Evaluation of the DAVROS (Development And Validation of Risk-adjusted Outcomes for Systems of emergency care) risk-adjustment model as a quality indicator for healthcare.

BACKGROUND AND OBJECTIVE: Risk-adjusted mortality rates can be used as a quality indicator if it is assumed that the discrepancy between predicted and actual mortality can be attributed to the quality of healthcare (ie, the model has attributional validity). The Development And Validation of Risk-adjusted Outcomes for Systems of emergency care (DAVROS) model predicts 7-day mortality in emergency medical admissions. We aimed to test this assumption by evaluating the attributional validity of the DAVROS risk-adjustment model. METHODS: We selected cases that had the greatest discrepancy between observed mortality and predicted probability of mortality from seven hospitals involved in validation of the DAVROS risk-adjustment model. Reviewers at each hospital assessed hospital records to determine whether the discrepancy between predicted and actual mortality could be explained by the healthcare provided. RESULTS: We received 232/280 (83%) completed review forms relating to 179 unexpected deaths and 53 unexpected survivors. The healthcare system was judged to have potentially contributed to 10/179 (8%) of the unexpected deaths and 26/53 (49%) of the unexpected survivors. Failure of the model to appropriately predict risk was judged to be responsible for 135/179 (75%) of the unexpected deaths and 2/53 (4%) of the unexpected survivors. Some 10/53 (19%) of the unexpected survivors died within a few months of the 7-day period of model prediction. CONCLUSIONS: We found little evidence that deaths occurring in patients with a low predicted mortality from risk-adjustment could be attributed to the quality of healthcare provided.

The role of youth mental health services in the treatment of young people with serious mental illness: 2-year outcomes and economic implications.

AIM: This study aims to evaluate the outcomes and economic case for a UK innovative youth-specific mental health service for 16-25 year olds. METHODS: A pre-, during- and post-treatment comparative design for 20 young people at high risk of developing psychosis who received 2 years' treatment with the service, using outcomes that concurred with the service aims: changes in mental health, employment rates and service use. RESULTS: Forty-five percent of those at risk and with symptoms of serious mental illness commencing treatment were not receiving mental health services at baseline. Compared with service use prior to treatment at the youth-specific service, hospital admissions, Accident and Emergency, and criminal justice system use appear to decrease over the 2 years of treatment and the year after treatment, with potential cost differences of £473 000. Mental health improved or stayed the same, compared with baseline. Employment rates improved, although the sample size for this is very small. Potential cost differences associated with service users moving into employment over the 2 years are £148 000. The estimated cost over 2 years of providing the youth-specific mental health service to these young people was £106 000. CONCLUSIONS: Given the extensive long-term negative consequences and high costs of untreated mental illness in the 16-25 age group and the documented problems young people have in receiving appropriate services, this youth-specific, age-appropriate service model appears to be successful, with improved outcomes and cost differences in the short-term, and with encouraging implications for the longer term.

Nerve injury following shoulder dislocation: the emergency physician's perspective.

We describe the case of a 57-year-old woman who presented to the emergency department with a right anterior shoulder dislocation following a fall onto the right shoulder and right upper arm. She also complained of numbness in the right forearm and dorsum of the right hand. The examination revealed a bruise to the upper aspect of the right arm resulting from the impact following the fall. The patient also had a right wrist drop and loss of sensation in the lateral border of the right forearm and on the dorsum of the right hand, suggesting a radial nerve injury. She also had altered sensation in the ulnar distribution of her right hand, suspicious of concomitant ulnar nerve injury. No loss of sensation in the distribution of the axillary nerve (regimental patch) was observed. These findings were carefully documented and the patient subsequently had the shoulder reduced under entonox and morphine. The neurological deficits remained unchanged. The patient was sent home from the emergency room with arrangements for orthopaedic and physiotherapy follow-up. After a 3-month period, she had clinical and electromyography evidence of persistent radial and ulnar nerve deficit. She continues to have physiotherapy. This case highlights the need for awareness of the potential for nerve damage following shoulder dislocation and also to ensure that appropriate follow-up plan is instituted on discharge from the emergency department.

The development of a simple risk score to predict early outcome in severe acute acidotic cardiogenic pulmonary edema: the 3CPO score.

BACKGROUND: Acute cardiogenic pulmonary edema is a common medical emergency with high early mortality. Initial clinical assessment would benefit from accurate mortality prediction. We aimed to develop a simple clinical score based on presenting characteristics that would predict 7-day mortality in patients with acute cardiogenic pulmonary edema. METHODS AND RESULTS: We used data from patients recruited to the 3CPO trial (a pragmatic multicenter trial comparing continuous positive airway pressure, noninvasive positive pressure ventilation, and standard oxygen therapy in emergency department patients with acute cardiogenic pulmonary edema) to investigate the association between baseline characteristics and 7-day mortality. Factors associated with mortality (P<0.1) were entered into a multivariable model. Independent predictors of mortality from the multivariable model (P<0.05) were assigned integer weights based on their coefficients and incorporated into a risk score. The discriminant ability of the score was tested by receiver operator characteristic analysis. Data from 1069 patients (78+/-10 years; 43% men; 7-day mortality, 9.6%) were analyzed. Multivariable analysis identified age (P=0.003), systolic blood pressure (P<0.001), and Glasgow Coma Scale motor component dichotomized and simplified to the ability to obey commands or not (P=0.02) as the only independent predictors of 7-day mortality. These were weighted and used to develop a risk score ranging from 0 (7-day mortality, 1.9%; 95% CI, 0.8 to 4.5) to 7 (7-day mortality, 100%; 95% CI, 34.2 to 100). Receiver operator characteristic analysis demonstrated good risk prediction with a c-statistic of 0.794 (95% CI, 0.745 to 0.843). A simplified 3-point score with no weighting had a c-statistic of 0.754 (95% CI, 0.701 to 0.807). CONCLUSIONS: A simple clinical score based on age, systolic blood pressure, and the ability to obey commands predicts early mortality in patients with acute cardiogenic pulmonary edema. Clinical Trial Registration- clinicaltrials.gov Identifier: ISRCTN077448447.