Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources.

BACKGROUND: The effects of residence in an acute geriatrics-based ward (AGW) with emphasis on early rehabilitation and discharge planning for older patients with acute medical illnesses were assessed. Outcome and use of resources were compared with those of patients treated in general medical wards (MWs). A per-protocol rather than intention-to-treat analysis was performed. METHODS: A randomized trial with 3-months follow-up. A total of 190 patients aged 70 years and older were randomized to an acute geriatrics-based ward, and 223 patients were randomized to general medical wards. RESULTS: The two groups were comparable at inclusion. However, after care in the AGW, 71% of patients could be discharged directly home compared with 64% of those treated in MWs (relative risk 1.17; 95% CI, 0.93-1.49). The length of stay was shorter in the AGW (mean 5.9 vs 7.3 days; P = .002). The proportion of patients in geriatric or other hospital wards or in nursing homes did not differ, but the proportion of AGW patients in sheltered living tended to be lower (P = .085). At the follow-up, case fatality, ADL function, psychological well-being, need for daily personal assistance, drug consumption, need for readmission to hospital, and total health care costs after discharge did not differ between the two groups. Poor global outcome was observed in 37% of AGW and 34% of MW patients. CONCLUSIONS: A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long-term institutional living. This occurred despite patients in an acute geriatric ward not having better medical or functional outcome than older acute patients treated in general medical wards.

[Stroke unit care saves lives. The Swedish national quality assessment registry of stroke care is the first of its kind in the world]. / Vård på stroke-enhet räddar liv. Sverige först i världen med nationellt kvalitetsregister för slaganfall.

Meta-analyses of randomised trials of acute stroke treated in specialised stroke units have yielded convincing evidence of benefits in terms of reduced mortality rates, as compared with treatment in a general ward. However, no studies had been performed to ascertain whether the promising results could be reproduced in routine clinical practice. Accordingly, a comparison of routine care of acute stroke patients in stroke units (SUs) with that in general wards (GWs) was made on the basis of data for the 14,300 cases of acute stroke from 87 units in 80 Swedish hospitals registered in 1996 at the Swedish national stroke registry, the first of its kind in the world. Among patients capable of independent daily life and fully conscious at admission, the mortality rate was lower in the SU than in the GW subgroup, both at discharge from hospital and three months after the stroke event; and three months after stroke, a greater proportion of SU patients had been discharged to their homes, and a smaller proportion were in long-term care. However, no such subgroup differences were found among patients with impaired consciousness at admission. Thus, the promising results of the randomised trials of SU treatment would appear to be reproducible in routine clinical practice, though the beneficial effect is smaller in magnitude.

[Public health work needs new evaluation models. Primary care projects are more effective than large scale campaigns]. / Folkhälsoarbetet behöver nya utvärderingsmodeller. Primärvårdsstödda program når djupare än storskaliga kampanjer.

The need both of critical assessment of community intervention programmes and of alternatives to randomised controlled studies is discussed in the article. Examples are drawn from a review recently completed for the Swedish Council on Technology Assessment in Health Care [Statens Beredning för Utvärdering av medicinsk metodik (SBU)], and from the evaluation of a cardiovascular disease prevention programme currently in progress in northern Sweden.

Cost effectiveness and equity of a community based cardiovascular disease prevention programme in Norsjö, Sweden.

STUDY OBJECTIVE: To evaluate the cost effectiveness and equity of a community based cardiovascular disease prevention programme. DESIGN: A prospective cross sectional design. SETTING: A community based intervention to reduce cardiovascular disease in the district of Norsjö (n = 5500), Sweden. The intervention was aimed at both the general population and at individuals thought to be at special risk, the emphasis being on changing dietary habits and reducing cholesterol concentrations. PARTICIPANTS: The participants were men and women aged 30-60 years. MAIN RESULTS: The mean serum cholesterol concentration in the Norsjö population was reduced by nearly 20% during the first six years of intervention. It was estimated that the programme's overall total societal costs were 363,000 pounds and estimates of the cost per year of life saved ranged from 14,900 pounds to net savings, according to different assumptions. Taking only health care costs and savings into account, the cost per year of life saved ranged from 1100 pounds to 4050 pounds. The results varied between different sex and age groups, but not between social classes. Even if a causal relationship exists between low cholesterol concentrations and excess mortality, the estimated side effects of lowering cholesterol values in Norsjö were negligible in comparison with the expected benefits. CONCLUSIONS: The community based intervention in Norsjö seems to be cost effective even under conservative assumptions. The approach used seems to have benefited all social classes. Cost effectiveness analyses that take consequences for equity into account are valuable tools in decision making.

Stroke incidence, case fatality, and mortality in the WHO MONICA project. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease.

BACKGROUND AND PURPOSE: This report compares stroke incidence, case fatality, and mortality rates during the first years of the WHO MONICA Project in 16 European and 2 Asian populations. METHODS: In the stroke component of the WHO MONICA Project, stroke registers were established with uniform and standardized rules for case ascertainment and validation of events. RESULTS: A total of 13,597 stroke events were registered from 1985 through 1987 in a total background population of 2.9 million people aged 35 to 64 years. Age-standardized stroke incidence rates per 100,000 varied from 101 to 285 in men and from 47 to 198 in women. The combined stroke attack rates for first and recurrent events were approximately 20% higher than incidence rates in most populations and varied to the same extent. Stroke incidence rates were very high among the population of Finnish men tested. The incidence of stroke was, in general, higher among populations in eastern than in western Europe. It was also relatively high in the Chinese population studied, particularly among women. The case-fatality rates at 28 days varied from 15% to 49% among men and from 18% to 57% among women. In half of the populations studied, there were only minor differences between official stroke mortality rates and rates measured on the basis of fatal events registered and validated for the WHO MONICA stroke study. CONCLUSIONS: The WHO MONICA Project provides a unique opportunity to perform cross-sectional and longitudinal comparisons of stroke epidemiology in many populations. The present data show how large differences in stroke incidence and case-fatality rates contribute to the more than threefold differences in stroke mortality rates among populations.

Multinational comparisons of stroke epidemiology. Evaluation of case ascertainment in the WHO MONICA Stroke Study. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease.

BACKGROUND AND PURPOSE: As part of the WHO MONICA Project (World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease), mortality and incidence rates of acute stroke in 14 centers covering 21 populations from 11 countries were compared. METHODS: In this report, coverage and quality of the MONICA stroke registers were evaluated on five key indicators using data submitted to the MONICA Data Center. RESULTS: A low ratio of MONICA stroke register to routine statistics of stroke mortality and a low proportion of nonfatal out-of-hospital events were the most common biases; they indicate that identifications of fatal cases and/or case finding of nonfatal events occurring outside the hospital were inadequate in many MONICA centers. In 10 populations, the data quality analyses suggested that clarification of possible biases would be needed before these populations can be included in a comparative study. Data from the remaining 11 populations meet the data quality standards for multinational comparisons with respect to case ascertainment. CONCLUSIONS: These results show that multinational comparisons of stroke incidence involve considerable problems in developing and maintaining appropriate standards of data quality. However, after considerable efforts to ensure quality, comparisons of stroke data within the MONICA Project are possible among a large number of the MONICA populations. Our observations also indicate that results from multinational comparisons of stroke mortality based on routine statistics must be interpreted with caution.

Costs of stroke in Sweden. A national perspective.

BACKGROUND AND PURPOSE: Cost-effectiveness analyses of stroke management are hampered by paucity of economic data. We made an update of the direct and indirect costs of stroke in Sweden (population, 8.5 million). METHODS: Direct costs (ie, the costs for hospital and outpatient care and social services) were estimated on the basis of two prospective population-based studies of stroke and of two nationwide cross-sectional inventories of bed-days and diagnoses. Indirect costs (ie, the costs for loss of productivity and early retirement) were based on official statistics. RESULTS: The direct annual costs of care for stroke patients in 1991 equaled 7836 million Swedish krona (SKr) ($1306 million in US dollars), and the indirect costs, 2430 million SKr ($405 million). The cost of stroke care was 1208 SKr ($201) per inhabitant in Sweden. The expected direct costs per patient from first stroke to death were 440,000 SKr ($73,333). When prestroke costs for other diseases and advanced age were subtracted, the sum was reduced to 180,000 SKr ($30,000). CONCLUSIONS: Costs for hospital and outpatient care and social services accounted for 76% of Swedish stroke costs and for 24% of costs for loss of production and early retirement. Only 41% of direct costs were stroke-related.

Cost effectiveness of primary stroke prevention in atrial fibrillation: Swedish national perspective.

OBJECTIVE: To assess the potential effects of primary prevention with anticoagulants or aspirin in atrial fibrillation on Swedish population. DESIGN: Analysis of cost effectiveness based on the following assumptions: about 83,000 people have atrial fibrillation in Sweden, of whom 22,000 would be potential candidates for treatment with anticoagulants and 55,000 for aspirin treatment; the annual 5% stroke rate is reduced by 64% (with anticoagulants) and 25% (with aspirin); incidence of intracranial haemorrhage of 0.3%, 1.3%, or 2.0% per year; direct and indirect costs of a stroke of Kr180,000 and Kr90,000; estimated annual cost of treatment is Kr5030 for anticoagulants and Kr100 for aspirin. SETTING: Total Swedish population. MAIN OUTCOME MEASURES: Direct and indirect costs of stroke saved, number of strokes prevented, and cost of preventive treatment. RESULTS: Depending on the rate of haemorrhagic complications 34 to 83 patients would need to be treated annually with anticoagulants to prevent one stroke; 83 patients would need to be treated with aspirin. Giving anticoagulant treatment only would reduce costs by Kr60 million if the incidence of intracranial haemorrhage were 0.3% but would imply a net expense if the complication rate exceeded 1.3%. The total savings from giving anticoagulant (22,000 patients) and aspirin (55,000 patients) treatment would be Kr175 million per year corresponding to 2 million pounds per million inhabitants each year. CONCLUSIONS: Treatment with anticoagulants and, if contraindications exist, with aspirin is cost effective provided that the risk of serious haemorrhage complications due to anticoagulants is kept low.

Men who never married. A socio-medical study in northern Sweden.

In a population-based study 50 never-married men aged 40-64 years were compared with 503 similarly aged other men (married, co-habitant, divorced or widowed). The never-married had shorter education than other men, and had been unemployed more often. The never-married mens' emotional relationships were of lower quality. There was modest tendency towards higher blood pressures and higher serum cholesterol levels among the never-married men, but the differences did not reach statistical significance. In conclusion, never-married men were found to be worse off in terms of social support, education, employment status and health knowledge. Differences in health status, however, were small. It is possible that positive factors, not fully elucidated in this study, counterbalance the adverse socio-medical characteristics. Another possibility is that differences will become manifest at an older age which could be surveyed in a follow-up study.

Unemployment and cardiovascular risk indicators. Data from the MONICA survey in northern Sweden.

We studied the effect of unemployment, or the threat of unemployment, on indicators of cardiovascular risk in a randomly selected cross-sectional sample of the population aged 25-64 years in northern Sweden with interviews and a health examination. In men, unemployment for more than one year correlated significantly with systolic blood pressure, serum cholesterol level, HDL-quotients, cigarette smoking and physical inactivity. In women, unemployment correlated significantly with body mass index, HDL-quotient, cigarette smoking and physical inactivity. Our results support the hypothesis that correlations between unemployment and cardiovascular disease found in other studies could be partly explained by elevated risk indicators due to unemployment.

Impact of day care on dementia patients--costs, well-being and relatives' views.

Forty-seven patients in psychogeriatric day centre were analysed regarding use of resources, costs and well-being. The level of well-being was based on interviews with staff and relatives and related to the economic outcome--a cost utility analysis. A 6 month period prior to day care was compared with the first 6 months in such care. The use of resources at home increased by 20% while the use of institutional care was reduced by 22%. Fifty-three percent of the patients improved in their well-being after participation in day care. When the cost of utility analysis was applied, the cost for a well-year was 4293 pounds.

Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency.

A basal plasma cortisol value taken in a physically unstressed state in 68 patients with or without hypothalamic-pituitary-adrenocortical disease was compared with the maximal plasma cortisol concentration during an insulin tolerance test. There was a strong positive correlation between the values. Basal cortisol levels above 300 nmol/l (RIA method) almost excluded ACTH-cortisol insufficiency and those below 100 nmol/l strongly suggested dysfunction. A repeated basal cortisol estimation within a month was especially valuable in categorizing patients with levels between 100 and 200 nmol/l. We suggest that a basal cortisol measurement may be used as a first laboratory test in patients evaluated for possible hypothalamic-pituitary-adrenocortical insufficiency; in many patients, this approach obviates more sophisticated and expensive testing.

Nutritional assessment of psychogeriatric patients.

The nutritional status of 91 patients on four psychogeriatric wards was assessed by anthropometric measurements and determination of circulating proteins. The patients had low mean values for weight, arm muscle circumference, plasma albumin and serum transferrin. Indicators of malnutrition were combined to define the nutritional status in each individual. Energy and/or protein undernutrition was found in 30% and obesity in 4%. Energy undernutrition was more common than protein deficiency. Undernutrition was quite common during the first year of hospitalization and did not correlate with the duration of hospital stay. Subjects with their own teeth had a lower prevalence of undernutrition than edentulous patients. Food intake was similar in patients with and without undernutrition. The possible interactions between malnutrition and chronic psychiatric disorders in the elderly are discussed.