Expectation and outlook: the impact of patient preference on arthritis care among African Americans.

We investigated beliefs of blacks with osteoarthritis (OA) regarding total knee replacement (TKR) surgery. These beliefs potentially related to the known racial disparity in the use of TKR. Ninety-four community-dwelling blacks aged 50 to 89 with knee OA in Harlem, NY, were assessed for arthritis knowledge, expectations, quality of life (QoL), and disability. Subjects have had OA for a median of 6 years and the disability was severe. Only 36% believed that TKR was likely to improve knee pain; 45% stated that TKR would not improve their current health. Mean QoL was 7.6 +/- 1.7 (max 10). Despite debilitating OA, African American patients perceive a high QoL, yet have low expectations from TKR and are therefore less likely to consider TKR as a treatment for OA.

The case for more active policy attention to health promotion.

Until recently, when anthrax triggered a concern about preparedness in the public health infrastructure, U.S. health policy and health spending had been dominated by a focus on payment for medical treatment. The fact that many of the conditions driving the need for treatment are preventable ought to draw attention to policy opportunities for promoting health. Following a brief review of the determinants of population health-genetic predispositions, social circumstances, environmental conditions, behavioral patterns, and medical care-this paper explores some of the factors inhibiting policy attention and resource commitment to the nonmedical determinants of population health and suggests approaches for sharpening the public policy focus to encourage disease prevention and health promotion.

Assessment of decline in health-related quality of life among angina-free patients undergoing coronary artery bypass graft surgery.

PURPOSE: Coronary artery bypass graft (CABG) surgery generally decreases symptoms and improves quality of life, but for those patients without angina, prolongation of life takes precedence. We used the SF-36 to assess changes in health-related quality of life (HRQOL) among patients who were angina free prior to CABG compared to those reporting angina. METHODS: We combined data from two randomized trials of hemodynamic management during surgery. Prior to CABG, demographic, clinical and SF-36 data were obtained. Patients were reevaluated at a 6-month follow-up. Patients with a decline of > or =15 points from baseline to follow-up for individual SF-36 domains and >5 points for summary components were classified as having a decline. We used logistic regression models that controlled for baseline SF-36 score and other baseline characteristics to assess HRQOL decline with respect to angina status. RESULTS: Of 590 patients, 28% were angina free at baseline. A third of the patients angina free at baseline had a postoperative decline in physical function. Patients who were angina free at baseline were three times more likely to suffer a decline in physical function than those with angina (odds ratio 3.29, 95% confidence interval 1.86-5.82). This finding remained after addition of adverse outcomes to the model. Baseline angina status was not related to any other SF-36 domain or to physical or mental summary component scores. Major adverse outcomes did not differ between angina-free patients and those with angina. CONCLUSIONS: The incidence of patients reporting a decline in physical function after CABG was greater in patients without angina preoperatively, even when adjusting for baseline score. Given the substantial risk of decreased physical functioning, employing interventions to maintain HRQOL in this population should be considered.

Assessing sedation with regional anesthesia: inter-rater agreement on a modified Wilson sedation scale.

UNLABELLED: A valid and reliable means for measuring sedation during regional anesthesia would be valuable for both research and practice. Current methods of monitoring sedation include machine-, patient-, and observer-based assessment. The reliability of machine-based methods is limited at lower levels of sedation, whereas patient-based methods are impractical at higher levels. Observer-based methods offer the best alternative for assessing sedation during regional anesthesia; however, their reliability has not been adequately documented. We examined the interrater reliability of the Wilson sedation scale. Sedation was assessed by pairs of anesthesia care providers in 100 patients undergoing surgical procedures with regional anesthesia. On the basis of the findings, the scale was modified, and 50 additional patients were assessed. The study protocol called for a series of standardized stimuli administered by a research assistant. Raters were blinded to each other's ratings. Interrater reliability was assessed by using the kappa statistic, a measure of actual agreement beyond agreement by chance. When continuing checks on its operationalization and reliability are included, the modified Wilson scale provides a simple and reliable means by which to assess and monitor intraoperative sedation. IMPLICATIONS: We evaluated the interrater reliability of the Wilson scale for measuring sedation during regional anesthesia. Paired anesthesia care providers' ratings of patient sedation indicated very good interrater reliability in both the original scale and a modified version. The modified Wilson scale provides a quick noninvasive means of monitoring sedation during regional anesthesia.

Patients' expectations of shoulder surgery.

Patients' preoperative expectations of shoulder surgery affect both the decision to proceed with surgery and how patients assess outcomes of surgery. Our goals were to identify patients' expectations of shoulder surgery, to develop and test a patient-derived shoulder surgery expectations survey, and to determine the prevalence of major expectations by diagnosis. An initial sample of 409 patients (mean age, 51 +/- 17 years; 58% men) with diverse shoulder diagnoses were asked open-ended questions preoperatively about their expectations of shoulder surgery. Their responses were grouped into 38 categories including the following: pain relief, increasing range of motion, improving the ability to wash and dress, returning to sports, improving the ability to interact and care for others, and for the shoulder to be back to the way it was before shoulder symptoms started. Expectations varied by demographic characteristics, diagnosis, and functional status measured by the L'Insalata Shoulder Rating Questionnaire and the Short Form 36. The most frequently cited categories were then assembled into closed-format questions to form a draft survey. A second sample of 100 patients with diverse shoulder diagnoses completed the draft survey on 2 separate occasions to establish test-retest reliability. Items retained to form the final survey were frequently cited, represented clinically relevant or potentially unrealistic expectations, and had concordance levels of 0.40 to 0.83 measured by the kappa statistic (71% had kappa >or= 0.60). The final 17-item Hospital for Special Surgery Shoulder Surgery Expectations Survey requires less than 5 minutes to complete. This patient-derived, self-administered survey has several possible uses in daily clinical practice, such as providing a way to learn about the patient's perspectives, providing the orthopaedist with a template to guide a formal discussion about realistic and unrealistic goals, and providing a prospective record that can be used jointly by the orthopaedist and patient postoperatively to assess the outcome of surgery.

New postoperative depressive symptoms and long-term cardiac outcomes after coronary artery bypass surgery.

The authors evaluated the impact of an increase in depressive symptoms at 6 months after elective coronary artery bypass graft surgery on long-term cardiac morbidity and mortality between 6 and 36 months postoperatively. Patients who had low scores for depressive symptomatology pre-operatively and who completed follow-up at 6 months were contacted again 36 months after surgery to assess cardiac and neurologic morbidity and mortality. At 36 months after surgery, an interval history was completed, and baseline questionnaires were readministered. Follow-up was obtained on 123/124 patients (99%). The rate of combined new cardiac morbidity/mortality between 6 and 36 months was 13.6% among those with newly increased depressive symptoms at 6 months vs. 3.0% in the patients without new depressive symptoms at 6 months. Only an increase in depressive symptoms at 6 months was related to the occurrence of subsequent cardiac complications between 6 and 36 months. In this small sample of patients, increased depressive symptoms at 6 months after surgery appear to be associated with the occurrence of subsequent major cardiac morbidity/ mortality.