Psoas:lumbar vertebra index: central sarcopenia independently predicts morbidity in elderly trauma patients.

INTRODUCTION: Central sarcopenia as a surrogate for frailty has recently been studied as a predictor of outcome in elderly medical patients, but less is known about how this metric relates to outcomes after trauma. We hypothesized that psoas:lumbar vertebral index (PLVI), a measure of central sarcopenia, is associated with increased morbidity and mortality in elderly trauma patients. METHODS: A query of our institutional trauma registry from 2005 to 2010 was performed. Data was collected prospectively for the Pennsylvania Trauma Outcomes Study (PTOS). INCLUSION CRITERIA: age >55 years, ISS >15, and ICU LOS >48 h. Using admission CT scans, psoas:vertebral index was computed as the ratio between the mean cross-sectional areas of the psoas muscles and the L4 vertebral body at the level of the L4 pedicles. The 50th percentile of the psoas:L4 vertebral index value was determined, and patients were grouped into high (>0.84) and low (≤0.83) categories based on their relation to the cohort median. Primary endpoints were mortality and morbidity (as a combined endpoint for PTOS-defined complications). Univariate logistic regression was used to test the association between patient factors and mortality. Factors found to be associated with mortality at p < 0.1 were entered into a multivariable model. RESULTS: A total of 180 patients met the study criteria. Median age was 74 years (IQR 63-82), median ISS was 24 (IQR 18-29). Patients were 58 % male and 66 % Caucasian. Mean PLVI was 0.86 (SD 0.25) and was higher in male patients than female patients (0.91 ± 0.26 vs. 0.77 ± 0.21, p < 0.001). PLVI was not associated with mortality in univariate or multivariable modeling. After controlling for comorbidities, ISS, and admission SBP, low PLVI was found to be strongly associated with morbidity (OR 4.91, 95 % CI 2.28-10.60). CONCLUSIONS: Psoas:lumbar vertebral index is independently and negatively associated with posttraumatic morbidity but not mortality in elderly, severely injured trauma patients. PLVI can be calculated quickly and easily and may help identify patients at increased risk of complications.

Methodological recommendations for comparative research on the treatment of chronic wounds.

OBJECTIVE: To provide specific recommendations to product developers and clinical researchers on the design of comparative effectiveness studies for the treatment of chronic wounds, specifically those pertaining to arterial and venous-disease related ulcers, diabetic foot ulcers, pressure ulcers and burn wounds. METHOD: The recommendations were developed based on a process defined by the Center for Medical Technology Policy (CMTP). After selecting the subject area, semi-structured phone interviews were conducted by one of the authors (SSS) with representatives of payers, manufacturers, clinicians, clinician/researchers and patient advocates. Next, a broad range of stakeholders participated in a meeting convened by CMTP to determine their needs. A technical working group comprising key stakeholders then participated in clarifying recommendations developed by CMTP staff and adding important considerations for their implementation. The resulting draft document was finalised based on public and solicited comment from individual manufacturers; a consortium of product developers and manufacturers; and an alliance of physicians, providers, manufacturers and patient organisations. This article is a summary of the full effectiveness guidance document. RESULTS: To address the needs of patients, clinicians, guideline developers, payers and other post-regulatory decision makers, this work makes ten recommendations to guide comparative effectiveness research for chronic wound care. These recommendations fall into four categories: study design, population, comparators and outcomes. CONCLUSION: This paper suggests that using the recommendations outlined to conduct comparative effectiveness research on treatments for chronic wound therapies would facilitate trials that provide patients, clinicians, and payers with the information they need to make optimal treatment decisions. These recommendations focus on design changes that would have the largest impact in improving the usability of the results by decision makers and provide specific guidance on the design of prospective studies intended to inform decision making by patients, clinicians and payers. DECLARATION OF INTEREST: There were no external sources of funding for these recommendations. The Value Institute and the Center for Medical Technology Policy (CMTP) are both private, non-profit organisations. The authors have no financial, commercial or social conflicts of interest to declare with respect to the article or its content.

Wait list death and survival benefit of kidney transplantation among nonrenal transplant recipients.

The disparity between the number of patients waiting for kidney transplantation and the limited supply of kidney allografts has renewed interest in the benefit from kidney transplantation experienced by different groups. This study evaluated kidney transplant survival benefit in prior nonrenal transplant recipients (kidney after liver, KALi; lung, KALu; heart, KAH) compared to primary isolated (KA1) or repeat isolated kidney (KA2) transplant. Multivariable Cox regression models were fit using UNOS data for patients wait listed and transplanted from 1995 to 2008. Compared to KA1, the risk of death on the wait list was lower for KA2 (p < 0.001;HR = 0.84;CI = 0.81-0.88), but substantially higher for KALu (p < 0.001; HR = 3.80;CI = 3.08-4.69), KAH (p < 0.001; HR = 1.92; CI = 1.66-2.22), and KALi (p < 0.001; HR = 2.69; CI = 2.46-2.95). Following kidney transplant, patient survival was greatest for KA1, similar among KA2, KALi, KAH, and inferior for KALu. Compared to the entire wait list, renal transplantation was associated with a survival benefit among all groups except KALu (p = 0.017; HR = 1.61; CI = 1.09-2.38), where posttransplant survival was inferior to the wait list population. Recipients of KA1 kidney transplantation have the greatest posttransplant survival and compared to the overall kidney wait list, the greatest survival benefit.

Does race affect postoperative outcomes in patients with low-risk prostate cancer who undergo radical prostatectomy?

OBJECTIVES: To assess the magnitude of racial disparities in prostate cancer outcomes following radical prostatectomy for low-risk prostate cancer. METHODS: We retrospectively reviewed our database of 2407 patients who under went radical prostatectomy and isolated 2 cohorts of patients with low-risk prostate cancer. Cohort 1 was defined using liberal criteria, and cohort 2 was isolated using more stringent criteria. We then studied pre- and postoperative parameters to discern any racial differences in these 2 groups. Statistical analyses, including log-rank, chi(2), and Fisher's exact analyses, were used to ascertain the significance of such differences. RESULTS: Preoperatively, no significant differences were found between the white and African-American patients with regard to age at diagnosis, mean prostate-specific antigen, median follow-up, or percentage of involved cores on prostate biopsy. African-American patients in cohort 1 had a greater mean body mass index than did white patients (26.9 vs 27.8, P = .026). The analysis of postoperative data demonstrated no significant difference between white and African-American patients in the risk of biochemical failure, extraprostatic extension, seminal vesicle involvement, positive surgical margins, tumor volume, or risk of disease upgrading. African-American patients in cohort 2 demonstrated greater all-cause mortality compared with their white counterparts (9.4% vs 3.1%, P = .027). CONCLUSIONS: In patients with low-risk prostate cancer treated with radical prostatectomy, there exist no significant differences in surrogate measures of disease control, risk of disease upgrading, estimated tumor volume, or recurrence-free survival between whites and African-Americans.

Implications of increased left ventricular mass index on in-hospital outcomes in patients undergoing aortic valve surgery.

BACKGROUND: Increased left ventricular mass index has been shown to be associated with higher mortality in epidemiologic studies. However, the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement is unknown. METHODS: We studied 473 consecutive patients undergoing elective aortic valve replacement to assess the influence of left ventricular mass index on outcomes in patients having this procedure. Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index (considered increased if >134 g/m(2) in male patients and >110 g/m(2) in female patients). RESULTS: Left ventricular mass index was increased in 24% of patients undergoing aortic valve replacement. Postprocedural complications (respiratory failure, renal insufficiency, congestive heart failure, and atrial and ventricular arrhythmias), length of stay in the intensive care unit, and in-hospital mortality were increased in patients with increased left ventricular mass index. Multivariable analysis identified prior valve surgery (odds ratio, 4.3; 95% confidence interval, 1.2-15.7; P =.030), left ventricular ejection fraction (odds ratio, 1.07; 95% confidence interval, 1.01-1.14; P =.020), history of hypertension (odds ratio, 8.2; 95% confidence interval, 2.2-30.4; P =.002), history of liver disease (odds ratio, 50.4; 95% confidence interval, 4.2-609.0; P =.002), and increased left ventricular mass index (odds ratio, 38; 95% confidence interval, 9.3-154.1; P <.001) as independent predictors of in-hospital mortality. Furthermore, low output syndrome was identified as the most common mode of death (36%) after aortic valve replacement in patients with increased left ventricular mass index. CONCLUSIONS: Increased left ventricular mass index is associated with increased adverse in-hospital clinical outcomes in patients undergoing aortic valve replacement. Although this finding warrants special modification in perioperative management, further studies are needed to address whether outcomes in asymptomatic patients with aortic valve disease could be improved by earlier aortic valve replacement before a significant increase in left ventricular mass index.

Burnout among American surgeons.

BACKGROUND: The long-term consequences of stress on the surgeon are unknown. One manifestation of stress is burnout. The purpose of this study was to measure the prevalence of burnout in actively practicing American surgeons. METHODS: The Maslach Burnout Inventory and a questionnaire of our own design were sent to 1706 graduates of various University of Michigan surgical residencies (1222) and members of the Midwest Surgical Association (484). The response rate was 44%. Responses from 582 actively practicing surgeons were the sample used for analysis. RESULTS: Thirty-two percent of actively practicing surgeons showed "high" levels of emotional exhaustion, 13% showed "high" levels of depersonalization, and 4% showed evidence for low personal accomplishment. Younger surgeons were more susceptible to burnout (r = -0.28, P <.01). Burnout was not related to caseload, practice setting, or percent of patients insured by a health maintenance organization. Important etiologic factors were a sense that work was "overwhelming" (r = 0.61, P <.01), a perceived imbalance between career, family, and personal growth (r = -0.56), P <.01), perceptions that career was unrewarding (r = -0.42, P <.01), and lack of autonomy or decision involvement (r = -0.39, P <.01). A strong association was noted between burnout elements and a desire to retire early (r = 0.50, P <.01). CONCLUSIONS: Burnout is an important problem for actively practicing American surgeons. These data could be used to modify existing surgical training curricula or as an aid to surgical leadership when negotiating about the surgical work environment.

Prophylactic mitral reconstruction for mitral regurgitation.

BACKGROUND: Mitral regurgitation (MR) will produce myocardial dysfunction. The goal of this study was to review outcomes of mitral valve reconstruction in asymptomatic patients with severe MR. METHODS: From 1992 to 2000, 93 asymptomatic patients with degenerative disease and severe MR underwent mitral valve reconstruction. Mean preoperative left ventricular internal diameter diastole was 56 +/- 8 mm and ejection fraction was 60% +/- 6%. Mean age was 47 +/- 10 years and mean follow-up 23 +/- 27 months. All patients underwent complex reconstruction. RESULTS: There were no deaths and two late reoperations. One was for systolic anterior motion of the anterior leaflet of the mitral valve requiring valve replacement and one for hemolysis requiring re-repair. There was one perioperative transient ischemic attack and no late thromboembolic events. At follow-up all but 1 patient remains in NYHA class I and all had no MR except in 2 patients at 63 and 89 months. CONCLUSIONS: Mitral valve reconstruction for "asymptomatic" MR can be performed with no mortality and low morbidity before development of left ventricular dysfunction. Early prophylactic repair is advocated in the presence of severe MR if valve reparability is assured.

Management of hepatitis C patients by primary care physicians in the USA: results of a national survey.

Hepatitis C is a major health problem worldwide, yet very little research has been performed to assess the knowledge base and practice patterns of primary care physicians (PCPs) regarding hepatitis C. The aim of this study is to determine the knowledge base and practice patterns of a nationwide cohort of PCPs. A survey was developed to assess the knowledge of PCPs regarding risk factors for hepatitis C, management of hepatitis C patients and attitude regarding testing for hepatitis C. The survey was mailed to 4000 PCPs in the USA. A total of 1412 (39%) PCPs completed the survey. The vast majority, > 90%, of PCPs correctly identified the most common risk factors for hepatitis C. However, only 59% indicated they ask all patients about hepatitis C risk factors, 70% reported they test all patients with hepatitis C risk factors and 78% test all patients with elevated liver enzymes for hepatitis C. Most (72%) PCPs would refer an HCV-positive patient with elevated aminotransferase but only 28% would refer an HCV-positive patient with normal aminotransferase to a specialist. One-fourth of the PCPs did not know what treatment to recommend for hepatitis C patients. Our data suggest that hepatitis C patients may be underdiagnosed and under-referred. Specific educational initiatives and practice guidelines for PCPs are needed to optimize the recognition of patients at risk for hepatitis C and to ensure appropriate testing and referral.

Doctor-patient communication in surgery: attitudes and expectations of general surgery patients about the involvement and education of surgical residents.

BACKGROUND: Education is a major function of academic medical centers. At these teaching institutions residents provide a substantial amount of care on medical and surgical services. The attitudes of patients about the training of surgical residents and the impact of residents on patients' perceptions of care in a surgical setting are unknown. STUDY DESIGN: Patients admitted to the gastrointestinal surgery service completed a 30-item survey designed for this study. Patients included in the study underwent operations and had a postoperative inpatient hospital stay. We analyzed patients' answers to determine frequency and correlations among answers. RESULTS: Two hundred patients participated in the study during a 7-month period between July 1999 and January 2000. A majority of patients were comfortable having residents involved in their care (86%) and felt it was important to help educate future surgeons (91%). Most did not feel inconvenienced by being at a teaching hospital (71%) and felt they received extra attention there (74%). Patients were more willing to participate in resident education if they expected to have several physicians involved in their care, felt that they received extra attention, or if the teaching atmosphere did not inconvenience them. Despite the stated willingness of patients to help with surgical resident education, 32% answered that they would not want residents doing any of their operation. CONCLUSIONS: Surgical resident education is well received and considered important by patients. Patient orientation to the resident education process is vital to patients' perceptions of care and may render patients more willing to participate in educational activities.

Aortic dissection: CT features that distinguish true lumen from false lumen.

OBJECTIVE: The purpose of this study was to determine which CT findings are reliable indicators of the true or false lumen in an aortic dissection. CONCLUSION: The beak sign and a larger cross-sectional area were the most useful indicators of the false lumen for both acute and chronic dissections. Features generally indicative of the true lumen included outer wall calcification and eccentric flap calcification. In cases showing one lumen wrapping around the other lumen in the aortic arch, the inner lumen was invariably the true lumen.

Mammography messages in popular media: implications for patient expectations and shared clinical decision-making.

OBJECTIVE: To examine the relationship between the quantity and content of information about mammography in popular magazines and the educational level of their target audience. DESIGN: Articles published in popular magazines from January 1988 through April 1994 in which >or= 25% of all readers were females >or= 35 years of age were identified (n=65). We used the proportion of readers who were college graduates to stratify the magazines into three education levels. We used a content analysis to assess the relationship between media messages about mammography and readers' education levels. RESULTS: Seventy-eight percent of lowest education level articles were categorized as persuasive or prescriptive compared with 28% of articles in the highest education level (P < 0.01). Only 26% of the lowest education level articles that discussed screening guidelines for women under 50 years of age considered the issue controversial, while 59% of the high education level articles considered it controversial (P < 0.01). CONCLUSION: Women with lower education levels received a clearly persuasive or prescriptive message urging mammography screening, while higher educated women received more balanced and informative messages. Such differences suggest that women may be entering their physicians' offices with very different sets of information from which to draw when faced with clinical decisions. Physicians and other health-care providers should be aware of these potential differences, and further research should be done to explore the relationship between women's preferences for participation in shared decision-making and the types of messages they are receiving from popular media.

Providing health information to women. The role of magazines.

OBJECTIVES: We were interested in health coverage in women's magazines in the United States and how it compared with articles in medical journals, women's health interests, and women's greatest health risks. METHODS: We examined 12 issues of Good Housekeeping (GH) and Woman's Day (WD) and 63 issues of the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA). We tallied the most common health questions of women presenting to the University of Michigan's Women's Health Resource Center (WHRC) during the same period. RESULTS: Less than a fifth of the magazine articles dealt with health-related topics. Of those, a third dealt with diet, with the majority emphasizing weight loss rather than eating for optimal health. Few of the articles cited research studies, and even fewer included the name of the journal in which the study was published. In JAMA and NEJM, less than one-fifth of original research studies dealt with women's health topics, most commonly pregnancy-related issues, hormone replacement therapy, breast and ovarian cancer, and birth defects. At the same time, the most common requests for information at the WHRC related to pregnancy, fertility, reproductive health, and cancer. CONCLUSION: The topics addressed in women's magazines do not appear to coincide with the topics addressed in leading medical journals, nor with women's primary health concerns or greatest health risks. Information from women's magazines may be leading women to focus on aspects of health and health care that will not optimize risk reduction.

Electron-beam computed tomography in the diagnosis of coronary artery disease: a meta-analysis.

BACKGROUND: Electron-beam computed tomography (EBCT) is a new, noninvasive method of detecting coronary artery calcification that is being increasingly advocated as a diagnostic test for coronary artery disease (CAD). Before its clinical use is justified, however, the overall accuracy of EBCT must be better defined. OBJECTIVE: To estimate the accuracy of EBCT in diagnosing obstructive CAD. DATA SOURCES: English-language studies from January 1, 1979, through February 29, 2000, were retrieved using MEDLINE and Current Contents databases, bibliographies, and expert consultation. STUDY SELECTION: We included a study if it (1) used EBCT as a diagnostic test; (2) reported cases in absolute numbers of true-positive, false-positive, true-negative, and false-negative results; and (3) used coronary angiography as the reference standard for diagnosing obstructive CAD (defined as > or = 50% diameter stenosis). DATA EXTRACTION: Data were extracted from the included articles by 2 independent reviewers. DATA SYNTHESIS: Weighted pooled analysis and summary receiver operating characteristic (ROC) curve analysis were used to determine sensitivity and specificity rates. Results from 9 studies with 1662 subjects were included. Pooled sensitivity for EBCT was 92.3% (95% confidence interval [CI], 90.7%-94.0%) and pooled specificity was 51.2% (95% CI, 47.5%-54.9%). Maximum joint sensitivity and specificity for EBCT from its summary ROC curve was 75%. As the threshold for defining an abnormal test varied, sensitivity and specificity changed. For a threshold that resulted in a sensitivity of 90%, specificity was 54%; when sensitivity was 80%, specificity rose to 71%. CONCLUSION: The performance of EBCT as a diagnostic test for obstructive CAD is reasonable based on sensitivity and specificity rates from its summary ROC curve.

Accuracy of MR imaging for staging prostate cancer: a meta-analysis to examine the effect of technologic change.

RATIONALE AND OBJECTIVES: The purpose of this study was to summarize the accuracy of magnetic resonance (MR) imaging for staging prostate cancer and to determine the effect of high magnetic field strength, use of the endorectal coil, use of fast spin-echo (SE) imaging, and study size on staging accuracy. MATERIALS AND METHODS: A literature search and review yielded 27 studies comparing MR imaging to a pathologic standard in patients with clinically limited prostate cancer. Subgroup analyses examined magnetic field strength, use of an endorectal coil, use of fast SE imaging, publication date, and study size. RESULTS: A summary receiver operating characteristic curve for all studies had a maximum joint sensitivity and specificity of 74%. At a specificity of 80% on this curve, sensitivity was 69%. Subgroup analyses showed that fast SE imaging was statistically significantly more accurate than conventional SE techniques (P < .001). Unexpectedly, studies employing higher magnetic field strength and those employing an endorectal coil were less accurate. CONCLUSION: Seemingly small technologic advances may influence test accuracy. Early and small studies, however, may overstate accuracy because of publication bias, bias in small samples, or earlier studies being performed by the experts who developed the technology itself.

Ulcerlike lesions of the aorta: imaging features and natural history.

PURPOSE: To document the natural history of ulcerlike aortic lesions and determine whether any computed tomographic (CT) features predict outcome. MATERIALS AND METHODS: CT scans from 1994 to 1998 that depicted an ulcerlike aortic lesion were retrospectively evaluated. Features evaluated included lesion and aortic size and intramural hematoma. Initial CT findings were correlated with clinical data and subsequent CT findings. RESULTS: There were 56 lesions in 38 patients. Follow-up (mean, 18.4 months) CT scans were available for 33 lesions. Stability of the lesion and adjacent aorta was noted in 21 lesions. Two lesions were unchanged, although associated intramural hematoma regressed over 1-2 months. Ten lesions showed mild to moderate increase in aortic diameter (mean follow-up, 19.8 months) either with (seven lesions) or without (one lesion) increase in size of the lesion or with incorporation of the lesion into the aortic wall contour (two lesions). Of all 56 lesions, 37 were clinically stable, two were associated with recurrent chest and/or back pain, eight underwent surgical resection or stent placement, and two were in patients who died. Seven lesions were in patients lost to follow-up. No initial CT feature was predictive of CT outcome, although lack of pleural effusion correlated with clinical stability. CONCLUSION: Most ulcerlike aortic lesions are asymptomatic and do not enlarge. About one-third of lesions progress, generally resulting in mild interval aortic enlargement.

Effect of postoperative atrial fibrillation on length of stay after cardiac surgery (The Postoperative Atrial Fibrillation in Cardiac Surgery study [PACS(2)].

Atrial fibrillation (AF) after cardiac surgery is thought to increase length of stay (LOS). A clinical pathway focused on the management of postoperative AF, including prophylaxis with beta blockers, was implemented to assess the effect of AF on LOS after cardiac surgery. Data were obtained on consecutive cardiac surgery patients in preoperative normal sinus rhythm, no prior history of AF, and no chronic antiarrhythmic therapy from January to May 1995 (control) and November 1996 to June 1997 (pathway). Statistical analysis was performed to assess the effect of postoperative AF on the LOS, clinical outcomes, and cost after cardiac surgery. Despite the clinical pathway, the LOS (7 days for both periods; p = 0.12) and incidence of AF (28.9% vs 28.4%; p = 0.92) remained unchanged. Unadjusted direct costs were 15% higher in the pathway period (p <0.001). Increased rates of beta-blocker therapy had a marginal effect on the incidence of postoperative AF, except in the group who only underwent primary coronary artery bypass graft surgery (31.2% vs 25.3%; p = 0.31). Multivariate analysis revealed that AF contributed only 1 to 1.5 days to the LOS. Thus, this investigation represents the most recent analysis of the effects of postoperative AF on LOS, clinical outcomes, and cost after cardiac surgery. Unlike prior studies, the impact of postoperative AF is less prominent in the current era of cardiac surgical care regardless of the presence of a clinical pathway addressing AF.

Comorbidities and quality of life in patients with interferon-refractory chronic hepatitis C.

OBJECTIVES: Patients with chronic hepatitis C (HCV) consistently report a reduction in multiple domains of health-related quality of life (HRQOL) that does not correlate with liver disease severity. This may in part be due to the use of insensitive HRQOL instruments or extrahepatic factors that independently influence HRQOL. We hypothesized that a past history of substance abuse or active medical and psychiatric comorbidities would correlate with HRQOL scores. METHODS: In 107 patients who had failed previous interferon therapy, HRQOL was measured by using the modified SF-36, a disease-specific instrument, and the Health Utilities Index (HUI) Mark III, a generic instrument. RESULTS: Multiple SF-36 subscale and summary scores as well as the HUI Mark III attributes of emotion and pain were significantly reduced in the study population compared with healthy controls (p < 0.001). Serum alanine aminotransferase and HCV RNA levels, HCV genotype, liver histology, and HCV risk factors as well as demographic variables did not correlate with modified SF-36 and HUI scores. In addition, a history of alcohol abuse or dependency and intravenous drug use or dependency, identified in 52 and 51% of participants, respectively, did not correlate with HRQOL scores. However, the presence of one or more active medical comorbidities, defined as a chronic medical condition requiring treatment and monitoring, was significantly associated with both the modified SF-36 scores and HUI attribute deficits (p < 0.001). In particular, painful medical comorbidities or depressed mood requiring treatment were significantly associated with modified SF-36 scores and with HUI attribute deficits and utility scores (p < 0.001). CONCLUSIONS: Active medical and psychiatric comorbidities may account for some of the reduction and variability in HRQOL scores in patients with chronic HCV who have failed previous interferon therapy. Future studies that control for the presence of active comorbidities in large groups of treatment naive patients with varying severity of chronic HCV are needed to confirm these findings.

Quality of life in obstructive sleep apnea: a systematic review of the literature.

OBJECTIVE: To review the literature on obstructive sleep apnea (OSA) and health-related quality of life (HRQOL). BACKGROUND: OSA affects nearly one in four men and one in ten women aged 30-60 years in the United States. Health consequences of OSA can include neuropsychiatric and cardiovascular sequela that disrupt professional, family, and social life and negatively impact HRQOL. METHODS: We conducted a comprehensive review of the literature on HRQOL and OSA, with special attention paid to instruments developed specifically for OSA. RESULTS: Generic instruments used to study HRQOL and OSA include: Medical Outcomes Study Short Form-36, Nottingham Health Profile, Sickness Impact Profile, Functional Limitations Profile, EuroQol, and Munich Life Quality Dimension List. Specific instruments include: Calgary Sleep Apnea Quality of Life Instrument, Functional Outcomes of Sleep Questionnaire, OSA Patient Oriented Severity Index, the OSA-18, and Cohen's pediatric OSA surgery quality of life questionnaire. CONCLUSIONS: OSA patients have impaired HRQOL when compared with healthy age- and gender-matched controls. Treatment with continuous positive airway pressure appears to improve HRQOL. Other treatment modalities have not been rigorously studied. In addition, more data are needed from preference-based measures that allow conversion to utility scores, which can be used to calculate quality-adjusted life years and cost-effectiveness ratios.

Comparing physician and administrator responses to cesarean section guidelines and actual practice.

BACKGROUND: A cross-sectional study was conducted in 1996 to determine to what extent hospitals have adopted guidelines to improve the appropriate use of cesarean section (C-section); discover attitudes of obstetricians toward C-section guidelines; and explore how physician attitudes toward guidelines interact with organizational features. METHODS: The study consisted of two components: (1) Telephone interviews with hospital administrators from Michigan hospitals providing obstetric care (response rate: 100%); these interviews were intended to determine whether guidelines were in use and the processes for their development and implementation. (2) A self-administered mail survey assessing the attitudes of 266 Michigan obstetricians (response rate: 57%), intended to assess their attitudes toward the content and effects of C-section guidelines. RESULTS: Twenty-nine percent of hospitals were using C-section guidelines, according to reports from hospital administrators. Mean C-section rates were not significantly different between hospitals using guidelines and those not using guidelines (23.2% and 22.4%, p = 0.49). More than 80% of physicians felt that the guidelines were supported by the literature and were applicable in daily practice, and agreed with their ideas about C-section performance, and 67% reported that guidelines would have no or minimal effect on their practice. However, only 55% of physicians and administrators agreed on the presence or absence of guidelines at their hospital (kappa = 0.09). DISCUSSION: Physicians appear to agree with guidelines and believe they are already following them, despite high C-section rates. Physicians' attitudes toward guidelines are not necessarily a reflection of actual practice. If C-section guidelines are to decrease excessive C-section rates, stronger, more integrated implementation strategies are needed.