Comprehensive geriatric assessment in older patients suffering from infective endocarditis. A prospective multicentric cohort study.

OBJECTIVES: The aim was to describe the impact of infective endocarditis (IE) on functional, cognitive and nutritional statuses, and to estimate the influence of these parameters on surgical management and mortality. METHOD: This was a prospective study over 13 months in 14 French hospitals, including patients ≥75 years of age with definite or possible IE. A comprehensive geriatric assessment (CGA) was performed during the first week of hospitalization, including a retrospective estimation of functional status 2 months before hospitalization, and 3 months after. RESULTS: A total of 120 patients were included (mean age 83.1 ± 5.0 (75-101) years). IE was associated with a dramatic impairment of functional status between 2 months prior hospitalization and the first geriatric evaluation (90.8% able to walk vs. 35.5% (p < 0.0001), ADL (Activities in Daily Living) 5.0 ± 1.7 vs. 3.1 ± 2.1 (p < 0.0001)). The 19 operated patients (15.8%) had less comorbidities (cumulative illness rating scale geriatric 10.8 ± 8.2 vs. 15.3 ± 7.1 (p 0.0176)), better functional (ADL 5.9 ± 0.4 vs. 4.9 ± 1.8 (p 0.0171) and nutritional (mini nutritional assessment 20.4 ± 5.0 vs. 17.3 ± 6.2 (p 0.0501)) statuses than non-operated patients. Among all infectious, cardiac and geriatric parameters, body mass index (HR 0.9, range 0.8-1, p 0.05) and ADL at the time of the first evaluation (HR 0.7, range 0.6-0.9, p 0.002) were the sole independent predictors of the 3-month (32.5%) and 1-year mortality (42.5%). Three months later, the 57 assessed patients only partially recovered their ADL (3.7 ± 1.9 vs. 5.3 ± 1.4 2 months prior hospitalization and 4.6 ± 1.9 at the first CGA; p < 0.0001). CONCLUSION: Functional and nutritional abilities are crucial components that can be accurately explored through a CGA when managing IE in oldest patients.

Unjustified variations in patient management for acute myocardial infarction in the Rhône-Alpes region of France. PRIMA Group.

OBJECTIVES: To examine determinants of use of cardiac procedures after acute myocardial infarction and identify variation factors. METHODS: Observational prospective cohort study of 2,519 patients in 48 centers with a two-level logistic-regression analysis. RESULTS: Elderly patients were less likely to undergo pre- and inhospital thrombolysis (odds ratios, 0.71 and 0.64; 95% CI, 0.62-0.81 and 0.58-0.69, respectively). The elderly, females, and patients with heart failure on admission were less likely to undergo noninvasive tests (0.74, 0.62, and 0.51; 95% CI, 0.67-0.81, 0.46-0.83, and 0.38-0.68, respectively) and coronary angiography (0.38, 0.53, and 0.67; 95% CI, 0.34-0.42, 0.38-0.74, and 0.52-0.86, respectively) but not revascularization. Hospital factors were more difficult to interpret. CONCLUSIONS: Elderly, women, and heart failure patients underwent fewer cardiac procedures than lower-risk patients. Physicians should change their attitude toward these groups and use advanced procedures, bearing in mind the patients' needs rather than good procedural outcomes.

[Epidemiology and economic impact of heart failure in France]. / Epidémiologie et impact économique de l'insuffisance cardiaque en France.

There are little epidemiological data available about heart failure in France, despite its considerable impact on the system of health care and the fact that this problem will become even more acute in the future. Here are some important statistics: in France, there are about 500,000 people suffering from heart failure with about 120,000 new cases every year. The incidence increases from 4% in men and 3% in women of 55 to 64 years of age to 50% in men and 85% in women of 85 to 94 years of age. The average age of diagnosis is 73.5 years: two thirds of patients are over 70 years of age. There are about 3.5 million consultations and 150,000 hospital admissions for heart failure per year. The average length of hospital stay is 11 days. There are more than 32,000 deaths per year from heart failure. The cost of treating heart failure represents more than 1% of total medical expenses. Heart failure is a major problem of public health which is on the increase. This should incite physicians to provide optimal treatment for those affected and to place greater emphasis on preventive measures.

[The impact of the data collection method on the medico-economic classification of admissions for myocardial infarction at the public hospitals in Lyon]. / Impact du mode de recueil des données sur le classement médico-économique des séjours pour infarctus du myocarde aux Hospices Civils de Lyon.

The aim of the PMSI (Programme de Médicalisation du Système d'Information) is to describe the activity of hospitals for budget allocation. To control the quality of this information, the authors carried out a study comparing the classification in homogenous disease groups (HDG) obtained from the PMSI with that obtained from the epidemiological data base of the PRIMA trial for patients admitted to the Civil Hospitals of Lyon for myocardial infarction between September 1st 1993 and January 31st 1995. Six hundred and fifty standardised hospital summaries were reconstituted form PRIMA data and grouped using the GENRSA 3 software. Five hundred and forty-one of these hospital stays were found in the PMSI data base and grouped. The concordance not due to chance between the two classifications was then assessed by the global kappa coefficient. It was less than the 40% threshold under which concordance not due to chance is considered to be unlikely. The discordances were essentially due to the presence of an associated diagnosis classifying the hospital stay in the HDG corresponding to complicated myocardial infarction. The presence of a classifying associated diagnosis was observed significantly more often in the PRIMA than in the PMSI data base. This results in an underestimation of the hospital activity and could have important repercussions in terms of budget allocation.

[Management of myocardial infarction in the Rhone-Alps area. Are there many variations in practice?]. / Prise en charge de l'infarctus du myocarde dans la région Rhône-Alpes. Existe-t-il une variation des pratiques?

The aim of this study was to determine the diagnostic and therapeutic strategies after myocardial infarction and to examine variations in medical and surgical practice with respect to the severity of disease, status of the hospital and patients' characteristics. The method used was a prospective study with follow-up at 30 days and 18 months. The subjects came from an exhaustive cohort of all patients admitted to hospital for myocardial infarction during the month of April 1991 in 57 public and private hospitals in the Rhone-Alps region (n = 311). The patients were identified after admission by consulting physicians of the Department of Social Security. The study included all patients with acute myocardial infarction with at least two of the three usual diagnostic criteria (prolonged, constrictive chest pain, enzyme increases and electrocardiographic changes). The study excluded patients who were dead before arrival at hospital. The parameters analysed included the clinical management, use of echocardiography, exercise stress testing, myocardial scintigraphy, coronary angiography, thrombolysis, angioplasty and coronary bypass surgery in the first 30 days after admission. The severity of infarction was assessed by seven clinical, enzymatic and electrocardiographic criteria by physicians from the Department of Social Security (pain, syncope, shock, left ventricular dysfunction, elevation of CPK > 1000 IU, anterior or extensive necrosis, arrhythmias). The mortality rate of this cohort was calculated from hospital statistics and then by enquiring in the town halls of the region. The demographic features of the cohort were marked by a predominance of men (69.5%) and a relatively high mean age (69 years; 23% over 80 years). Complementary investigations were used with the following frequencies: echocardiography, 61.1%; coronary angiography, 26.4%; exercise stress testing 22.8%; myocardial scintigraphy, 5.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

Data quality in a DRG-based information system.

The aim of this study initiated in May 1990 was to evaluate the quality of the medical data collected from the main hospital of the "Hospices Civils de Lyon", Edouard Herriot Hospital. We studied a random sample of 593 discharge abstracts from 12 wards of the hospital. Quality control was performed by checking multi-hospitalized patients' personal data, checking that each discharge abstract was exhaustive, examining the quality of abstracting, studying diagnoses and medical procedures coding, and checking data entry. Assessment of personal data showed a 4.4% error rate. It was mainly accounted for by spelling mistakes in surnames and first names, and mistakes in dates of birth. The quality of a discharge abstract was estimated according to the two purposes of the medical information system: description of hospital morbidity per patient and Diagnosis Related Group's case mix. Error rates in discharge abstracts were expressed in two ways: an overall rate for errors of concordance between Discharge Abstracts and Medical Records, and a specific rate for errors modifying classification in Diagnosis Related Groups (DRG). For abstracting medical information, these error rates were 11.5% (SE +/- 2.2) and 7.5% (SE +/- 1.9) respectively. For coding diagnoses and procedures, they were 11.4% (SE +/- 1.5) and 1.3% (SE +/- 0.5) respectively. For data entry on the computerized data base, the error rate was 2% (SE +/- 0.5) and 0.2% (SE +/- 0.05). Quality control must be performed regularly because it demonstrates the degree of participation from health care teams and the coherence of the database.(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis of the medical decision]. / L'analyse de la décision médicale.

Analysis of clinical decision making is a quantitative method using probabilities to evaluate the process in uncertain situations. It provides a model of clinical decision making by integrating experimental and epidemiological data, the opinions of specialists and an assessment of the patient's state of health. There is also a place for the integration of the patients' opinions and of their quality of life. Using this information and eventually associating the cost of management, analysis of decision making tries to demonstrate a preference for a given strategy in a given clinical or public health problem. This article presents the methodological basis of analysis of decision making using a simple example of clinical cardiological practice and discusses the value of this method for debating a clinical choice with criteria integrating the patients' quality of life and the cost to society.

[The facts about cholesterol (condensed translation and comments of the common declaration of AHA and NHLBI)]. / Les faits sur le cholestérol (traduction condensée de la déclaration commune de l'AHA et du NHLBI et commentaires).

Many epidemiological and experimental studies have confirmed the continuous positive relationship between serum cholesterol levels and coronary risk. Therapeutic trials have demonstrated that the lowering of serum cholesterol by diet or drugs can lower this coronary risk. The benefits have been shown in men and women, the young and old, in those with a high coronary risk due to raised serum cholesterol and LDL and those with only moderately increased risk. In addition, therapeutic interventions on serum cholesterol are cost-effective. These observations more than justify the present national program of lowering the serum cholesterol.

Meta-analysis.

Meta-analysis corresponds to all systematic methods which use statistical techniques for combining results from several independent studies. The aim is to get a consistent estimation of the global effect of a procedure on a specified outcome. The technique allows us to increase the power of statistical testing, and to get information which cannot be drawn from one individual study. Two approaches are possible, and often combined: the qualitative approach consists of weighing various studies according to their methodological quality; the quantitative approach consists of pooling the results of different studies, in order to generate results with a higher statistical power. A meta-analysis is a long and rigorous process, which follows several steps: statement of objectives; definition of articles inclusion and exclusion criteria; literature search; collection of data and evaluation of the quality of each study; tests for homogeneity; pooling; sensitivity analyses; presentation of results; and conclusions. Meta-analysis has several advantages: it estimates the size of an effect; it improves the generalizability; it compels to rigor; it lessens the part of subjectivity. When meta-analysis is cautiously and properly done, it brings new useful information, and helps physicians and health policy makers in answering to a specific question.