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Davies TW, Kelly E, van Gassel RJJ, van de Poll MCG, Gunst J, Casaer MP, Christopher KB, Preiser JC, Hill A, Gundogan K, Reintam-Blaser A, Rousseau AF, Hodgson C, Needham DM, Schaller SJ, McClelland T, Pilkington JJ, Sevin CM, Wischmeyer PE, Lee ZY, Govil D, Chapple L, Denehy L, Montejo-González JC, Taylor B, Bear DE, Pearse RM, McNelly A, Prowle J, Puthucheary ZA. A systematic review and meta-analysis of the clinimetric properties of the core outcome measurement instruments for clinical effectiveness trials of nutritional and metabolic interventions in critical illness (CONCISE). Crit Care 2023; 27:450. [PMID: 37986015 PMCID: PMC10662687 DOI: 10.1186/s13054-023-04729-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND CONCISE is an internationally agreed minimum set of outcomes for use in nutritional and metabolic clinical research in critically ill adults. Clinicians and researchers need to be aware of the clinimetric properties of these instruments and understand any limitations to ensure valid and reliable research. This systematic review and meta-analysis were undertaken to evaluate the clinimetric properties of the measurement instruments identified in CONCISE. METHODS Four electronic databases were searched from inception to December 2022 (MEDLINE via Ovid, EMBASE via Ovid, CINAHL via Healthcare Databases Advanced Search, CENTRAL via Cochrane). Studies were included if they examined at least one clinimetric property of a CONCISE measurement instrument or recognised variation in adults ≥ 18 years with critical illness or recovering from critical illness in any language. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for systematic reviews of Patient-Reported Outcome Measures was used. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in line with COSMIN guidance. The COSMIN checklist was used to evaluate the risk of bias and the quality of clinimetric properties. Overall certainty of the evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation approach. Narrative synthesis was performed and where possible, meta-analysis was conducted. RESULTS A total of 4316 studies were screened. Forty-seven were included in the review, reporting data for 12308 participants. The Short Form-36 Questionnaire (Physical Component Score and Physical Functioning), sit-to-stand test, 6-m walk test and Barthel Index had the strongest clinimetric properties and certainty of evidence. The Short Physical Performance Battery, Katz Index and handgrip strength had less favourable results. There was limited data for Lawson Instrumental Activities of Daily Living and the Global Leadership Initiative on Malnutrition criteria. The risk of bias ranged from inadequate to very good. The certainty of the evidence ranged from very low to high. CONCLUSIONS Variable evidence exists to support the clinimetric properties of the CONCISE measurement instruments. We suggest using this review alongside CONCISE to guide outcome selection for future trials of nutrition and metabolic interventions in critical illness. TRIAL REGISTRATION PROSPERO (CRD42023438187). Registered 21/06/2023.
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Affiliation(s)
- T W Davies
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK.
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK.
| | - E Kelly
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - R J J van Gassel
- Department of Intensive Care Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M C G van de Poll
- Department of Intensive Care Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - M P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - K B Christopher
- Division of Renal Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - J C Preiser
- Medical Direction, Erasme University Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - A Hill
- Department of Intensive Care Medicine, University Hospital RWTH, 52074, Aachen, Germany
- Department of Anesthesiology, University Hospital RWTH, 52074, Aachen, Germany
| | - K Gundogan
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - A Reintam-Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - A-F Rousseau
- Department of Intensive Care, University Hospital of Liège, Liege, Belgium
| | - C Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 3/553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - D M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
- Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S J Schaller
- Department of Anesthesiology and Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany
- Department of Anesthesiology and Intensive Care, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - T McClelland
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - J J Pilkington
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK
| | - C M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, DUMC, Box 3094 Mail # 41, 2301 Erwin Road, Durham, NC, 5692 HAFS27710, USA
| | - Z Y Lee
- Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac, Anesthesiology & Intensive Care Medicine, Charité, Berlin, Germany
| | - D Govil
- Institute of Critical Care and Anesthesia, Medanta: The Medicty, Gurugram, Haryana, India
| | - L Chapple
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - L Denehy
- School of Health Sciences, The University of Melbourne, Melbourne, Australia
- Department of Allied Health, Peter McCallum Cancer Centre, Melbourne, Australia
| | - J C Montejo-González
- Instituto de Investigación I+12, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - B Taylor
- Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - D E Bear
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R M Pearse
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - A McNelly
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - J Prowle
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - Z A Puthucheary
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
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Lau F, Cloutier-Fisher D, Kuziemsky C, Black F, Downing M, Borycki E, Ho F. A Systematic Review of Prognostic Tools for Estimating Survival Time in Palliative Care. J Palliat Care 2019. [DOI: 10.1177/082585970702300205] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Francis Lau
- School of Health Information Science, University of Victoria
| | | | - Craig Kuziemsky
- School of Health Information Science, University of Victoria
| | | | - Michael Downing
- School of Health Information Science, University of Victoria, and Victoria Hospice Society
| | | | - Francis Ho
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada
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Frush BW, Brauer SG, Yoon JD, Curlin FA. Physician Decision-Making in the Setting of Advanced Illness: An Examination of Patient Disposition and Physician Religiousness. J Pain Symptom Manage 2018; 55:906-912. [PMID: 29109001 DOI: 10.1016/j.jpainsymman.2017.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Little is known about patient and physician factors that affect decisions to pursue more or less aggressive treatment courses for patients with advanced illness. OBJECTIVES This study sought to determine how patient age, patient disposition, and physician religiousness affect physician recommendations in the context of advanced illness. METHODS A survey was mailed to a stratified random sample of U.S. physicians, which included three vignettes depicting advanced illness scenarios: 1) cancer, 2) heart failure, and 3) dementia with acute infection. One vignette included experimental variables to test how patient age and patient disposition affected physician recommendations. After each vignette, physicians indicated their likelihood to recommend disease-directed medical care vs. hospice care. RESULTS Among eligible physicians (n = 1878), 62% (n = 1156) responded. Patient age and stated patient disposition toward treatment did not significantly affect physician recommendations. Compared with religious physicians, physicians who reported that religious importance was "not applicable" were less likely to recommend chemotherapy (adjusted odds ratio [OR] 0.39, 95% CI 0.23-0.66) and more likely to recommend hospice (OR 1.90, 95% CI 1.15-3.16) for a patient with cancer. Compared with physicians who ever attended religious services, physicians who never attended were less likely to recommend left ventricular assist device placement for a patient with congestive heart failure (OR 0.57, 95% CI 0.35-0.92). In addition, Asian ethnicity was independently associated with recommending chemotherapy (OR 1.72, 95% CI 1.13-2.61) and being less likely to recommend hospice (OR 0.59, 95% CI 0.40-0.91) for the patient with cancer; and it was associated with recommending antibiotics for the patient with dementia and pneumonia (OR 1.64, 95% CI 1.08-2.50). CONCLUSION This study provides preliminary evidence that patient disposition toward more and less aggressive treatment in advanced illness does not substantially factor into physician recommendations. Non-religious physicians appear less likely to recommend disease-directed medical treatment in the setting of advanced illness, although this finding was not uniform and deserves further research.
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Affiliation(s)
- Benjamin W Frush
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA; Duke Divinity School, Durham, North Carolina, USA.
| | - Simon G Brauer
- Duke University Sociology Department, Durham, North Carolina, USA
| | - John D Yoon
- MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA; Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Farr A Curlin
- Duke Divinity School, Durham, North Carolina, USA; Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
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JD KR, MD JL, PhD ZZ, MD MB, Dawson NV. Dying with End Stage Liver Disease with Cirrhosis: Insights from SUPPORT. J Am Geriatr Soc 2015. [DOI: 10.1111/j.1532-5415.2000.tb03121.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Risk factors for hospitalization and medical intensive care unit (MICU) admission among HIV-infected Veterans. J Acquir Immune Defic Syndr 2013; 62:52-9. [PMID: 23111572 DOI: 10.1097/qai.0b013e318278f3fa] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE With improved survival of HIV-infected persons on antiretroviral therapy and growing prevalence of non-AIDS diseases, we asked whether the VACS Index, a composite measure of HIV-associated and general organ dysfunction predictive of all-cause mortality, predicts hospitalization and medical intensive care unit (MICU) admission. We also asked whether AIDS and non-AIDS conditions increased risk after accounting for VACS Index score. METHODS We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV-infected Veterans receiving care between 2002 and 2008. Data were obtained from the electronic medical record, VA administrative databases, and patient questionnaires and were used to identify comorbidities and calculate baseline VACS Index scores. The primary outcome was first hospitalization within 2 years of VACS enrollment. We used multivariable Cox regression to determine risk factors associated with hospitalization and logistic regression to determine risk factors for MICU admission, given hospitalization. RESULTS Of 3410 patients, 1141 were hospitalized within 2 years; 203 (17.8%)/1141 patients included an MICU admission. Median VACS Index scores were 25 (no hospitalization), 34 (hospitalization only), and 51 (MICU). In adjusted analyses, a 5-point increment in VACS Index score was associated with 10% higher risk of hospitalization and MICU admission. In addition to VACS Index score, Hispanic ethnicity, current smoking, hazardous alcohol use, chronic obstructive pulmonary disease, hypertension, diabetes, and prior AIDS-defining event predicted hospitalization. Among those hospitalized, VACS Index score, cardiac disease, and prior cancer predicted MICU admission. CONCLUSIONS The VACS Index predicted hospitalization and MICU admission as did current smoking, hazardous alcohol use, and AIDS and certain non-AIDS diagnoses.
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Lone NI, Walsh TS. Impact of Intensive Care Unit Organ Failures on Mortality during the Five Years after a Critical Illness. Am J Respir Crit Care Med 2012; 186:640-7. [DOI: 10.1164/rccm.201201-0059oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ostir GV, Berges I, Kuo YF, Goodwin JS, Ottenbacher KJ, Guralnik JM. Assessing gait speed in acutely ill older patients admitted to an acute care for elders hospital unit. ACTA ACUST UNITED AC 2012; 172:353-8. [PMID: 22371922 DOI: 10.1001/archinternmed.2011.1615] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Assessment of mobility in geriatric hospital units relies primarily on subjective observation or patient self-reports. We objectively examined the gait speed of hospitalized older patients. METHODS Prospective study of 322 patients 65 years or older admitted from the community to a geriatric hospital unit between March 2008 and October 2009. Associations of gait speed (in meters per second) and activities of daily living with length of stay and home discharge were examined in multivariable logistic and generalized linear regression models. RESULTS In total, 206 of 322 patients completed the gait speed walk, with a mean gait speed of 0.53 m/s. A strong association was found between faster gait speed and shorter length of stay. Patients unable to complete the walk and patients having gait speeds of less than 0.40 m/s had significantly longer lengths of stay by 1.9 and 1.4 days, respectively, compared with patients having gait speeds of at least 0.60 m/s. Similarly, patients unable to complete the walk (odds ratio, 0.03; 95% CI, 0.003-0.21) and patients having gait speeds of less than 0.40 m/s (odds ratio, 0.07; 95% CI, 0.001-0.63) had significantly decreased odds of home discharge compared with patients having gait speeds of at least 0.60 m/s. Activities of daily living were less robust than gait speed in discriminating the risk of length of stay or home discharge. CONCLUSIONS Gait speed is a clinically relevant indicator of functional status and is associated with important geriatric health outcomes, including length of stay and home discharge. Gait speed could be used to complement information obtained by self-reported activities of daily living.
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Affiliation(s)
- Glenn V Ostir
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0177, USA.
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Abstract
Neurocritical care is a subspecialty of critical care medicine, dedicated to the care and the advancement of care of critically ill patients with neurosurgical or neurological diseases. Neurocritical care patients are heterogeneous, in both their disease process and the therapies they receive, however, several studies demonstrate that care of these patients in dedicated NeuroIntensive Care Units (neuroICUs) by neurointensivists, who coordinate their care is associated with reduced mortality and resource utilization. NeuroICUs foster innovation, and yet despite all the recent advances, much research needs to be undertaken in neurocritical care to better understand the disease pathophysiology and to demonstrate improved outcome with the use of goal-directed therapy based on evolving techniques and therapies.
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Critical illness in HIV-infected patients in the era of combination antiretroviral therapy. Ann Am Thorac Soc 2011; 8:301-7. [PMID: 21653532 DOI: 10.1513/pats.201009-060wr] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
As HIV-infected persons on combination antiretroviral therapy (ART) are living longer and rates of opportunistic infections have declined, serious non-AIDS-related diseases account for an increasing proportion of deaths. Consistent with these changes, non-AIDS-related illnesses account for the majority of ICU admissions in more recent studies, in contrast to earlier eras of the AIDS epidemic. Although mortality after ICU admission has improved significantly since the earliest HIV era, it remains substantial. In this article, we discuss the current state of knowledge regarding the impact of ART on incidence, etiology, and outcomes of critical illness among HIV-infected patients. In addition, we consider issues related to administration of ART in the ICU and identify important areas of future research.
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Gehlbach BK, Salamanca VR, Levitt JE, Sachs GA, Sweeney MK, Pohlman AS, Charbeneau JT, Krishnan JA, Hall JB. Patient-related factors associated with hospital discharge to a care facility after critical illness. Am J Crit Care 2011; 20:378-86. [PMID: 21885459 PMCID: PMC3735167 DOI: 10.4037/ajcc2011827] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Many critically ill patients are transferred to other care facilities instead of to home at hospital discharge. OBJECTIVE To identify patient-related factors associated with hospital discharge to a care facility after critical illness and to estimate the magnitude of risk associated with each factor. METHODS Retrospective cohort study of 548 survivors of critical illness in a medical intensive care unit. Multivariable logistic regression was used to identify independent risk factors for discharge to a care facility. Only the first 72 hours of intensive care were analyzed. RESULTS Approximately one-quarter of the survivors of critical illness were discharged to a care facility instead of to home. This event occurred more commonly in older patients, even after adjustment for severity of illness and comorbid conditions (odds ratio [OR] 1.8 for patients ≥ 65 years of age vs patients < 65 years; 95% confidence interval [CI], 1.1-3.1; P = .02). The risk was greatest for patients who received mechanical ventilation (OR, 3.4; 95% CI, 2.0-5.8; P < .001) or had hospitalizations characterized by severe cognitive dysfunction (OR, 8.1; 95% CI, 1.3-50.6; P = .02) or poor strength and/or mobility (OR, 31.7; 95% CI, 6.4-157.3; P < .001). The model showed good discrimination (area under the curve, 0.82; 95% CI, 0.77-0.86). CONCLUSION The model, which did not include baseline function or social variables, provided good discrimination between patients discharged to a care facility after critical illness and patients discharged to home. These results suggest that future research should focus on the debilitating effects of respiratory failure and on conditions with cognitive and neuromuscular sequelae.
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Affiliation(s)
- Brian K. Gehlbach
- University of Chicago, Section of Pulmonary and Critical Care Medicine
| | | | - Joseph E. Levitt
- Stanford University Medical Center, Division of Pulmonary and Critical Care Medicine
| | - Greg A. Sachs
- Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics; Indiana University Center for Aging Research; and Regenstrief Institute, Inc
| | - Mary Kate Sweeney
- University of Chicago, Section of Pulmonary and Critical Care Medicine
| | - Anne S. Pohlman
- University of Chicago, Section of Pulmonary and Critical Care Medicine
| | | | - Jerry A. Krishnan
- University of Chicago, Section of Pulmonary and Critical Care Medicine
- University of Chicago, Department of Health Studies
| | - Jesse B. Hall
- University of Chicago, Section of Pulmonary and Critical Care Medicine
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Alsultan MA, Alrshed RS, Aljumah AA, Baharoon SA, Arabi YM, Aldawood AS. In-hospital mortality among a cohort of cirrhotic patients admitted to a tertiary hospital. Saudi J Gastroenterol 2011; 17:387-90. [PMID: 22064336 PMCID: PMC3221112 DOI: 10.4103/1319-3767.87179] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND/AIM To determine the mortality rate in a cohort of hospitalized patients with cirrhosis and examine their resuscitation status at admission. MATERIALS AND METHODS A retrospective chart review was conducted of patients with cirrhosis who were admitted to a tertiary care hospital in Riyadh, Saudi Arabia, from January 1, 2009, to December 31, 2009. RESULTS We reviewed 226 cirrhotic patients during the study period. The hospital mortality rate was 35%. A univariate analysis revealed that worse outcomes were seen in patients with advanced age or who had worse child-turcotte-pugh (CPT) scores, worse model for end-stage liver disease (MELD) scores, low albumin and high serum creatinine. Using a multivariate analysis, we found that advanced age (P=0.004) and high MELD (P=0.001) scores were independent risk factors for the mortality of cirrhotic patients. The end-of-life decision were made in 34% of cirrhotic patients, and the majority of deceased patients were "no resuscitation" status (90% vs. 4%, P<0.001). CONCLUSIONS The relatively high mortality in cirrhotic patients admitted for care in a tertiary hospital, Saudi Arabia was comparable to that reported in the literature. Furthermore, end-of-life discussions should be addressed early in the hospitalization of cirrhotic patients.
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Affiliation(s)
- Mohammad A. Alsultan
- Department of Intensive Care Medicine and Emergency Medicine, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Rashed S. Alrshed
- Vice-president of King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Salim A. Baharoon
- Department of Intensive Care Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen M. Arabi
- Department of Intensive Care, King Saud Bin Abdulaziz University for Health Sciences,, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz S. Aldawood
- Department of Intensive Care, King Saud Bin Abdulaziz University for Health Sciences,, King Abdulaziz Medical City, Riyadh, Saudi Arabia,Address for correspondence: Dr. Abdulaziz S. Aldawood, Department of Intensive Care, King Saud Bin Abdulaziz University for Health Sciences and King Abdulaziz Medical City, Riyadh, Saudi Arabia. E-mail:
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Institutional variations in frequency of discharge of elderly intensive care survivors to postacute care facilities. Crit Care Med 2010; 38:2319-28. [PMID: 20890195 DOI: 10.1097/ccm.0b013e3181fa02e4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine variations in the frequency of discharge of elderly patients to postacute care facilities across multiple intensive care units and identify the influence of institutional and patient factors on the frequency of postacute care discharge. DESIGN Observational cohort study. SETTING Consecutive admissions from 65 intensive and coronary care units in 24 US hospitals during 2002-2008. Each hospital had a clinical information system in place. PATIENTS A total of 13,370 admissions in patients aged≥65 yrs who were alive at hospital discharge and met inclusion criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic, clinical, diagnostic, and physiological variables were obtained on all patients. In addition, information for each hospital and intensive care unit was recorded. Among hospital survivors, 46.2% were discharged to postacute care facilities with a range of 8.8-77.8%. A multivariable logistic regression model was developed that predicted discharge to a postacute care facility. The major variables affecting postacute care discharge were diagnosis, day 5 physiology, and day 5 therapy; these variables accounted for 61% of the model's explanatory power. Patient age, hospital bed size, teaching status, and intensive care unit type also affected postacute care discharge. Physiology and therapy on day 1 had little impact on postacute care discharge. The model accounted for only 31% of the variation in rates across intensive care units, indicating that unmeasured factors play a part in dictating discharge location. CONCLUSION Discharge of elderly intensive care unit patients to postacute care facilities varies widely by institution. These variations are only partially explained by differences in patient and institutional characteristics and are affected more by diagnosis and physiology on day 5, respectively. Unmeasured factors such as admission from a postacute care facility, postacute care availability, patient preferences, and socioeconomic factors may account for unexplained variations in postacute care discharge.
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Boyd CM, Ricks M, Fried LP, Guralnik JM, Xue QL, Xia J, Bandeen-Roche K. Functional decline and recovery of activities of daily living in hospitalized, disabled older women: the Women's Health and Aging Study I. J Am Geriatr Soc 2009; 57:1757-66. [PMID: 19694869 DOI: 10.1111/j.1532-5415.2009.02455.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine, in disabled, older, community-dwelling women who were hospitalized, the rates and predictors of functional decline, the probability and time course of subsequent functional recovery, and predictors of functional recovery. DESIGN Population-based observational cohort. SETTING Woman's Health and Aging Study. PARTICIPANTS A subset of the 1,002 moderately to severely disabled community-dwelling older women who were hospitalized over 3 years (N=457). MEASUREMENTS Functional decline and complete and partial recovery were defined using a 0 to 6 scale of dependencies in activities of daily living (ADLs) evaluated every 6 months over 3 years. Complete recovery was defined as returning to baseline function (function at visit immediately preceding hospitalization) after functional decline; partial recovery was defined as any improvement in the ADL scale after functional decline. Multiple logistic regression analysis was used to determine predictors of functional decline. Kaplan-Meier curves estimate the proportions recovering as a function of time since hospitalization. Discrete-time proportional hazards models regress the time-to-recovery hazards on the predictor variables. RESULTS Thirty-three percent of hospitalized women experienced functional decline at the first visit after hospitalization. Frailty, longer length of stay, and higher education were associated with functional decline. Fifty percent fully recovered over the subsequent 30 months, with 33% recovering within 6 months and an additional 14% over the following 6 months. Younger women were more likely to recover (aged 80 to 70, hazard ratio=0.39, 95% confidence interval=0.24-0.64). CONCLUSION Although most recovery of function occurs by 6 months after the first visit after a hospitalization, a substantial proportion of disabled community-dwelling women recover over the following 2 years.
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Affiliation(s)
- Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, School of Medicine and Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland 21224, USA.
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Keogan F. Abstracts of the Rehabilition and Therapy Research Society Fourth Annual Conference. PHYSICAL THERAPY REVIEWS 2008. [DOI: 10.1179/174328808x309223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
Making a prognosis is one of the primary functions of the medical profession. At the end of the nineteenth century prognostication took up approximately ten percent of medical textbooks, by 1970 this had fallen to nearly zero. Given medical technology's awesome ability to prolong the process and suffering of dying today's patients need to know their prognosis in order to make choices about their treatment options. Whilst precise predictions of the future are obviously not possible, relatively simple mathematical modelling techniques can make reasonable estimates of likely outcomes for individual patients. The life expectancy of a patient of any age with any illness can be estimated provided the disease-specific mortality of the illness is known. Decision analysis or logistic regression models can then be used to determine the risks and benefits of various treatment options. A patient's prognosis does not just depend on their age and primary diagnosis, but also on the severity of their illness, their functional capacity both prior to and during the illness and the number of co-morbidities also suffered from. Several predictive instruments have been developed to help simplify the prediction of the outcome of individual patients. There are conflicting reports on how these models compare with doctors' intuition--whatever their strengths and weaknesses it is unlikely that they worsen clinical judgement. Therefore, all doctors should become familiar with them and use them appropriately.
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Affiliation(s)
- John Kellett
- Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland.
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Arora VM, McGory ML, Fung CH. Quality Indicators for Hospitalization and Surgery in Vulnerable Elders. J Am Geriatr Soc 2007; 55 Suppl 2:S347-58. [PMID: 17910557 DOI: 10.1111/j.1532-5415.2007.01342.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Vineet M Arora
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA.
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Scharpf TP, Colabianchi N, Madigan EA, Neuhauser D, Peng T, Feldman PH, Bridges JFP. Functional status decline as a measure of adverse events in home health care: an observational study. BMC Health Serv Res 2006; 6:162. [PMID: 17181868 PMCID: PMC1774572 DOI: 10.1186/1472-6963-6-162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2006] [Accepted: 12/20/2006] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Research that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous. The objectives in this study are to develop models to predict functional decline for three indices of functional status as measures of adverse events in home health care and determine which index is most appropriate for risk-adjusting for future quality research. METHODS Data come from the Outcomes and Assessment Information Set (OASIS) from a large urban home health care agency and other agency data. Prognostic data yields 49,437 episodes, while follow-up data yields 47,684 episodes. We tested three indices defined as substantial decline in three or more (gt3_ADLs), two or more (gt2_ADLs), and one or more (gt1_ADLs) ADLs. Multivariate logistic regression determines the performance of the models for each index as measured by the c-statistic and Hosmer-Lemeshow chi square (chi2). RESULTS Frequencies for gt3_ADLs, gt2_ADLs, and gt1_ADLs are 212 (0.43%), 783 (1.58%), and 4,271 (8.64%) respectively. Follow-up results are comparable with frequencies of 218 (0.46%), 763 (1.60%), and 3,949 (8.28%) for each index. Gt3_ADLs does not produce valid models. The model for gt2_ADLs consistently yields a higher c-statistic compared to gt1_ADLs (0.754 vs. 0.679, respectively). Both indices' models yield non-significant Hosmer-Lemeshow chi square indicating reasonable model fit. Findings for gt2_ADLs and gt1_ADLs are consistent over time as indicated by follow-up data results. CONCLUSION Gt2_ADLs yields the best models as indicated by a high c-statistic and a non-significant Hosmer-Lemeshow chi2, both of which exhibit exceptional consistency. We conclude that gt2_ADLs may be preferable in defining ADL adverse events in the context of home health care.
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Affiliation(s)
- Tanya Pollack Scharpf
- Case Western Reserve University, Department of Epidemiology and Biostatistics, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Natalie Colabianchi
- Case Western Reserve University, Department of Epidemiology and Biostatistics, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Elizabeth A Madigan
- Case Western Reserve University, Frances Payne Bolton School of Nursing, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Duncan Neuhauser
- Case Western Reserve University, Department of Epidemiology and Biostatistics, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Timothy Peng
- The Center for Home Care Policy and Research, Visiting Nurse Service of New York, 107 East 70Street, New York, New York 10021, USA
| | - Penny H Feldman
- The Center for Home Care Policy and Research, Visiting Nurse Service of New York, 107 East 70Street, New York, New York 10021, USA
| | - John FP Bridges
- Department of Tropical Hygiene and Public Health, University of Heidelberg – Medical School, Im Neuenheimer Feld 324, D-69120, Heidelberg, Germany
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Jones CA, Feeny DH. Agreement Between Patient and Proxy Responses During Recovery After Hip Fracture: Evidence for the FIM Instrument. Arch Phys Med Rehabil 2006; 87:1382-7. [PMID: 17023250 DOI: 10.1016/j.apmr.2006.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Revised: 05/23/2006] [Accepted: 06/09/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the agreement between patient and proxy responses of the FIM instrument at 4 different periods of time during the first 6 months after hip fracture. DESIGN Prospective cohort study. SETTING A large urban health region with 2 tertiary hospitals that treat hip fractures. PARTICIPANTS Patients (n=137) who were 65 years or older, admitted to the health region with a primary diagnosis of hip fracture, who had Mini-Mental State Examination scores greater than 17. Family caregivers (n=137) participated as proxy respondents. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The FIM instrument. Agreement was evaluated at each of the 4 assessments during the 6-month follow-up after hip fracture using intraclass correlation coefficient. RESULTS FIM scores improved over the 6 months with the greatest improvement occurring within the first month of recovery. Agreement was higher for more observable activities than less observable ones. The magnitude of agreement improved over the 6 months with the proportion of clinically important systematic differences decreasing over time. Agreement for change scores was lower than the agreement at each of the 4 assessments. CONCLUSIONS Patient-proxy agreement levels are acceptable; the agreement varies with the subscale and the recovery phase. Substitution of proxy for patient responses across time may be used guardedly when patient responses are missing.
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Affiliation(s)
- C Allyson Jones
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada.
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Beuks BC, Nijhof AC, Meertens JHJM, Ligtenberg JJM, Tulleken JE, Zijlstra JG. A good death. Intensive Care Med 2006; 32:752-3. [PMID: 16501943 DOI: 10.1007/s00134-006-0097-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Accepted: 02/06/2006] [Indexed: 11/28/2022]
Abstract
We describe the cases of two patients discharged home directly from the ICU. Both patients had the strong wish to die at home after being told that there were no therapeutic options. Sometimes discharge is feasible and can mean very much for patients and their family. Taking measures to ensure a "good deathbed" is an obligation for doctors and nursing staff. However, due to the focus on cure this palliative goal is not always pursued.
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Affiliation(s)
- Brigitte C Beuks
- Intensive and Respiratory Care, Department of Internal Medicine, University Medical Centre Groningen, University of Groningen, 30.001, 9700 RB, Groningen, The Netherlands
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Jones CA, Feeny DH. Agreement Between Patient and Proxy Responses of Health-Related Quality of Life After Hip Fracture. J Am Geriatr Soc 2005; 53:1227-33. [PMID: 16108944 DOI: 10.1111/j.1532-5415.2005.53374.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine agreement between patient and proxy respondents on health-related quality of life (HRQL) over time during the 6-month recovery after hip fracture. DESIGN Prospective longitudinal cohort study. SETTING A healthcare region serving Edmonton, Alberta, and the surrounding area. PARTICIPANTS Two hundred forty-five patients aged 65 and older, were treated for hip fracture, and had Mini-Mental State Examination scores greater than 17; 245 family caregivers participated as proxy respondents. MEASUREMENTS Primary outcome was HRQL (Health Utilities Mark 2 and Mark 3). Interviews were completed within 5 days after surgery and at 1, 3, and 6 months. Agreement was evaluated using intraclass correlation coefficients (ICCs). RESULTS Agreement was considered moderate to excellent for HRQL. ICC values ranged from 0.50 to 0.85 (P<.001) for physically based observable dimensions of health status and from 0.32 to 0.66 (P<.01) for less-observable dimensions. Agreement improved with time. Time and the number of days between patient and proxy interviews were significant factors in accounting for patient-proxy differences. CONCLUSION Although proxy and patient responses are not interchangeable, proxy responses provide an option for assessing function and health status in patients who are unable to respond on their own behalf.
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Affiliation(s)
- C Allyson Jones
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada.
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Doll H, Miravitlles M. Health-related QOL in acute exacerbations of chronic bronchitis and chronic obstructive pulmonary disease: a review of the literature. PHARMACOECONOMICS 2005; 23:345-63. [PMID: 15853435 DOI: 10.2165/00019053-200523040-00005] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
There is a lack of emphasis on health-related QOL (HR-QOL) changes associated with acute exacerbation of chronic bronchitis (CB) or chronic obstructive pulmonary disease (COPD). The aim of this review is to examine the use of HR-QOL instruments to evaluate acute exacerbation of CB or COPD, so as to form recommendations for future research.A literature search of papers published between 1966 and July 2003 identified more than 300 articles that used acute exacerbation of CB or COPD as the search term. However, only 21 of these studies employed HR-QOL measures as predictors of outcome or in the assessment of the impact, evolution or treatment of acute exacerbations of COPD or CB. A variety of HR-QOL measures were used, both generic and disease specific. The disease-specific St George's Respiratory Questionnaire (SGRQ), devised for patients with stable CB and with a recall period of 1-12 months, was the most widely used measure, with the Chronic Respiratory disease Questionnaire (CRQ) and the Baseline and Transitional Dyspnoea Index (BDI, TDI) being the only other disease-specific measures used. Most measures, both generic and disease specific, performed adequately when used during acute exacerbation of CB or COPD and indicated poor HR-QOL during acute exacerbation, which improved on resolution of the exacerbation. Relationships were evident between HR-QOL during an acute exacerbation and various outcomes, including post-exacerbation functional status, hospital re- admission for acute exacerbation or COPD, and mortality. There is a need for studies of treatments for acute exacerbation of CB or COPD to include an appropriate HR-QOL instrument to aid in the stratification of patients so as to target the right treatment to the right patient group. While a new instrument could be developed to measure HR-QOL during acute exacerbation of CB or COPD, currently available disease-specific measures such as the CRQ and the SGRQ appear to be acceptable to patients during acute exacerbation. However, the recall period of the SGRQ symptoms component should be shortened to make it more appropriate for use during acute exacerbation.
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Affiliation(s)
- Helen Doll
- Oxford Outcomes, Old Barn, Jericho Farm, Cassington, Oxford, UK.
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Garland A, Dawson NV, Altmann I, Thomas CL, Phillips RS, Tsevat J, Desbiens NA, Bellamy PE, Knaus WA, Connors AF. Outcomes up to 5 Years After Severe, Acute Respiratory Failure. Chest 2004; 126:1897-904. [PMID: 15596690 DOI: 10.1378/chest.126.6.1897] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To use an existing database from a large cohort study with follow-up as long as 5.5 years to assess the extended prognosis of patients who survived their hospitalizations for severe acute respiratory failure (ARF). DESIGN, SETTING, AND PATIENTS Secondary analysis of an inception cohort of 1,722 patients with ARF requiring mechanical ventilation from five major medical centers who were entered into the prospective Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. The 1,075 patients (62.4%) who survived hospitalization had systematic follow-up of vital status for a median time of 662 days (interquartile range, 327 to 1,049 days; range, 2 to 2,014 days). Interviews performed a median of 5 months after hospital discharge assessed functional capacity and quality of life (QOL). The main outcome measure was survival after hospital discharge. Secondary measures were functional status and QOL. Cox proportional hazard regression identified factors influencing posthospital survival. RESULTS The median survival time after hospital discharge for ARF was > 5.3 years. The posthospital survival time was shorter for those with older age, male gender, several preexisting comorbid conditions, worse prehospital functional status, greater acute physiologic derangement, and a do-not-resuscitate order while in the hospital, and for those discharged to a location other than home. Five months after hospital discharge, 48% of survivors needed help with at least one activity of daily living, and 27% rated their QOL as poor or fair. However, most of these impairments were present before respiratory failure occurred. CONCLUSIONS Extended survival is common among patients with ARF who require mechanical ventilation and who survive hospitalization. Among these patients, only a small fraction of the impairment in activity and QOL can be considered to be a sequela of the respiratory failure or its therapy. These findings are relevant to the care decisions for such critically ill patients.
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Affiliation(s)
- Allan Garland
- Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
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Conforti DA, Basic D, Rowland JT. Emergency department admissions, older people, functional decline, and length of stay in hospital. Australas J Ageing 2004. [DOI: 10.1111/j.1741-6612.2004.00048.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Guyatt G, Cook D, Weaver B, Rocker G, Dodek P, Sjokvist P, Hamielec C, Puksa S, Marshall J, Foster D, Levy M, Varon J, Thorpe K, Fisher M, Walter S. Influence of perceived functional and employment status on cardiopulmonary resuscitation directives. J Crit Care 2004; 18:133-41. [PMID: 14595566 DOI: 10.1016/j.jcrc.2003.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Perceptions about functional and employment status before admission to the intensive care unit (ICU) may influence how patients and clinicians make decisions about cardiopulmonary resuscitation. OBJECTIVE To examine the relationship between cardiopulmonary resuscitation directives established within 24 hours of admission to the ICU and clinical perceptions of premorbid functional and employment status. DESIGN Prospective observational study in 15 university-affiliated centers in Canada, the United States, Australia, and Sweden. PATIENTS A total of 1,008 ICU patients aged 18 years or older expected to stay in the ICU at least 72 hours. MEASUREMENTS By using multinomial logistic regression, we examined the relationship between functional status and employment status perceived by the ICU team 1 month before ICU admission (the independent variables) and resuscitation status (the dependent variable). Each patient had either an explicit resuscitation directive (to resuscitate or not to resuscitate), or an implicit resuscitation directive to resuscitate. RESULTS On average, patients were 61.7 years (+/-17.4 y) old with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.5 (+/-8.7); 846 (83.9%) were ventilated mechanically within 48 hours and 345 (34.2%) died in the ICU. Most patients (793, 78.7%) had no explicit resuscitation directive; 98 (9.7%) had an explicit plan to resuscitate, whereas 117 (11.6%) had an explicit plan of do-not-resuscitate. Of 1,008 patients, 98 (9.7%) were severely functionally limited, 217 (21.5%) were somewhat limited, 628 (62.3%) were totally independent, and 65 (6.4%) had unknown functional status 1 month before ICU admission. Severe functional status impairment was associated moderately with an explicit plan to resuscitate (odds ratio, 2.2 relative to no explicit directive) and associated strongly with an explicit do-not-resuscitate plan (odds ratio, 6.2 relative to no explicit directive, P value on the difference =.011). This relationship was not influenced by age, sex, APACHE II score, medical or surgical status, admission diagnosis, employment status, or city. However, severe functional status was associated strongly and significantly with an explicit do-not-resuscitate directive among those who could not participate in decision making (odds ratio, 8.2; 95% confidence interval, 4.5-15.0), and more weakly associated in those who could participate (odds ratio, 1.7; 95% confidence interval, 0.3-8.6). Being unemployed was associated with an increased odds of an explicit resuscitation directive versus no explicit directive (odds ratio, 5.5; 95% confidence interval, 2.2-13.4). CONCLUSIONS Functional status impairment perceived by the ICU team is associated clearly with do-not-resuscitate directives in patients unable to participate in decision making. However, the association appears much weaker in patients able to participate in decision making. PATIENTS' perceived employment status also may influence resuscitation decisions. Our results emphasize the challenges of ensuring that crucial resuscitation decisions are not affected adversely by patients' inability to participate in decisions, and by their functional and employment status.
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Chelluri L, Im KA, Belle SH, Schulz R, Rotondi AJ, Donahoe MP, Sirio CA, Mendelsohn AB, Pinsky MR. Long-term mortality and quality of life after prolonged mechanical ventilation. Crit Care Med 2004; 32:61-9. [PMID: 14707560 DOI: 10.1097/01.ccm.0000098029.65347.f9] [Citation(s) in RCA: 235] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe and identify factors associated with mortality rate and quality of life 1 yr after prolonged mechanical ventilation. DESIGN Prospective, observational cohort study with patient recruitment over 26 months and follow-up for 1 yr. SETTING Intensive care units at a tertiary care university hospital. PATIENTS Adult patients receiving prolonged mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We measured mortality rate and functional status, defined as the inability to perform instrumental activities of daily living (IADLs) 1 yr following prolonged mechanical ventilation. The study enrolled 817 patients. Their median age was 65 yrs, 46% were women, and 44% were alive at 1 yr. Median ages at baseline of 1-yr survivors and nonsurvivors were 53 and 71 yrs, respectively. At the time of admission to the hospital, survivors had fewer comorbidities, lower severity of illness score, and less dependence compared with nonsurvivors. Severity of illness on admission to the intensive care unit and prehospitalization functional status had a significant association with short-term mortality rate, whereas age and comorbidities were related to long-term mortality. Fifty-seven percent of the surviving patients needed caregiver assistance at 1 yr of follow-up. The odds of having IADL dependence at 1-yr among survivors was greater in older patients (odds ratio 1.04 for 1-yr increase in age) and those with IADL dependence before hospitalization (odds ratio 2.27). CONCLUSIONS Mortality rate after prolonged mechanical ventilation is high. Long-term mortality rate is associated with older age and poor prehospitalization functional status. Many survivors needed assistance after discharge from the hospital, and more than half still required caregiver assistance at 1 yr. Interventions providing support for caregivers and patients may improve the functional status and quality of life of both groups and thus need to be evaluated.
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Affiliation(s)
- Lakshmipathi Chelluri
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA.
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Pauwels R, Calverley P, Buist AS, Rennard S, Fukuchi Y, Stahl E, Löfdahl CG. COPD exacerbations: the importance of a standard definition. Respir Med 2004; 98:99-107. [PMID: 14971871 DOI: 10.1016/j.rmed.2003.09.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Efforts to assess the efficacy of new therapies in the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD) have been hampered by the lack of a widely agreed and consistently used definition. A variety of definitions have been used in clinical studies, based on changes in patient symptoms or the requirement for antibiotic therapy, oral steroids or hospitalisation. To date, none of these definitions have been assessed in detail for their reliability, responsiveness and validity determined. Considerable heterogeneity in the aetiology and manifestation of COPD exacerbations makes identification and quantification of defining symptoms extremely difficult. New approaches are therefore being sought with a view to identifying a serum or tissue marker that can be used as a valuable diagnostic tool. Improvements in data recording will also contribute to the accuracy of data retrieval and assessment. If we are to progress to a level of sophistication seen in the diagnosis and management of other diseases, it is evident that considerable research efforts will be required to improve our understanding of COPD exacerbations and develop a standard definition for these events, thereby facilitating the assessment of therapeutic approaches.
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Affiliation(s)
- R Pauwels
- Department of Respiratory Diseases, Ghent University Hospital, De Pintelaan 185, Ghent 9000, Belgium.
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Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, Burant CJ, Landefeld CS. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc 2003; 51:451-8. [PMID: 12657063 DOI: 10.1046/j.1532-5415.2003.51152.x] [Citation(s) in RCA: 1003] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function. DESIGN Prospective observational study. SETTING The general medical service of two hospitals. PARTICIPANTS Two thousand two hundred ninety-three patients aged 70 and older (mean age 80, 64% women, 24% nonwhite). MEASUREMENTS At the time of hospital admission, patients or their surrogates were interviewed about their independence in five ADLs (bathing, dressing, eating, transferring, and toileting) 2 weeks before admission (baseline) and at admission. Subjects were interviewed about ADL function at discharge. Outcome measures included functional decline between baseline and discharge and functional changes between baseline and admission and between admission and discharge. RESULTS Thirty-five percent of patients declined in ADL function between baseline and discharge. This included the 23% of patients who declined between baseline and admission and failed to recover to baseline function between admission and discharge and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Twenty percent of patients declined between baseline and admission but recovered to baseline function between admission and discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23%, 28%, 38%, 50%, and 63% in patients aged 70-74, 75-79, 80-84, 85-89, and > or =90, respectively, P <.001). After adjustment for potential confounders, age was not associated with ADL decline before hospitalization (odds ratio (OR) for patients aged > or =90 compared with patients aged 70-74 = 1.26, 95% confidence interval (CI) = 0.88-1.82). In contrast, age was associated with the failure to recover ADL function during hospitalization in patients who declined before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 2.09, 95% CI = 1.20-3.65) and with new losses of ADL function during hospitalization in patients who did not decline before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 3.43, 95% CI = 1.92-6.12). CONCLUSION Many hospitalized older people are discharged with ADL function that is worse than their baseline function. The oldest patients are at particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization
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Affiliation(s)
- Kenneth E Covinsky
- Division of Geriatrics, University of California at San Francisco, San Francisco, California, USA.
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Binder EF, Kruse RL, Sherman AK, Madsen R, Zweig SC, D'Agostino R, Mehr DR. Predictors of short-term functional decline in survivors of nursing home-acquired lower respiratory tract infection. J Gerontol A Biol Sci Med Sci 2003; 58:60-7. [PMID: 12560413 DOI: 10.1093/gerona/58.1.m60] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Scant information exists about the risk of functional decline following treatment of acute illness in the nursing home (NH) setting. The aim of this study was to determine the incidence of short-term (30-day) functional decline among survivors of NH-acquired lower respiratory tract infection (LRI) and the factors that predict such decline, including the role of initial hospitalization. METHODS We used a prospective cohort design to study 781 episodes of LRI in 1044 NH residents in 36 NHs in central Missouri and the St. Louis metropolitan area. Functional decline was defined as a 3-point increase on the Minimum Data Set (MDS) activities of daily living (ADL) long form scale. RESULTS Of 781 LRI cases who survived to 30 days, the incidence of ADL decline was 28.8%. In a logistic regression model that used generalized estimating equations to adjust for clustering, variables associated with ADL decline included the following: chronic feeding tube use (AOR = 4.54, 95% confidence interval, or CI, 1.61, 12.80), decubitus ulcer (adjusted odds ratio [AOR] = 2.29, 95% CI 1.35, 3.90), shortness of breath (AOR = 2.18, 95% CI 1.44, 3.30), short-term memory problems (AOR = 2.07, 95% CI 1.33, 3.23), decline in self-performance of toilet use in the 24 hours prior to evaluation (AOR = 1.65, 95% CI 1.29, 2.12), age (AOR = 1.02, 95% CI 1.00, 1.05), and baseline ADL score. Addition of treatment variables to the model showed that initial hospitalization was also associated with ADL decline (AOR = 1.90, 95% CI 1.20, 3.00). Residents with ADL decline at 30 days were less likely to recover to their baseline ADL status at 90 days. CONCLUSIONS Many NH residents who survive to 30 days following LRI develop new functional limitations, and such individuals are at risk for ADL decline at 90 days. A limited number of clinical variables may predict short-term functional decline. Initial hospitalization for acute treatment of LRI may increase the risk of subsequent ADL decline among individuals who survive to 30 days.
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Affiliation(s)
- Ellen F Binder
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
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Sands LP, Yaffe K, Covinsky K, Chren MM, Counsell S, Palmer R, Fortinsky R, Landefeld CS. Cognitive screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalized elders. J Gerontol A Biol Sci Med Sci 2003; 58:37-45. [PMID: 12560409 DOI: 10.1093/gerona/58.1.m37] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Many older adults lose functional ability during the course of acute illness and fail to recover function. We sought to determine whether performance on a cognitive screen at the time of hospital admission predicted the magnitude of functional recovery after hospitalization. METHODS We studied 2557 patients from two teaching hospitals to examine the association between level of impaired performance on a cognitive status screen and maintenance and recovery of functioning from admission through 90 days after discharge. On admission, 14% had mildly impaired cognitive performance with three or four errors on the Short Portable Mental Status Questionnaire; 28% had moderate to severely impaired cognitive performance with five or more errors on the cognitive status screen or inability to complete the screen and a diagnosis of dementia. RESULTS Performance on a brief cognitive screen on admission was strongly related to subsequent change in function. Among patients who needed help performing one or more activities of daily living at the time of admission, 23% of patients with moderate to severely impaired cognitive performance, 49% of patients with mildly impaired cognitive performance, and 67% of patients with little to no impairment in cognitive performance recovered ability to independently execute an additional activity of daily living by discharge (p <.001). Similar relationships were seen for change in instrumental activities of daily living and mobility. In multivariate repeated measures analyses of basic and instrumental activities of daily living and mobility on admission, discharge, and 30 and 90 days after discharge, patients with mildly impaired cognitive performance on admission showed less improvement than patients who did not have impaired cognitive performance, but more than those with moderate to severely impaired cognitive performance. The pattern of results did not change when patients with any signs of delirium were excluded. Patients with impaired cognitive performance were more likely to be admitted to a nursing home for the first time by 90 days after discharge. The odds ratios were 2.8 (95% confidence interval = 1.8-4.5) for patients with mildly impaired cognitive performance and 6.7 (95% confidence interval = 4.5-9.8) for patients with moderate to severely impaired cognitive performance. CONCLUSION Cognitive screening at hospital admission can be used to stratify patients according to the magnitude of expected functional recovery after an acute illness that required hospitalization.
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Affiliation(s)
- Laura P Sands
- UCSF/Mt. Zion Center on Aging and Department of Medicine, University of California, San Francisco, USA.
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End-of-Life Care in the Intensive Care Unit: Toward a New Concept of Futility. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Clermont G, Angus DC, Linde-Zwirble WT, Griffin MF, Fine MJ, Pinsky MR. Does acute organ dysfunction predict patient-centered outcomes? Chest 2002; 121:1963-71. [PMID: 12065364 DOI: 10.1378/chest.121.6.1963] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Long-term patient-centered outcomes after acute illness may be associated with baseline health status, the development of acute organ dysfunction (AOD), or both. STUDY OBJECTIVE To determine whether AOD (occurring in the first 30 days) was independently associated with 90-day survival, functional status, and health-related quality of life (HRQL) after controlling for baseline health status in patients who were hospitalized with community-acquired pneumonia (CAP) and survived to day 30. DESIGN Prospective observational study. SETTING Four hospitals in Pennsylvania, Massachusetts, and Nova Scotia, Canada, between October 1991 and March 1994. PATIENTS One thousand three hundred thirty-nine patients who were hospitalized with CAP. INTERVENTIONS Baseline and 90-day quality-of-life and functional status questionnaires. MEASUREMENTS AND RESULTS We determined the 90-day survival rate in all patients (n = 1,339) and the functional status and HRQL in subsets of 261 and 219 patients, respectively. AOD occurred in one or more organ system in 639 patients (47.7%) and in two or more organ systems in 255 patients (19.1%). In univariate analyses, greater AOD was associated with a higher mortality rate (p < 0.0001), a lower HRQL (p = 0.006), and lower functional status (p = 0.009) at 90 days. However, after adjusting for baseline HRQL, AOD was not associated with mortality (p = 0.47) or HRQL (p = 0.14) at 90 days and was only weakly associated with 90-day functional status (p = 0.02). CONCLUSIONS Although patients who develop AOD are at risk for late adverse outcomes, their risk is due predominantly to poor baseline status prior to illness and not to the organ dysfunction per se. Therefore, AOD does not appear to have significant long-term ramifications for patient-centered outcomes.
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Affiliation(s)
- Gilles Clermont
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Teno JM, Weitzen S, Fennell ML, Mor V. Dying trajectory in the last year of life: does cancer trajectory fit other diseases? J Palliat Med 2002; 4:457-64. [PMID: 11798477 DOI: 10.1089/109662101753381593] [Citation(s) in RCA: 208] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To examine differences in the pattern of functional decline among persons dying of cancer and other leading noncancer causes of death. DESIGN Mortality followback survey of next of kin listed on death certificate. SETTING Probability sample of all deaths in the United States. PARTICIPANTS Next of kin for 3,614 decedents that represented 914,335 deaths. MEASUREMENTS Days of difficulty with activities of daily living and mobility in the last year of life. RESULTS Relative to other decedents, patients with cancer experienced an increased rate of functional impairment beginning as late as 5 months prior to death. For example, only 13.9% of patients with cancer had difficulty getting out of bed or a chair 1-year prior to death. This increased from 22.2% to 63.0% in the last five months of life. In contrast, decedents from other diseases had higher rates of functional impairment 1 year prior to death (approximately 35% had difficulty getting out of bed or chair) and they manifested a more gradual increase in the level of functional decline (approximately 50% had difficulty getting out of bed). Precipitous functional decline was associated with hospice involvement and dying at home. CONCLUSION Persons dying of cancer experienced sharp functional decline in the last months of life whereas other decedents' have a more gradual decline. The more precipitous functional decline was associated with hospice involvement and dying at home.
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Affiliation(s)
- J M Teno
- Department of Community Health, Center for Gerontology and Health Care Research, Brown University School of Medicine, Providence, Rhode Island, USA.
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Abstract
BACKGROUND The questions patients are asked about their preferences with regard to life-sustaining treatment usually focus on specific interventions, but the outcomes of treatment and their likelihood affect patients' preferences. METHODS We administered a questionnaire about treatment preferences to 226 persons who were 60 years of age or older and who had a limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease. The study participants were asked whether they would want to receive a given treatment, first when the outcome was known with certainty and then with different likelihoods of an adverse outcome. The outcome without treatment was specified as death from the underlying disease. RESULTS The burden of treatment (i.e., the length of the hospital stay, extent of testing, and invasiveness of interventions), the outcome, and the likelihood of the outcome all influenced treatment preferences. For a low-burden treatment with the restoration of current health, 98.7 percent of participants said they would choose to receive the treatment (rather than not receive it and die), but 11.2 percent of these participants would not choose the treatment if it had a high burden. If the outcome was survival but with severe functional impairment or cognitive impairment, 74.4 percent and 88.8 percent of these participants, respectively, would not choose treatment. The number of participants who said they would choose treatment declined as the likelihood of an adverse outcome increased, with fewer participants choosing treatment when the possible outcome was functional or cognitive impairment than when it was death. Preferences did not differ according to the primary diagnosis. CONCLUSIONS Advance care planning should take into account patients' attitudes toward the burden of treatment, the possible outcomes, and their likelihood. The likelihood of adverse functional and cognitive outcomes of treatment requires explicit consideration.
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Affiliation(s)
- Terri R Fried
- Clinical Epidemiology Unit, West Haven Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
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Wu AW, Young Y, Dawson NV, Brant L, Galanos AN, Broste S, Landefeld SC, Harrell FE, Lynn J. Estimates of future physical functioning by seriously ill hospitalized patients, their families, and their physicians. J Am Geriatr Soc 2002; 50:230-7. [PMID: 12028203 DOI: 10.1046/j.1532-5415.2002.50053.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare prognostic estimates made by seriously ill hospitalized patients, their surrogates, and their physicians about the patients' activities of daily living (ADLs) 2 months after admission; compare the accuracy of their estimates; and identify factors associated with the optimism and accuracy of these estimates. DESIGN Prospective cohort study. SETTING Five teaching hospitals. PARTICIPANTS A subset (n = 716) of patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. MEASUREMENTS Prognostic estimates of ADL function. RESULTS Physicians were less likely than patients or surrogates to give very high or very low estimates for future functioning. Seven of ten (69.3) patients who survived 2 months estimated that they would be functionally independent at Month 2, compared with 58.5 of their surrogates and 49.2 of their physicians. Agreement on prognosis was highest between patients and surrogates (64.2) and lowest between patients and physicians (48.4). Factors significantly associated with an optimistic estimate of independent functioning were better baseline ADL function, male gender, and higher level of education. Patients were significantly more accurate than surrogates and even more so than physicians in predicting independent functioning at Month 2. Worse baseline function and higher income were significantly associated with accurate estimation. CONCLUSION At hospital admission, seriously ill patients were more optimistic about their prognosis for physical functioning at 2 months, and more accurate in their estimates, than surrogates and physicians. Physicians tended to underestimate the prognosis for future functioning. Physicians should consider patients' and families' estimates before giving advice about treatment options and discharge planning.
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Affiliation(s)
- Albert W Wu
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA.
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Yeh CH. Health-related quality of life in pediatric patients with cancer. A structural equation approach with the Roy Adaptation Model. Cancer Nurs 2002; 25:74-80. [PMID: 11838723 DOI: 10.1097/00002820-200202000-00013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The purpose of this study was to test the Roy Adaptation Model-based theory of health-related quality of life in Taiwanese children with cancer. The environmental stimuli included severity of illness, age, gender, communication with others, and understanding of the illness. The severity of the illness was considered as a latent variable construct, including the stage of illness, laboratory values, and number of hospitalizations. Biopsychosocial responses, that is health-related quality of life, was hypothesized as a latent variable that consisted of (1) physical function, (2) psychologic function, (3) peer/school func tion, (4) treatment/disease symptoms, and (5) cognition functions. In total, 102 children with cancer participated in the study. Structural equation modeling was used to examine 2 Roy Adaptation Model-based theory propositions. The findings showed that the construct of severity of illness demonstrated excellent fit with the stage of illness, laboratory values, and total number of hospitalizations. Second, the health-related quality of life also demonstrated good construct validity with 5 domains. Third, this study supported the Roy Adaptation Model-based theory proposition that environmental stimuli influenced biopsychosocial responses.
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Affiliation(s)
- Chao-Hsing Yeh
- Graduate Institute of Nursing Science, Chang Gung University, Kwei-San, Tao-Yuen, Taiwan, Republic of China.
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Stull DE, Clough LA, Van Dussen D. Self-report quality of life as a predictor of hospitalization for patients with LV dysfunction: a life course approach. Res Nurs Health 2001; 24:460-9. [PMID: 11746075 DOI: 10.1002/nur.10006] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For this secondary data analysis of a large clinical drug study, researchers investigated the independent prognostic utility of self-report quality-of-life measures versus clinical measures for assessing patient risk for heart-failure-related hospitalization. The experience of heart failure varies over the life course; hence, four age groups were investigated. Quality-of-life measures, specifically health-related quality-of-life and psychosocial quality-of-life measures, were found to be independent and significant predictors of heart-failure-related hospitalizations, as compared to traditional clinical indicators. In addition, the psychosocial quality-of-life measure varied by age group in its importance as a predictor of hospitalization, suggesting differential relevance over the life course. Specifically, psychosocial quality of life was most strongly predictive of hospitalization for those ages 21-44, was less predictive for those ages 45-54, and was nonsignificant for those 55-64 years of age and those 65 and over. Including self-report quality-of-life measures provides a more complete picture of the factors associated with risk of hospitalization at different points in the life course for individuals with heart failure. These findings suggest that researchers and practitioners could use self-report quality-of-life measures as additional prognostic indicators of a patient's condition and risk for heart-failure-related hospitalization, especially for younger patients.
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Affiliation(s)
- D E Stull
- Department of Adult Health Nursing, School of Nursing, University of Maryland, 655 West Lombard Street, Baltimore, MD 21201-1579, USA
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Black NA, Jenkinson C, Hayes JA, Young D, Vella K, Rowan KM, Daly K, Ridley S. Review of outcome measures used in adult critical care. Crit Care Med 2001; 29:2119-24. [PMID: 11700407 DOI: 10.1097/00003246-200111000-00012] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- N A Black
- London School of Hygiene and Tropical Medicine, London, UK
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Rivera-Fernández R, Sánchez-Cruz JJ, Abizanda-Campos R, Vázquez-Mata G. Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate. Crit Care Med 2001; 29:1701-9. [PMID: 11546968 DOI: 10.1097/00003246-200109000-00008] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze the quality of life of critically ill patients before their intensive care admission and its relation to age, variables measured in the intensive care unit (ICU; severity of illness, therapeutic effort, resource utilization, and length of stay), and in-hospital mortality rate. DESIGN Observational prospective multicenter study. SETTING Eighty-six medical-surgical ICUs in Spain, including coronary patients. PATIENTS We studied 8,685 patients between 1992 and 1993. Patients <16 yrs old and those dying within the first 6 hrs were excluded. MEASUREMENTS AND MAIN RESULTS Data collection included age, gender, admission diagnosis, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) III, quality of life survey score, therapeutic activity level by Therapeutic Intervention Scoring System (TISS), and ICU and hospital mortality rate. Pre-ICU quality-of-life score was 3.74 +/- 4.42 points; 33.24% of patients had a normal quality of life (0 points), and numbers of patients declined logarithmically in relationship to increasing quality-of-life scores, with only 189 patients having a score >15 points. Pre-ICU quality-of-life score correlated with age (r =.289, p <.001), with severity level by APACHE III score (r =.217, p <.001), and weakly with TISS (r =.067, p <.001). There was no correlation between quality of life and length of ICU stay. Patients dying in hospital after ICU discharge (n = 429) had worse quality of life (5.88 +/- 5.38 points) than those dying in the ICU (n = 1,453, 4.8 +/- 4.94), who themselves had a worse quality of life than hospital survivors (n = 6,803, 5.05 +/- 5.07; p <.0001 by analysis of variance), with significant differences between all three groups. In the multivariate analysis, pre-ICU quality-of-life was related to age, APACHE III score, and hospital mortality rate but not to TISS or ICU length of stay. Pre-ICU quality of life was introduced as a variable in the APACHE III prediction model and entered the model after acute physiology score, diagnosis, and age and before prior patient location and comorbidities. The area under the receiver operating characteristics curve was 0.834 when quality-of-life was included and 0.83 when not. CONCLUSIONS In Spain, the quality of life of critically ill patients before their ICU admission is good, and only a small proportion of patients have a low quality of life before admission. Previous quality of life is related to hospital mortality rate but contributes very little to the discriminatory ability of the APACHE III prediction model and has little influence on ICU resource utilization as measured by length of stay and therapeutic activity.
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Affiliation(s)
- R Rivera-Fernández
- Spanish Project for the Epidemiological Analysis of Critical Care Patients (PAEEC), Granada, Spain
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Permanyer Miralda C, Brotons Cuixart C, Ribera Solé A, Alonso Caballero J, Cascant Castelló P, Moral Peláez I. [Outcomes of coronary artery surgery: determinants of quality of life related to postoperative health]. Rev Esp Cardiol 2001; 54:607-16. [PMID: 11412752 DOI: 10.1016/s0300-8932(01)76363-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Little is known of the clinical and nonclinical determinants of health related quality of life after coronary artery bypass graft in routine clinical practice. The aim of this study was to assess the quality of life and its determinants after a first coronary bypass in a representative population of Catalonia, Spain. PATIENTS AND METHOD Clinical and quality of life questionnaires were given to all the patients (n = 710) undergoing a first coronary bypass in private and public Catalan hospitals, prior to surgery and at six months and one year of follow-up. Quality of life was assessed with the DASI and the SF-36. RESULTS The rate of clinical events at one year was 23%. The mean quality of life improved to levels slightly below those in general population; with greater changes reported in physical than in mental condition although the latter was less impaired. In 24%, the quality of life scores at one year were below 1.5 standard deviations of those in the general population. Females, patients with comorbidity and those with public health care insurance showed lower quality of life scores. Independent predictors of one-year quality of life included initial quality of life scores, public insurance, comorbidity, gender, age and chronic disease. Postoperative angina and dyspnoea were also associated with quality of life. CONCLUSION The mean quality of life improves after coronary bypass, although up to one fourth of the patients may have unsatisfactory one-year clinical or quality of life outcome. Female patients, public insurance and comorbidity predict a worse quality of life.
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Affiliation(s)
- C Permanyer Miralda
- Unidad de Epidemiología. Servicio de Cardiología. Hospital General Vall d'Hebron.
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Desbiens NA, Mueller-Rizner N, Virnig B, Lynn J. Stress in caregivers of hospitalized oldest-old patients. J Gerontol A Biol Sci Med Sci 2001; 56:M231-5. [PMID: 11283196 DOI: 10.1093/gerona/56.4.m231] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Stress in caregivers of elderly patients is a well-recognized health care problem. However, little has been published about the stress in caregivers of the oldest-old patients, the most rapidly growing segment of our population. METHODS A prospective cohort study was conducted in four teaching hospitals. Questionnaires were administered to patients 80 years of age and older and their surrogates (the person who would make decisions if the patient were unable to-usually a family member) who identified themselves as the primary caregivers for the patients. Data were abstracted from medical records. RESULTS Caregivers tended to be female and 50 years of age or older. About one in five described her own health as fair or poor; nearly half of them lived with the patient. About one quarter spent at least 8 h/d caring for the patient, and they had few persons available to help them with care. Most of the caregivers reported mild-to-moderate levels of stress. After adjustment, higher stress scores were associated with female caregivers, poorer caregiver health, more hours per day spent caring for the patient, and the presence of patient depression and hearing impairment. CONCLUSION Stress is common in caregivers of the hospitalized oldest-old patients. Women who are in poor health and spend 8 or more hours every day caring for relatives aged 80 and over are at high risk for caregiver stress. Treatment of patient depression and hearing impairment may ameliorate caregiver stress.
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Affiliation(s)
- N A Desbiens
- University of Tennessee College of Medicine-Chattanooga Unit, Department of Medicine, Tennessee 37403, USA.
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McCrory DC, Brown C, Gelfand SE, Bach PB. Management of acute exacerbations of COPD: a summary and appraisal of published evidence. Chest 2001; 119:1190-209. [PMID: 11296189 DOI: 10.1378/chest.119.4.1190] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To critically review the available data on the diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of COPD. DESIGN, SETTING, AND PARTICIPANTS English-language articles were identified from the following databases: MEDLINE (from 1966 to week 5, 2000), EMBASE (from 1974 to week 18, 2000), HealthStar (from 1975 to June 2000), and the Cochrane Controlled Trials Register (2000, issue 1). The best available evidence on each subtopic then was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification. Study design and results were summarized in evidence tables. Individual studies were rated as to their internal validity, external validity, and quality of study design. Statistical analyses of combined data were not performed. MEASUREMENT AND RESULTS Limited data exist regarding the utility of most diagnostic tests. However, chest radiography and arterial blood gas sampling appear to be useful, while short-term spirometry measurements do not. In terms of the risk of relapse and the risk of death after hospitalization for an acute exacerbation, there are identifiable clinical variables that are associated with these outcomes. Therapies for which there is evidence of efficacy include bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. Based on limited data, mucolytics and chest physiotherapy do not appear to be of benefit, and oxygen supplementation appears to increase the risk of respiratory failure in an identifiable subgroup of patients. CONCLUSIONS Although suggestions for appropriate management can be made based on available evidence, the supporting literature is spotty. Further high-quality research is needed and will require an improved, generally acceptable, and transportable definition of the syndrome "acute exacerbation of COPD" and improved methods for observing and measuring outcomes.
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Affiliation(s)
- D C McCrory
- Center for Clinical Health Policy Research, Duke Evidence-Based Practice Center and Duke University Medical Center, Durham, NC, USA
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Chatila W, Kreimer DT, Criner GJ. Quality of life in survivors of prolonged mechanical ventilatory support. Crit Care Med 2001; 29:737-42. [PMID: 11373458 DOI: 10.1097/00003246-200104000-00007] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the long-term quality of life (QOL) in a group of patients after prolonged mechanical ventilatory support. DESIGN Prospective cohort study. SETTING Outpatient follow-up. PATIENTS Survivors of prolonged mechanical ventilatory support who were discharged from a ventilator rehabilitation unit (VRU). INTERVENTIONS Measurement of health-related QOL using the Sickness Impact Profile (SIP). MEASUREMENTS AND MAIN RESULTS Forty-six patients were contacted approximately 2 yrs after their discharge from the VRU and asked to complete the SIP. Twenty-five patients (age, 59 +/- 17 yrs; duration of mechanical ventilatory support, 45 +/- 36 days [mean +/- sd]) agreed to participate in this study and completed the SIP questionnaire 23 +/- 18 months after their discharge from the VRU. Patients' VRU stay was 29 +/- 21 days. Two patients were discharged with nocturnal ventilatory support, and the rest were completely weaned of mechanical ventilatory support before discharge. Fifteen patients (60%) were discharged to home, eight patients (32%) were discharged to a rehabilitation facility, and two patients (8%) were discharged to a skilled-care facility. Most patients had mild dysfunction, and the global SIP score was 12 +/- 10, the physical dimension score was 12 +/- 12, and the psychosocial dimension score was 9 +/- 11 (SIP scores range from 0 to 100, with higher scores indicating worse QOL). Subgroup analysis showed that postoperative patients had lower SIP scores compared with patients with chronic respiratory diseases (global SIP, 7 +/- 6 vs. 19 +/- 8; p <.05). Moreover, the patients in the postoperative group were older, but had similar SIP scores as patients who had acute lung injury (17 +/- 15). Global SIP scores correlated with age (r = -.40; p =.046), but not with duration of mechanical ventilatory support (r = -.23) or VRU admission Acute Physiology and Chronic Health Evaluation II scores (r = -.39; p =.06). CONCLUSIONS In survivors of prolonged mechanical ventilatory support, using specific selection criteria shows that there is minimal impairment in the QOL at long-term follow-up. Although some patients continue to have moderate to severe limitations, it is the cause of respiratory failure and the underlying disease, rather than duration of ventilatory support, that have a significant impact on QOL.
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Affiliation(s)
- W Chatila
- Division of Pulmonary and Critical Care Medicine, the Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA.
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Nguyen HB, Rivers EP, Havstad S, Knoblich B, Ressler JA, Muzzin AM, Tomlanovich MC. Critical care in the emergency department: A physiologic assessment and outcome evaluation. Acad Emerg Med 2000; 7:1354-61. [PMID: 11099425 DOI: 10.1111/j.1553-2712.2000.tb00492.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The changing landscape of health care in this country has seen an increase in the delivery of care to critically ill patients in the emergency department (ED). However, methodologies to assess care and outcomes similar to those used in the intensive care unit (ICU) are currently lacking in this setting. This study examined the impact of ED intervention on morbidity and mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Multiple Organ Dysfunction Score (MODS). METHODS This was a prospective, observational cohort study over a three-month period. Critically ill adult patients presenting to a large urban ED and requiring ICU admission were enrolled. APACHE II, SAPS II, and MODS scores and predicted mortality were obtained at ED admission, ED discharge, and 24, 48, and 72 hours in the ICU. In-hospital mortality was recorded. RESULTS Eighty-one patients aged 64 +/- 18 years were enrolled during the study period, with a 30.9% in-hospital mortality. The ED length of stay was 5.9 +/- 2.7 hours and the hospital length of stay was 12.2 +/- 16.6 days. Nine (11.1%) patients initially accepted for ICU admission were later admitted to the general ward after ED intervention. Septic shock was the predominant admitting diagnosis. At ED admission, there was a significantly higher APACHE II score in nonsurvivors (23.0 +/- 6.0) vs survivors (19.8 +/- 6.5, p = 0.04), while there was no significant difference in SAPS II or MODS scores. The APACHE II, SAPS II, and MODS scores were significantly lower in survivors than nonsurvivors throughout the hospital stay (p </= 0.001). The hourly rates of change (decreases) in APACHE II, SAPS II, and MODS scores were significantly greater during the ED stay (-0.55 +/- 0.64, -1.02 +/- 1.10, and -0.16 +/- 0.43, respectively) than subsequent periods of hospitalization in survivors (p < 0.05). There was a significant decrease in APACHE II and SAPS II predicted mortality during the ED stay (-8.0 +/- 14.0% and -6.0 +/- 14.0%, respectively, p < 0.001) and equally at 24 hours in the ICU (-7.0 +/- 13.0% and -4.0 +/- 16.0%, respectively, p </= 0.02). The APACHE II and SAPS II predicted mortality approached actual in-hospital mortality at approximately 12 hours and 36 hours after ED admission (in the ICU), respectively. CONCLUSIONS The care provided during the ED stay for critically ill patients significantly impacts the progression of organ failure and mortality. Although this period is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. This study emphasizes the importance of ED intervention. It also suggests that unique physiologic assessment methodologies should be developed to examine the quality of patient care, improve the accuracy of prognostic decisions, and objectively measure the impact of clinical interventions and pathways in the ED setting.
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Affiliation(s)
- H B Nguyen
- Department of Emergency Medicine, Henry Ford Hospital/Case Western Reserve University, Detroit, MI, USA
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Abstract
OBJECTIVE To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization. DESIGN Secondary analysis of a prospective cohort study. PARTICIPANTS Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed. MEASUREMENTS One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization. RESULTS One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P =.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7. 6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11. 9) times more likely to be admitted to a nursing home in the month after hospitalization. CONCLUSION Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence.
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Affiliation(s)
- J E Mahoney
- Department of Medicine, University of Wisconsin School of Medicine, and Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI 53705, USA
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Alarcón T, González-Montalvo JI, Bárcena A, Salgado A. [Factors associated with functional deterioration during hospitalization in the elderly admitted for acute diseases]. Rev Clin Esp 2000; 200:463-4. [PMID: 11076193 DOI: 10.1016/s0014-2565(00)70694-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Borum ML, Lynn J, Zhong Z. The effects of patient race on outcomes in seriously ill patients in SUPPORT: an overview of economic impact, medical intervention, and end-of-life decisions. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc 2000; 48:S194-8. [PMID: 10809475 DOI: 10.1111/j.1532-5415.2000.tb03132.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Black Americans have significantly lower life expectancy than white Americans. Racial differences in medical access, management, and DNR orders have been documented. OBJECTIVE To review the effects of patient race on intervention and end-of-life decisions in seriously ill patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN Review of published analyses from SUPPORT. SETTING Five teaching hospitals PARTICIPANTS A total of 9105 patients aged 18 years or older (15% black race) meeting diagnostic and illness severity criteria. MEASUREMENT Analysis of data collected by chart abstraction and interviews. RESULTS Blacks reported significant loss in savings, although adjusting for diagnosis and disease severity did not demonstrate significant racial differences. Economic hardship was associated with a preference for comfort care, except in black patients (OR 0.71; CI 95%, 0.57-0.88). Blacks received less intervention with no significant difference in survival. Pain level and control were not affected by race. Blacks were more likely to want CPR, although adjustment for self-pay or Medicaid eliminated racial differences. Blacks were more likely to continue to prefer CPR 2 months after hospitalization (28% vs 17%) and were more likely to change a DNR order to preferring CPR (40 vs 27%). Blacks also more frequently wished to discuss CPR preferences with their physicians but were less likely to have this type of communication (OR 1.53; CI 95%, 1.11-2.11). CONCLUSIONS Patient race may impact on medical intervention and preferences in seriously ill patients. However, in this population, the differences are of modest clinical importance.
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Affiliation(s)
- M L Borum
- Department of Medicine, The George Washington University Medical Center, Washington, DC 20037, USA
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Hamel MB, Lynn J, Teno JM, Covinsky KE, Wu AW, Galanos A, Desbiens NA, Phillips RS. Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT. J Am Geriatr Soc 2000; 48:S176-82. [PMID: 10809472 DOI: 10.1111/j.1532-5415.2000.tb03129.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To review previously published findings about how patient age influenced patterns of care for seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN An observational prospective study. SETTING Five acute care hospitals. PARTICIPANTS A total of 9105 seriously ill patients enrolled in SUPPORT. MEASUREMENTS The outcomes examined included patients' preferences for aggressive care, decision making regarding cardiopulmonary resuscitation and use of other life-sustaining treatments, hospital costs, intensity of resource use, and survival. RESULTS Although older patients preferred less aggressive care than younger patients, many older patients wanted cardiopulmonary resuscitation and care focused on life extension. Patients' families and healthcare providers underestimated older patients' desire for aggressive care. After adjustment for illness severity, comorbidity, baseline function, and patients' preferences for aggressive care, older age was associated with lower hospital costs and resource intensity and higher rates of decisions to withhold life-sustaining treatments. In adjusted analyses, older age was associated with a slight survival disadvantage. This survival disadvantage persisted, even after adjustment for aggressiveness of care, suggesting that the relation between age and survival is not accounted for by less aggressive treatment of older patients. CONCLUSIONS Even after adjustment for patients' prognoses and care preferences, seriously ill hospitalized older patients were treated less aggressively than younger patients. SUPPORT cannot fully identify whether the relationship between older age and less aggressive treatment is better explained by the withholding of potentially beneficial treatments from older patients, or by the excessive provision of ineffective treatment to younger patients. However, the latter explanation is favored by the SUPPORT finding that less aggressive treatment for older patients does not contribute to the modest survival disadvantage associated with older age.
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Affiliation(s)
- M B Hamel
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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McCarthy EP, Phillips RS, Zhong Z, Drews RE, Lynn J. Dying with cancer: patients' function, symptoms, and care preferences as death approaches. J Am Geriatr Soc 2000; 48:S110-21. [PMID: 10809464 DOI: 10.1111/j.1532-5415.2000.tb03120.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To characterize the dying experience of patients with cancer over the last 6 months of life. STUDY DESIGN A retrospective analysis of the last 6 months of life among patients with colon cancer and non-small cell lung cancer enrolled in a prospective cohort study from June 1989 to June 1991 and from January 1992 to January 1994. SETTING Five geographically diverse tertiary care academic medical centers participating in the Study to Understand Patient Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) Project. PARTICIPANTS All patients enrolled in SUPPORT who had either colon cancer, metastatic to the liver or stage III or stage IV non-small cell lung cancer and died within 1 year of their index hospitalization. This report examines 316 of 520 patients with metastatic colon cancer and 747 of 939 patients with lung cancer enrolled in SUPPORT. METHODS Data were collected by interview and chart abstraction at several time points in the SUPPORT Project. To describe progression to death, we constructed four observational windows backward in time beginning with patients' date of death and ending with their date of entry into the SUPPORT Project or 6 months before their death, whichever came first: (1) 3 days before death, (2) 3 days to 1 month before death, (3) 1 month to 3 months before death, and (4) 3 months to 6 months before death. For each outcome, patients contributed information to all windows during which they had data collected. We describe the frequency distributions of each outcome over time and report tests for trend. OUTCOME MEASURES We examined several outcomes over time, including: percentage of days spent in a hospital; prognosis as measured by model-based prognostic estimates of 6-month survival; severity of illness as measured by the acute physiology score; functional status as measured by dependencies in activities of daily living (ADLs); severe physical and emotional symptoms, including pain, depression, and anxiety; patients' preferences for care; and the financial impact on patients' families. RESULTS The death rate within 1 year of study entry was high among patients with metastatic colon cancer and advanced non-small cell lung cancer enrolled in SUPPORT (61% and 80%, respectively). As patients with cancer progress toward death, their estimated 6-month prognosis decreases significantly and the severity of their disease worsens. Patients' functional status also declines significantly as they approach death, such that most patients have four or more impairments within the 3 days before death. Patients with cancer experience significantly more pain and confusion as death approaches. Severe pain is common; more than one-quarter of patients with cancer experience serious pain 3 to 6 months before death and more than 40% were in serious pain during their last 3 days of life. However, dying patients are only modestly depressed and anxious during their last 3 days of life. As death approaches, patients favor comfort measures over life-extension, and about two-thirds want to forego resuscitation within 3 days of death. Families of patients dying with cancer incurred significant financial burdens during the last 6 months of life, and much of this burden was already experienced by 3 to 6 months before death. CONCLUSIONS The last 6 months of life for patients with cancer is characterized by functional decline and poorly controlled severe pain and confusion. Although patients increasingly prefer comfort care as they near death, many die in severe pain. These findings highlight important opportunities to improve the quality of care at the end of life for patients dying with cancer.
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Affiliation(s)
- E P McCarthy
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02115, USA
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