were modelled for the total cohort and for age groups 60-69, 70-79, and 80+ years. Total cholesterol, LDL cholesterol, serum apo-B, total cholesterol/high density lipoprotein (HDL) cholesterol and apo-B/apo-A1 were significant predictors of CHD in the total cohort, but significant only in the sub-group of 60-69 years. The respective hazard ratios (CI 95%) were 1.21 (1.09-1.35), 1.21 (1.09-1.35), 1.25 (1.13-1.39), 1.25 (1.14-1.37) and 1.21 (1.10-1.38). Similar findings were applicable with respect to ischaemic stroke in the age group of 60-69 years. Total cholesterol predicted CHD in men above a threshold value of 7.06 mmol/l and in women above 7.8 mmol/l, but with stroke the prediction was incremental. Other risk factors such as HDL cholesterol, triglycerides, lipoprotein(a), diabetes, hypertension and smoking predicted CHD, although only HDL and hypertension similarly predicted ischaemic stroke. The findings support a case for cholesterol testing in older subjects up to 70 years, in whom there is ancillary evidence of CHD and stroke prevention through treatment designed to reduce LDL cholesterol.

[Annual incidence and risk factors for nosocomial bacterial infections in an acute care geriatric unit]

PURPOSE

Elderly inpatients are particularly exposed to the risk of nosocomial infections, thus the study of their risk factors and consequences is of interest.

METHODS

Among 1,565 subjects referred to a short-term geriatric unit, patients hospitalised for a year for an acute event and unable to move themselves were followed up for the occurrence of nosocomial infections.

RESULTS

Among these 402 immobilised patients (age: 86.3 +/- 7.6 years), 102 nosocomial infections occurred in 91 patients (22.6%), whereas the estimation of the incidence in the total hospitalised population (1,565 subjects, age: 85.1 +/- 6.2 years) was 9.4% (95% confidence interval [CI] 8.3-11.2). Forty-seven point seven percent of nosocomial infections were urinary tract nosocomial infections, 27.5% were lower respiratory nosocomial infections, 9.2% were cutaneous nosocomial infections, 7.3% were septicaemia and 8.2% were of unknown origin. The relative risk (RR) of NI linked to functional dependency for mobility was 5.5 (95% CI: 3.93-7.7, P < 0.001). Other risk factors were: for all nosocomial infections: cancer diagnosis (RR 1.1, 95% CI: 1.1-1.2, P = 0.01); and respectively for urinary tract NI: bladder indwelling (RR 4.8, 95% CI: 2.9-7.7, P < 0.001), pulmonary NI: swallowing disorders (RR 5.4, 95% CI: 2.8-10.5, P < 0.001); and septicaemia: venous catheter (RR 5.4, 95% CI: 1.3-23.3, P = 0.002). NI were associated with an increased length of stay (22.1 +/- 11.7 days in infected patients vs 16.3 +/- 9.5 days in immobilised non-infected subjects, P < 0.001). The mean length of stay for the 1,565 subjects was 10.3 +/- 7.6 days. Death was attributed to nosocomial infections in 13 subjects. In conclusion, functional dependency for mobility, bladder indwelling, venous catheter, swallowing disorders and diagnosis of cancer were risk factors for nosocomial infections in hospitalised elderly subjects in an acutecare setting.

Comorbidity and survival of elderly head and neck carcinoma patients

BACKGROUND

Alcohol and tobacco, the primary etiologic agents for head and neck carcinoma (HNCA), cause other chronic diseases and may contribute to the high prevalence of comorbid conditions and generally poor survival of persons with HNCA.

METHODS

The authors explored the prognostic role of comorbidity in persons with HNCA using Health Care Finance Administration Medicare (HCFA) files linked with the appropriate files of the Surveillance, Epidemiology, and End Results (SEER) Program. The Charlson comorbidity index was applied to in-patient data from the HCFA files. The SEER data were used to ascertain survival and identify persons with HNCA diagnosed from 1985 to 1993 (n = 9386).

RESULTS

In a proportional hazards regression model adjusted for age and historic stage at diagnosis, race, gender, marital status, socioeconomic status, histologic grade, anatomic site, treatment, and pre-1991 diagnosis, Charlson index scores of 0, 1, and 2+ had estimated relative hazards (RHs) with 95 confidence intervals (CIs) of 1.00, 1.33 (95% CI, 1.21-1.47), and 1.83 (95% CI, 1.64-2.05), respectively (P value for trend < 0.0001). The adjusted RH for a Charlson index score of 1 or more compared with 0, using stratified models, was found to be greater in whites (RH, 1.55; 95% CI, 1.43-1.67) than blacks (RH, 1.24; 95% CI, 0.96-1.60), local (RH, 1.72; 95% CI, 1.50-1.96) versus distant stage (RH, 1.25; 95% CI, 1.00-1.56), and age 65-74 years (RH, 1.53; 95% CI, 1.38-1.69) versus age 85+ years (RH, 1.42; 95% CI, 1.09-1.84).

CONCLUSIONS

This study establishes comorbidity as a predictor of survival in an elderly HNCA population and lends support to the inclusion of comorbidity assessment in prognostic staging of patients with HNCA diagnosed after 65 years of age.

Functional dependence after hip fracture

OBJECTIVES

To identify patients at high risk of functional dependence and examine the progression of disability after a hip fracture.

DESIGN

This was a population-based prospective inception cohort study of all patients aged 65+ yr who fractured a hip between July 1996 and August 1997. Demographic, socioeconomic, social support, and health status information was assessed in the hospital and 3 mo postfracture.

RESULTS

The analysis included 367 patients. Almost all patients with cognitive impairment were functionally dependent postfracture, with new disabilities frequently occurring in transferring. Among patients of high mental status, increased risk of functional dependence was associated with advanced age, more co-morbidities, hip pain, poor self-rated health, and previous employment in a prestigeous occupation. Bathing disability was most likely in those who functioned independently prefracture; a disability in dressing was most common otherwise.

CONCLUSION

Hip pain is amenable to treatment and may improve chances of functional recovery. Patients can be assisted in regaining prefracture function if they are targeted for rehabilitation on the basis of mental status. The focus should be on bathing and dressing among patients of high cognition and transferring among those patients with mental impairment.

Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation

Although there is substantial evidence that cardiac rehabilitation is beneficial for post myocardial infarction (MI) patients, such programs are currently under utilized. This study examined systematic criteria predicting physician referral to and patients' participation in cardiac rehabilitation programs. Patients discharged for MI were interviewed in-hospital and at 6-12 weeks post discharge to determine referral, participation, and completion. Stepwise logistic regression analyzed factors associated with rehabilitation. Factors associated with referral to rehab were catheterization (p < 0.001), bypass surgery (p < 0.01), cardiologist/cardiac surgeon appointment (p < 0.02), and age (p < 0.01). Participation was increased for those with bypass surgery (p < 0.001), and referral to cardiologist or cardiac surgeon (p < 0.001). Type of provider significantly influences referral to and participation in cardiac rehabilitation. This suggests that encouragement plays a strong role in attendance for rehabilitation. The same strong encouragement should be given to the broader range of MI patients who stand to benefit from cardiac rehabilitation.

Underuse of invasive procedures among Medicaid patients with acute myocardial infarction

OBJECTIVES

The purpose of this study was to determine whether underuse of cardiac procedures among Medicaid patients with acute myocardial infarction is explained by or is independent of fundamental differences in age, race, or sex distribution; income, coexistent illness; or location of care.

METHODS

Administrative data from 226 hospitals in New York were examined for 11,579 individuals hospitalized with a primary diagnosis of acute myocardial infarction. Use of various cardiac procedures was compared among Medicaid patients and patients with other forms of insurance.

RESULTS

Medicaid patients were older, were more frequently African American and female, and had lower median household incomes. They also had a higher prevalence of hypertension, diabetes, lung disease, renal disease, and peripheral vascular disease. After adjustment for these and other factors, Medicaid patients were less likely to undergo cardiac catheterization, percutaneous transluminal coronary angioplasty, and any revascularization procedure.

CONCLUSIONS

Factors other than age, race, sex, income, coexistent illness, and location of care account for lower use of invasive procedures among Medicaid patients. The influence of Medicaid insurance on medical practice and process of care deserves investigation.

Resource utilization of patients with hypochondriacal health anxiety and somatization

OBJECTIVES

To examine the resource utilization of patients with high levels of somatization and health-related anxiety.

DESIGN

Consecutive patients on randomly chosen days completed a self-report questionnaire assessing somatization and health-related, hypochondriacal anxiety. Their medical care utilization in the year preceding and following completion of the questionnaire was obtained from an automated patient record. The utilization of patients above and below a predetermined threshold on the questionnaire was then compared.

PATIENTS AND SETTING

Eight hundred seventy-six patients attending a primary care clinic in a large, urban, teaching hospital.

OUTCOME MEASURES

Number of ambulatory physician visits (primary care and specialist), outpatient costs (total, physician services, and laboratory procedures), proportion of patients hospitalized, and proportion of patients receiving emergency care.

RESULTS

Patients in the uppermost 14% of the clinic population on somatization and hypochondriacal health anxiety had appreciably and significantly higher utilization in the year preceding and the year following completion of the somatization questionnaire than did the rest of the patients in the clinic. After adjusting for group differences in sociodemographic characteristics and medical comorbidity, significant differences in utilization remained. In the year preceding the assessment of somatization, their adjusted total outpatient costs were $1,312 (95% CI $1154, $1481) versus $954 (95% CI $868, $1057) for the remainder of the patients and the total number of physician visits was 9.21 (95% CI 7.94, 10.40) versus 6.33 (95% CI 5.87, 6.90). In the year following the assessment of somatization, those above the threshold had adjusted total outpatient costs of $1,395 (95% CI $1243, $1586) versus $1,145 (95% CI $1038, $1282), 9.8 total physician visits (95% CI 8.66, 11.07) versus 7.2 (95% CI 6.62, 7.77), and had a 24% (95% CI 19%, 30%) versus 17% (95% CI 14%, 20%) chance of being hospitalized.

CONCLUSIONS

Primary care patients who somatize and have high levels of health-related anxiety have considerably higher medical care utilization than nonsomatizers in the year before and after being assessed. This differential persists after adjusting for differences in sociodemographic characteristics and medical morbidity.

Depressed mood, physician-rated prognosis, and comorbidity as independent predictors of 1-year mortality in consecutive medical inpatients

OBJECTIVE

To determine the independent effects of depressed mood and markers of medical disease severity on mortality in consecutive medical inpatients.

METHODS

Consecutive general medical inpatients were asked to complete the Hospital Anxiety and Depression Scale (HADS) at admission. Prognostic indicators were obtained from patients' records and physicians' ratings. The study endpoint was mortality from all causes at 1 year.

RESULTS

The baseline assessment was completed by 575 patients (87.7%). Survival data were available for 572 of these (86 deaths). HADS depression scores and several physical risk indicators predicted mortality. In multivariate analyses, physicians' rating of prognosis was the best predictor of mortality [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI), 2.5--5.4]. Other independent predictors included a principal diagnosis of hemato-oncological disease, comorbidity scores, and HADS depression (adjusted OR 1.75; 95% CI, 1.10--2.79).

CONCLUSION

Our data demonstrate an independent prognostic effect of depressed mood on mortality in general medical inpatients. Screening for depression may improve risk stratification in these patients over and above that obtained by routinely available physical parameters and physicians' clinical judgement.

Change in pain and function while waiting for major joint arthroplasty

The objective of this study was to examine the change in pain and physical function that occurs while waiting for major arthroplasty. Data were collected prospectively from a cohort of 313 patients who were waiting > 1 month for total hip arthroplasty or total knee arthroplasty. The WOMAC and the SF-36 health status instruments were administered at the time the patient was placed on the waiting list and again just before surgery. Minimal amounts of change in pain and physical and psychosocial function occurred for hip and knee arthroplasty patients while they waited. Overall, waiting time did not appear to have a negative impact on the amount of pain and dysfunction experienced.

Sistema de Informações Hospitalares como ajuste de risco em índices de desempenho

OBJETIVO: Analisar o uso do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS) no ajuste de risco das taxas de mortalidade hospitalar e avaliar a utilidade do índice de comorbidade de Charlson (ICC) no ajuste de risco de indicadores de desempenho. MÉTODOS: Foram selecionadas 40.299 internações ocorridas no Município do Rio de Janeiro entre dezembro de 1994 e dezembro de 1996. A medida de gravidade foi testada pelo ICC, que atribui pesos a 17 condições clínicas presentes nos diagnósticos secundários, a fim de obter a carga de morbidade do paciente (gravidade) independentemente do diagnóstico principal. Utilizou-se a regressão logística para avaliar o impacto do ICC na estimativa da chance de morrer no hospital. RESULTADOS: Nas internações selecionadas, observou-se que o ICC foi igual ou superior a um em apenas 5,7 % dos casos. Quando se aplicou o ICC combinado à idade, o percentual de casos com pontuação diferente de zero aumentou substancialmente. Os modelos testados apresentaram reduzida sensibilidade. CONCLUSÕES: Apesar de a presença de comorbidade ser importante na predição do risco de morrer, essa variável pouco discriminou a gravidade dos casos na base de dados do SIH/SUS, o que é explicado pela qualidade da informação diagnóstica nessa base de dados, na qual a idade é o preditor mais importante do risco de morrer, afora o diagnóstico principal. Apesar das limitações ainda existentes na qualidade da informação diagnóstica disponível no SIH/SUS, sugere-se o uso do ICC combinado como medida para ajuste do risco de morrer nas taxas calculadas a partir desses dados.

Persistence of impaired functioning and psychological distress after medical hospitalization for men with co-occurring psychiatric and substance use disorders

OBJECTIVE

To measure the persistence of impaired health-related quality of life (HRQL) and psychological distress associated with co-occurring psychiatric and substance use disorders in a longitudinal sample of medically hospitalized male veterans.

DESIGN

A random sample followed observationally for 1 year after study enrollment.

SETTING

Inpatient medical and surgical wards at 3 university-affiliated Department of Veterans Affairs Medical Centers.

PATIENTS/PARTICIPANTS

A random sample of 1,007 admissions to medical and surgical inpatient services, excluding women and admissions for psychiatric reasons. A subset of participants (n = 736) was designated for longitudinal follow-up assessments at 3 and 12 months after study enrollment. This subset was selected to include all possible participants with study-administered psychiatric diagnoses (52%) frequency-matched by date of study enrollment to approximately equivalent numbers of participants without psychiatric diagnoses (48%).

MEASUREMENTS AND MAIN RESULTS

All participants were administered a computerized structured psychiatric diagnostic interview for 13 psychiatric (include substance use) disorders and received longitudinal assessments at 3 and 12months on a multidimensional measure of HRQL, the SF-36, and a measure of psychological distress, the Symptom Checklist, 90-item version. On average, HRQL declined and psychological distress increased over time (P <.05). Psychiatric disorders were associated with significantly greater impairments in functioning and increased distress on all measures (P <.001) except physical functioning (P <.05). These results were replicated in the patients (n = 130) who received inpatient or outpatient mental health or substance abuse services.

CONCLUSIONS

General medical physicians need to evaluate the mental health status of their hospitalized and seriously ill patients. Effective mental health interventions can be initiated posthospitalization, either immediately in primary care or through referral to appropriate specialty care, and should improve health functioning over time.

The relationship between health-related quality of life and frequency of spells in patients with syncope

Chronic syncope has a wide range of symptom burden, and anecdotal data suggest substantial but variable physical and psychosocial morbidity. We hypothesized that health-related quality of life (HRQL) is impaired in syncope patients and the degree of impairment is proportional to syncope frequency. The EuroQol EQ-5D was completed by 136 patients (79 female and 57 male) with mean age 40 (SD = 17) prior to assessment. HRQL was substantially impaired in syncope patients compared to population norms in all five dimensions of health measured by the EQ-5D. In patients with six or more lifetime syncopal spells there was a significant (P < 0.001) negative relationship between the frequency of spells and overall perception of health, which was not evident in those who had a history of less than six lifetime spells. These relationships were maintained after controlling for comorbid conditions.

Effects of health insurance and race on colorectal cancer treatments and outcomes

OBJECTIVES

We hypothesized that health insurance payer and race might influence the care and outcomes of patients with colorectal cancer.

METHODS

We examined treatments received for all incident cases of colorectal cancer occurring in Florida in 1994 (n = 9551), using state tumor registry data. We also estimated the adjusted risk of death (through 1997), using proportional hazards regression analysis controlling for other predictors of mortality.

RESULTS

Treatments received by patients varied considerably according to their insurance payer. Among non-Medicare patients, those in the following groups had higher adjusted risks of death relative to commercial fee-for-service insurance: commercial HMO (risk ratio [RR] = 1.40; 95% confidence interval [CI] = 1.18, 1.67; P = .0001), Medicaid (RR = 1.44; 95% CI = 1.06, 1.97; P = .02), and uninsured (RR = 1.41; 95% CI = 1.12, 1.77; P = .003). Non-Hispanic African Americans had higher mortality rates (RR = 1.18; 95% CI = 1.01, 1.37; P = .04) than non-Hispanic Whites.

CONCLUSIONS

Patients with colorectal cancer who were uninsured or insured by Medicaid or commercial HMOs had higher mortality rates than patients with commercial fee-for-service insurance. Mortality was also higher among non-Hispanic African American patients.

Use of comorbidity scores for control of confounding in studies using administrative databases

BACKGROUND

Comorbidity scores are increasingly used to reduce potential confounding in epidemiological research. Our objective was to compare metrical and practical properties of published comorbidity scores for use in epidemiological research with administrative databases.

METHODS

The literature was searched for studies of the validity of comorbidity scores as predictors of mortality and health service use, as measured by change in the area under the receiver operating characteristic (ROC) curve for dichotomous outcomes, and change in R(2) for continuous outcomes.

RESULTS

Six scores were identified, including four versions of the Charlson Index (CI) which use either the three-digit International Classification of Diseases, Ninth Revision (ICD-9) or the full ICD-9-CM (clinical modification) code, and two versions of the Chronic Disease Score (CDS) which used outpatient pharmacy records. Depending on the population and exposure under study, predictive validities varied between c = 0.64 and c = 0.77 for in-hospital or 30-day mortality. This is only a slight improvement over age adjustment. In one study the simple measure 'number of diagnoses' outperformed the CI (c = 0.73 versus c = 0.65). Proprietary scores like Ambulatory Diagnosis Groups and Patient Management Categories do not necessarily perform better in predicting mortality. Comorbidity indices are susceptible to a variety of coding errors.

CONCLUSIONS

Comorbidity scores, particularly the CDS or D'Hoore's CI based on three-digit ICD-9 codes, may be useful in exploratory data analysis. However, residual confounding by comorbidity is inevitable, given how these scores are derived. How much residual confounding usually remains is something that future studies of comorbidity scores should examine. In any given study, better control for confounding can be achieved by deriving study-specific weights, to aggregate comorbidities into groups with similar relative risks of the outcomes of interest.

Association between depressive symptoms and mortality in medical inpatients

The authors interviewed a consecutive series of medical inpatients (N = 241) using the Schedule for Affective Disorders and Schizophrenia to determine which depressive symptoms are associated with in-hospital mortality. Fifteen depressive symptoms, pain, and physical discomfort were assessed along with medical comorbidity. Twenty patients died in-hospital (8.3%). Logistic regression showed that anhedonia, hopelessness, worthlessness, indecisiveness, and insomnia predicted in-hospital death after adjusting for physical comorbidity and age. Clinicians should be aware that these depressive symptoms may predict mortality in medical inpatients. Future studies should address which treatment modalities lead to better outcomes.

Geriatric oncology: challenges for the new century

The management of cancer in the older aged person represents one of the major immediate challenges of medicine. The response to this challenge involves answers to the following questions: I. Who is old? Currently. 70 years of age may he considered the lower limit of senescence because the majority of age-related changes occur after this age. Individual estimates of life expectancy and functional reserve may be obtained by a comprehensive and time-consuming multidimensional geriatric assessment. The current instrument may be fine-tuned and new instruments, including laboratory tests of ageing. may be developed. 2. Why do older persons develop more cancer? It is clear that ageing tissues are more susceptible to late-stage carcinogen. Older persons may represent a natural monitor system for new environmental carcinogens, and may also represent a fruitful ground to study the late stages of carcinogenesis. 3. Is cancer different in younger and older persons? Clearly. the behaviour of some tumors. including acute myeloid leukaemia, non-Hodgkin's lymphoma and breast cancer change with the age of the patient. The mechanisms of these changes that may involve both the tumour cell and the tumour host are poorly understood. 4. Can cancer he prevented in older individuals? Chemoprevention offers a new horizon of possibilities for cancer prevention: older persons may benefit most from chemoprevention due to increased susceptibility to environmental carcinogens. Screening tests may become more accurate in older individuals due to increased prevalence of cancer. hut may he less beneficial due to more limited patient life expectancy. 5. Do older persons benefit from cytotoxic treatment? The answer to this question partly stands on proper patient selection. partly on the development of safer forms of cancer treatment and prudent use of antidotes to chemotherapy toxicity. 6. What is the cost of treating older cancer patients? The treatment of older patients is generally more costly. This cost should be assessed against the cost of not treating cancer and promoting functional dependence. which by itself is extremely costly. 7. What are the endpoints of clinical trials in older cancer patients? With more limited life expectancy. the effect of treatment on quality of life is paramount. Reliable assessment of quality of life is essential for interpreting clinical trials in older individuals. 2000 Elsevier Science Ltd. All rights reserved.

Measurement and impact of comorbidity in older cancer patients

As the world population ages, oncologists are increasingly confronted with the problem of comorbidity in cancer patients. This has stemmed an increasing interest into approaching comorbidity in a systematic way, in order to integrate it in treatment decisions. So far, data on the subject have been widely scattered through the medical literature. This article is aimed at reviewing the available data on the interaction of comorbidity and prognosis. This overview should provide an accessible source of references for oncological investigators developing research in the field. Various methods have been used to sum comorbidity. However, a major effort remains to be done to analyze how various diseases combine in influencing prognosis. The main end-point explored so far is mortality, with which comorbidity globally is reliably correlated. A largely open challenge remains to correlate comorbidity with treatment tolerance, and functional and quality of life outcomes, as well as to integrate it in clinical decision-making.

Management of cancer in the older person: a practical approach

The management of cancer in the older aged person is an increasingly common problem. The questions arising from this problem are: Is the patient going to die with cancer or of cancer? Is the patient able to tolerate the stress of antineoplastic therapy? Is the treatment producing more benefits than harm? This article explores a practical, albeit evolving, approach to these questions including a multidimensional assessment of the older person and simple pharmacologic interventions that may ameliorate the toxicity of antineoplastic agents. Age may be construed as a progressive loss of stress tolerance, due to decline in functional reserve of multiple organ systems, high prevalence of comorbid conditions, limited socioeconomic support, reduced cognition, and higher prevalence of depression. Aging is highly individualized: chronologic age may not reflect the functional reserve and life expectancy of an individual. A comprehensive geriatric assessment (CGA) best accounts for the diversities in the geriatric population. The advantages of the CGA include:Recognition of potentially treatable conditions such as depression or malnutrition, that may lessen the tolerance of cancer treatment and be reversed with proper intervention; Assessment of individual functional reserve; Gross estimate of individual life expectancy; and Adoption of a common language to classify older cancer patients. The CGA allows the practitioner to recognize at least three stages of aging:People who are functionally independent and without comorbidity, who are candidates for any form of standard cancer treatment, with the possible exception of bone marrow transplant. People who are frail (dependence in one or more activities of daily living, three or more comorbid conditions, one or more geriatric syndromes), who are a candidate only for palliative treatment; and People in between, who may benefit from some special pharmacological approach, such as reduction in the initial dose of chemotherapy with subsequent does escalations. The pharmacological changes of age include decreased renal excretion of drugs and increased susceptibility to myelosuppression, mucositis, cardiotoxicity and neurotoxicity. Based on these findings, the proposal was made that all persons aged 70 and older, treated with cytotoxic chemotherapy of dose intensity comparable to CHOP, receive prophylactic growth factor treatment, and that the hemoglobin of these patients be maintained >/=12 gm/dl.

The health and activities limitation index in patients with acute myocardial infarction

Utility assessment is required to estimate quality-adjusted life years, but is often avoided due to the cumbersome nature of elicitation techniques. The Health Activities and Limitations Index (HALex) offers a method of utility assessment using existing values from the National Health Interview Survey (NHIS) and a utility algorithm to derive preferences. The authors assessed the construct validity of the HALex by comparing derived values with directly assessed HALex utilities in patients post acute myocardial infarction (AMI). OLS regression was used to model the relationship between utilities and patient demographics, comorbidities, and treatment. The mean and median utility for patients (n = 160) was.57 (SD = 22) and.55 respectively, and was not statistically different from the mean [.57 (SD =.30)] and median (.58) for similar NHIS respondents (n = 46). Patients with a comorbidity index of three or less had mean utilities.13 higher than the mean utility for patients with an index of four or more. No relationship was found between patients' age, race, and income and their utilities. The HALex scoring algorithm is a promising means to obtain utilities, and provides a methodology to easily estimate utilities for patients, but is not without limitations.

Strategies for improving comorbidity measures based on Medicare and Medicaid claims data

Claims-based measures of comorbid illness severity have generally relied on the diagnoses listed for a single hospitalization. Unfortunately, such diagnostic information is often limited because patients have not been hospitalized during periods of interest, because of incomplete coding of diagnoses on claims forms, or because listed diagnoses represent complications of the hospitalization rather than pre-existing comorbid conditions. To address these limitations, we developed and tested four comorbidity index scores for patients with breast cancer, each based on different sources of health services claims from Medicare and Medicaid: hospitalization for breast cancer surgery; outpatient care prior to the hospitalization; other inpatient care prior to the hospitalization; and all sources combined. Varying the number and type of sources of diagnostic information yielded only very small improvements in the prediction of mortality at 1 and 3 years. Surprisingly, even simpler measures of comorbidity (crude number of diagnoses) and of prior health care utilization (total days spent in the hospital) performed at least as well in predicting mortality as did the more complex index scores which assigned points and weights for specific conditions. The greatest improvement in explanatory power was observed when another source of clinical information (cancer stage derived from a population-based cancer registry) was used to supplement claims information. Expanding the source of claims diagnoses and focusing on time periods prior to an index hospitalization are insufficient for substantially improving the explanatory power of claims-based comorbidity indices. Other improvements suggested by our results should include: increasing the completeness and accuracy of claims diagnoses; supplementing diagnoses with health care utilization information in claims data; and supplementing claims data with other sources of clinical information.

Depression but not anxiety is a significant predictor of physicians' assessments of medical status in physically ill patients

BACKGROUND

In a cross-sectional study we investigated associations between self-ratings of anxiety and depression, physical factors and physicians' assessments of patients' medical status.

METHODS

Hospital inpatients (n = 574) consecutively admitted to internal medical wards were evaluated for the presence of anxiety and depressive symptoms using the Hospital Anxiety and Depression Scale (HADS). Physicians were asked for their perception of psychiatric problems in their patients and for their assessments of patients' severity of illness, functional impairment and 1-year prognosis on 3-point ranking scales. Detailed somatic data including comorbidity and accepted risk factors were taken from the patients' records.

RESULTS

Almost two thirds of all patients with abnormal HADS scores (65.2%) were not identified by their attending physicians as suffering from psychiatric problems. Using multiple-regression models, HADS scores for depression, but not for anxiety, proved to be an independent predictor for the clinicians' judgements of disease severity [exp(beta) = 1.08; 95% confidence interval (CI) 1. 03-1.13; p < 0.01] and functional impairment [exp(beta) = 1.11; 95% CI 1.05-1.17; p < 0.01]. The estimation of prognosis, however, was only related to physical predictors and showed no association with depressive symptoms or other psychosocial factors.

CONCLUSIONS

Our data demonstrate that internists' ratings of severity of illness and functional impairment, but not prognosis, are associated with HADS depression scores, whereas there is no such association with self-rated anxiety.

The use and outcomes of outpatient mastectomy in Florida

BACKGROUND

To identify patient characteristics associated with outpatient mastectomies and their outcomes.

METHODS

Patients diagnosed with breast cancer and treated with mastectomies in Florida in 1994 were identified from state discharge abstracts and the state tumor registry. The relationship between clinical/demographic characteristics and the odds of having an outpatient mastectomy was identified using multiple logistic regression. Outcomes were assessed by calculating the risk of being rehospitalized within 30 days of discharge.

RESULTS

Twenty percent of mastectomies were performed on an outpatient basis. Outpatient mastectomies were more likely to be performed on women who were older, who lived in higher income communities, or who were uninsured. Health insurance type was not associated with having an outpatient mastectomy. Women undergoing outpatient mastectomy were more likely to be readmitted within 30 days of discharge; however, the excess risk was very small (0.7%).

CONCLUSIONS

The risks from outpatient mastectomy are small. Ongoing monitoring of outcomes and assessment of patient satisfaction are needed.

Measuring comorbidity in older cancer patients

The aim of this article was to provide oncology researchers with adequate tools and practical advice to integrate comorbidity into clinical studies. Open research questions are also discussed. Commonly used comorbidity indexes were identified and a detailed literature search was done by MEDLINE and cross-referencing. Expert opinion was sought on each index. A common scheme exploring the description of the index, clinical experience, metrological performance, easiness of use, cross-compatibility and preservation of data was followed. The actual indexes are included in the Appendix. Four commonly used indexes were identified: the Charlson Comorbidity Index (Charlson), the Cumulative Illness Rating Scale (CIRS), the Index of Coexistent Disease (ICED), and the Kaplan-Feinstein index. The Charlson is the most commonly used whereas the performance of the first two indexes is best characterised. Most studies are retrospective and focus on mortality as an outcome and a base of grading. All indexes are easy to use and require a maximum of 10 min to be filled. Inter-rater and test-retest reliability is generally good. Little is known about other outcomes and the way various diseases cumulate in influencing prognosis. Thus, several reliable indexes are available to measure comorbidity in cancer patients. They show that globally comorbidity is a strong predictor of outcome. Since little is still known about the importance of individual comorbidities for various outcomes and the way comorbidity cumulates in influencing cancer treatment, a wide integration of comorbidity in prospective studies is essential.

Frailty bias in comorbidity risk adjustments of community-dwelling elderly populations

Our objective was to describe distortion in outcome studies due to "frailty bias" or differential susceptibility to adverse health outcomes due to frailties but attributed to other factors. We linked an administrative database to survey data (n = 5934) containing functional, condition, and outcome measures. The disease classification scheme of an empirically derived mortality model was used to categorize 7500 ICD-9-CM codes into five risk levels. Cox and logistic regressions were used to compare outcomes. Commonly employed measures differ in their sensitivity to detect and control frailty bias across a spectrum of major chronic diseases. Survival is inversely related to increasing functional impairment after adjusting for age, race, gender, education, number of comorbid conditions, and highest disease risk occurring during follow-up. Functional status appears to be a superior and essential element for control of the frailty bias that threatens comparability of outcome measures across community-dwelling populations containing chronically-ill disabled elderly.

Prospective audits of quality of PEM recognition and nutritional support in critically ill elderly patients

BACKGROUND AND AIMS

Undereating is a frequent concern in acute care geriatric settings and is supposed to worsen the outcomes of the underlying diseases, while the quality of nutritional support could be improved.

METHODS

Two consecutive and prospective audits (A and B) with team training over a 1 year period investigated the quality of malnutrition recognition and nutritional support and outcomes in immobilized, critically ill elderly subjects.

RESULTS

Audit A included 170 patients (86.3+/-6.1 years old) and audit B, 232 patients (86.3+/-6.3), respectively 20.6% and 31.4% of the hospitalized population. Misclassifications occurred in A in 54.0% compared to 34.05% in B (P < 0.001). 32.6% in A versus 86.9% in B adequately received oral supplements (P = 0.02). Significant risk factors for the adverse outcomes in the combined two audits were: dementia (RR: 1.8, 95%CI: 1.0 to 3.0, P= 0.04) and dehydration (RR: 2.0, 95%CI:1.0 to 4.1, P= 0.05) for pressure ulcer incidence; stroke (RR: 8.8, 95%CI: 4.8 to 16.0, P < 0.001) for pressure ulcer prevalence at discharge; neoplasms (RR: 1.1, 95%CI: 1.0 to 1.2, P = 0.02) for nosocomial infections; bladder indwelling for urinary tract infections (RR: 4.8, 95%CI: 2.9 to 7.7, P<< 0.001); swallowing problems for pulmonary infections (RR: 5.4, 95%CI: 2.8 to 10.5, P < 0.001); venous indwelling for septicaemia (RR: 5.4, 95%CI: 1.3 to 23. 3, P= 0.02). However, after adjustment on significant risk factors, the outcome rate was similar in audit B: death rate: A (15.6%), B (14.2%); length of stay: A (17.3+/-10.4 days), B (17.4+/-10.0); pressure ulcer incidence: A (26.4%), B (20.2%), (83% were erythema); pressure ulcer prevalence at discharge: A (14.7%), B (10.3%), (40% were erythema); nosocomial infections: A (26.4%), B (19.0%).

CONCLUSION

The improvement of malnutrition recognition and nutritional support was not followed by a perceptible decrease in adverse outcome rate, this latter being mainly related to the underlying conditions of these critically ill elderly patients.

Can cardiovascular clinical characteristics be identified and outcome models be developed from an in-patient claims database?

The objective of this study was to assess whether administrative (claims) databases can be used to assess clinical variables and predict outcome. Although administrative databases are useful for assessing resource utilization, their utility for assessing clinical information is less certain. Prospectively gathered clinical databases, however, are expensive and not widely available. The UB92 formulation of the hospital bill was used as an administrative source of data and compared with the clinical cardiovascular database at Emory University. The claims database was compared with the clinical database for 11 variables. Outcome models were developed with multivariate methods. A total of 11,883 patients who underwent catheterization (5,255 underwent percutaneous transluminal coronary angioplasty [PTCA] and 3,794 underwent coronary artery bypass surgery [CABG]) between 1991 and 1995 were included. For some variables, the claims database correlated well (diabetes, sensitivity 87%, specificity 99%), whereas for others the claims database was less accurate (peripheral vascular disease, sensitivity 20%, specificity 99%). Uncertain coding in the claims database, which can result in the same code being used for co-morbid states and severity of disease, as well as complications, limited the ability of claims to predict outcome. Clinical databases may also be limited by lack of objectivity and missing data. The utility of claims databases to assess severity of disease and co-morbid states is limited, and outcome modeling and risk assessment from claims databases may be inappropriate and spurious. Developing better data standards and less expensive methods for acquisition of clinical data is necessary for improved outcome assessment.

[Chronic comorbidity and homogeneity in diagnostic related groups]

OBJECTIVE

[corrected] One of the ways to compare the efficiency of different hospitals and services is to evaluate Diagnostic Related Groups (DRGs), with the hypothesis that patients in the same RDG will present homogeneous behavior with respect to length of stay. The object of this study was to evaluate in the context os the National Health System the internal variability of specific DRGs in terms of the patients' comorbidity.

METHODS

On the basis of various comorbidity scores measured with the Charlson index (ChI), we analyzed length of stay, inhospital mortality and emergency readmissions at 30 and 365 days in 106.673 hospitalizations (excluding subjects younger than 17 years of age, and obstetrics and psychiatric patients) in 12 hospitals, and in 17 DRGs selected on the basis of their greater frequency and comorbidity.

RESULTS

In the aggregated analysis, length of stay (from 8.5 days in patients with no comorbidity to 17.0 days in patients with scores higher than 4) and inhospital mortality rates (from 3.7% in patients with no comorbidity to 17.6% in patients with highest score) increased significantly with each level of the Charlson index. The readmission rate at 30 days rose from 4.7% to 10.9% also in step with increases in comorbidity scores. Readmissions at one year varied from 14.8% in patients with scores of 0 to 35.2% in patients with scores of 3-4, and dropped to 27.9% in patients with scores higher than 4. When analysing different DRGs, 8 of the 17 groups studied showed a significantly higher length of stay with increased comorbidity scores. Some DRGs also showed intra-group variability with respect to mortality and readmission, particularly at 365 days.

CONCLUSIONS

Some DRGs show significant internal variability in terms of comorbidity that may be generating a false worse evaluation of the efficiency of hospitals that treat patients with higher comorbidity.

Understanding changing risk factor associations with increasing age in adults

With an increasingly older population, there is considerable interest in understanding the potential for risk factor interventions in order to prevent, postpone, or slow down the common diseases seen in older persons. However, it is often reported that the strength of association between risk factors and common disease outcomes decreases with increasing age. Actually, many different age-related patterns are observed. Understanding these patterns requires knowledge of issues related to the pathophysiology of aging, including age-related physiologic and metabolic alterations, detection and diagnosis of disease in the elderly, measurement of risk factors, sample selection, comorbidity, competing risks, selective survival, ceiling effects, and methods of analysis in aging populations.

A comprehensive prognostic index to predict survival based on multiple comorbidities: a focus on breast cancer

BACKGROUND

The presence of comorbidities often influences clinical decision-making, although many studies exclude patients with comorbid disease for the sake of analysis.

OBJECTIVES

The purpose of this study was to develop a Comprehensive Prognostic Index (CPI), designed specifically for breast cancer patients.

RESEARCH DESIGN

This study linked Medicare claims with the Kentucky Cancer Registry and developed two models based on 1 year survival; one focused on deaths caused by breast cancer and the other on deaths from all causes. Comorbidities were derived from inpatient and ambulatory claims for up to 2 years before the diagnosis of breast cancer.

SUBJECTS

Subjects included a cohort of 848 elderly women first diagnosed with breast cancer in the state of Kentucky in 1993.

MEASURES

Each model identified the comorbidities specific to breast cancer that were detrimental to survival, and generated a refined comorbidity index. The CPI integrated these measures with age and stage of cancer into a comprehensive prognostic index.

RESULTS

Nearly two-thirds of the patients had evidence of at least one comorbidity. Survival rates decreased with age, more advanced stage, and increased comorbidity burden, as expected. The interaction of comorbidity burden with either age or stage was particularly strong for the older and more advanced stage of cancer.

CONCLUSIONS

The CPI could be a useful tool in breast cancer intervention studies and a prognostic aid for clinicians.