Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study.

BACKGROUND: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. OBJECTIVES: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. METHOD: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. RESULTS: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient's comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from -0.05 to 0.42 for patients with advanced disease, and from -0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. CONCLUSION: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.

Admission to intensive care: A qualitative study of triage and its determinants.

OBJECTIVE: To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING: ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN: We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS: Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS: Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS: Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.

Emergency assessment of patients with acute abdominal pain using low-dose CT with iterative reconstruction: a comparative study.

OBJECTIVES: To determine if radiation dose delivered by contrast-enhanced CT (CECT) for acute abdominal pain can be reduced to the dose administered in abdominal radiography (<2.5 mSv) using low-dose CT (LDCT) with iterative reconstruction algorithms. METHODS: One hundred and fifty-one consecutive patients requiring CECT for acute abdominal pain were included, and their body mass index (BMI) was calculated. CECT was immediately followed by LDCT. LDCT series was processed using 1) 40% iterative reconstruction algorithm blended with filtered back projection (LDCT-IR-FBP) and 2) model-based iterative reconstruction algorithm (LDCT-MBIR). LDCT-IR-FBP and LDCT-MBIR images were reviewed independently by two board-certified radiologists (Raters 1 and 2). RESULTS: Abdominal pathology was revealed on CECT in 120 (79%) patients. In those with BMI <30, accuracies for correct diagnosis by Rater 1 with LDCT-IR-FBP and LDCT-MBIR, when compared to CECT, were 95.4% (104/109) and 99% (108/109), respectively, and 92.7% (101/109) and 100% (109/109) for Rater 2. In patients with BMI ≥30, accuracies with LDCT-IR-FBP and LDCT-MBIR were 88.1% (37/42) and 90.5% (38/42) for Rater 1 and 78.6% (33/42) and 92.9% (39/42) for Rater 2. CONCLUSIONS: The radiation dose delivered by CT to non-obese patients with acute abdominal pain can be safely reduced to levels close to standard radiography using LDCT-MBIR. KEY POINTS: • LDCT-MBIR (<2.5 mSv) can be used to assess acute abdominal pain. • LDCT-MBIR (<2.5 mSv) cannot safely assess acute abdominal pain in obese patients. • LDCT-IR-FBP (<2.5 mSv) cannot safely assess patients with acute abdominal pain.

How do researchers determine the difference to be detected in superiority trials? Results of a survey from a panel of researchers.

BACKGROUND: There is currently no guidance for selecting a specific difference to be detected in a superiority trial. We explored 3 factors that in our opinion should influence the difference to be detected (type of outcome, patient age group, and presence of treatment side-effects), and 3 that should not (baseline level of risk, logistical difficulties, and cost of treatment). METHODS: We conducted an experimental survey using a factorial design among 380 corresponding authors of randomized controlled trials indexed in Medline. Two hypothetical vignettes were submitted to participants: one described a trial of a new analgesic in mild trauma injuries, the other described a trial of a new chemotherapy among cancer patients. The first vignette tested the baseline level of risk, patient age-group, patient recruitment difficulties, and treatment side-effects. The second tested the baseline level of risk, patient age-group, type of outcome, and cost of treatment. The respondents were asked to select the smallest gain of effectiveness that should be detected by the trial. RESULTS: In vignette 1, respondents selected a median difference to be detected corresponding to an improvement of 7.0 % in pain control with the new treatment. In vignette 2, they selected a median difference to be detected corresponding to a reduction of 5.0 % in mortality or cancer recurrence with the new chemotherapy. In both vignettes, the difference to be detected decreased significantly with the baseline risk. The other factor influencing difference to be detected was the age group, but the impact of this factor was smaller. Cost, side-effects, outcome severity, or mention of logistical difficulties did not significantly impact the difference to be detected selected by participants. CONCLUSIONS: Three of the anticipated effects conformed to our expectations (the effect of patient age, and absence of effect of the cost of treatment and of patient recruitment difficulties) and the other three did not. These findings can guide future research in determining differences to be detected in trials that can translate to meaningful clinical decision-making.

Does the patient's inherent rating tendency influence reported satisfaction scores and affect division ranking?

OBJECTIVE: To determine the impact of adjusting for rating tendency (RT) on patient satisfaction scores in a large teaching hospital and to assess the impact of adjustment on the ranking of divisions. DESIGN: Cross-sectional survey. SETTING: Large 2200-bed university teaching hospital. PARTICIPANTS: All adult patients hospitalized during a 1-month period in one of 20 medical divisions. INTERVENTION: None. MAIN OUTCOME MEASURES: Patient experience of care measured by the Picker Patient Experience questionnaire and RT scores. RESULTS: Problem scores were weakly but significantly associated with RT. Division ranking was slightly modified in RT adjusted models. Division ranking changed substantially in case-mix adjusted models. CONCLUSIONS: Adjusting patient self-reported problem scores for RT did impact ranking of divisions, although marginally. Further studies are needed to determine the impact of RT when comparing different institutions, particularly across inter-cultural settings, where the difference in RT may be more substantial.

What should be the basis for compulsory and optional health insurance premiums? Opinions of Swiss doctors.

PRINCIPLES: Little is known about doctors' opinions on how to finance health services. In Switzerland, mandatory basic health insurance currently uses regional flat fees that are unrelated to health and ability to pay, and optional complementary insurance uses risk-based premiums. Our objective was to assess Swiss physicians' opinions on what should determine health insurance premiums. METHODS: We surveyed doctors in the canton of Geneva, Switzerland, about the desirable funding mechanism for mandatory health insurance and complementary health insurance. The proposed determinants of insurance premiums were current health and past medical history, lifestyle, healthcare costs in the previous year, genetic susceptibility to disease, regional average healthcare costs, household income, and wealth and demographic characteristics. RESULTS: Among the 1,516 respondents, only a few (<5%) believed that the mandatory health insurance premium should depend on health risk (health status, previous costs, genetics, and age and sex). More than 30% of respondents supported premiums based on lifestyle (34.6%), regional average health expenditures (31.2%), and household income and wealth (39.6%). For complementary health insurance, most respondents supported premiums based on lifestyle (74.6%) and on health risk (46.4%), but surprisingly also on household income and wealth (44.9%) and regional average health expenditures (39.4%). The characteristic most influencing the answers was the medical specialty. CONCLUSION: Doctors' opinions about healthcare financing mechanisms varied considerably, for both mandatory and complementary health insurance. Lifestyle was a surprisingly frequent choice, even though this criterion is not currently used in Switzerland. Ability to pay was not supported by the majority.

Self-rated health: analysis of distances and transitions between response options.

PURPOSE: We explored health differences between population groups who describe their health as excellent, very good, good, fair, or poor. METHODS: We used data from a population-based survey which included self-rated health (SRH) and three global measures of health: the SF36 general health score (computed from the 4 items other than SRH), the EQ-5D health utility, and a visual analogue health thermometer. We compared health characteristics of respondents across the five health ratings. RESULTS: Survey respondents (N = 1.844, 49.2 % response) rated their health as excellent (12.2 %), very good (39.1 %), good (41.9 %), fair (6.0 %), or poor (0.9 %). The means of global health assessments were not equidistant across these five groups, for example, means of the health thermometer were 95.8 (SRH excellent), 88.8 (SRH very good), 76.6 (SRH good), 49.7 (SRH fair), and 33.5 (SRH poor, p < 0.001). Recoding the SRH to reflect these mean values substantially improved the variance explained by the SRH, for example, the linear r (2) increased from 0.50 to 0.56 for the health thermometer if the SRH was coded as poor = 1, fair = 2, good = 3.7, very good = 4.5, and excellent = 5. Furthermore, transitions between response options were not explained by the same health-related characteristics of the respondents. CONCLUSIONS: The adjectival SRH is not an evenly spaced interval scale. However, it can be turned into an interval variable if the ratings are recoded in proportion to the underlying construct of health. Possible improvements include the addition of a rating option between good and fair or the use of a numerical scale instead of the classic adjectival scale.

A model for dropout assessment of candidates with or without hepatocellular carcinoma on a common liver transplant waiting list.

UNLABELLED: In many countries, the allocation of liver grafts is based on the Model of End-stage Liver Disease (MELD) score and the use of exception points for patients with hepatocellular carcinoma (HCC). With this strategy, HCC patients have easier access to transplantation than non-HCC ones. In addition, this system does not allow for a dynamic assessment, which would be required to picture the current use of local tumor treatment. This study was based on the Scientific Registry of Transplant Recipients and included 5,498 adult candidates of a liver transplantation for HCC and 43,528 for non-HCC diagnoses. A proportional hazard competitive risk model was used. The risk of dropout of HCC patients was independently predicted by MELD score, HCC size, HCC number, and alpha-fetoprotein. When combined in a model with age and diagnosis, these factors allowed for the extrapolation of the risk of dropout. Because this model and MELD did not share compatible scales, a correlation between both models was computed according to the predicted risk of dropout, and drop-out equivalent MELD (deMELD) points were calculated. CONCLUSION: The proposed model, with the allocation of deMELD, has the potential to allow for a dynamic and combined comparison of opportunities to receive a graft for HCC and non-HCC patients on a common waiting list.

Growing discontent of Swiss doctors, 1998-2007.

BACKGROUND: Work satisfaction of doctors is a useful indicator of the functioning of the health-care system. We documented the work satisfaction of doctors nine years apart, before and after the implementation of several health-care reforms (limitation of working hours for medical trainees, restrictions on new doctors' offices, new reimbursement fee schedule, greater administrative controls). METHODS: Two surveys of all doctors working in the Canton of Geneva, Switzerland (1998: 1146 respondents, 2007: 1546 respondents). The doctors filled in a 17-item questionnaire rating their satisfaction with different aspects of their professional life, each on a scale between 1 and 7. For each item, proportions of highly satisfied (scores 6-7) and highly dissatisfied (scores 1-2) doctors were compared over time. RESULTS: The proportion of doctors who were highly satisfied decreased significantly for 15 out of 17 items between 1998 and 2007. Meanwhile, 'time available for family, friends, or leisure' improved, and 'opportunity for continuing education' remained stable. Proportions of highly satisfied respondents decreased the most for 'enjoyment of work' (-17.2%), 'autonomy in treating your patients' (-15.8%), 'autonomy in referring patients to a specialist' (-14.0%), 'relations with patients' (-13.9%) and 'global satisfaction with current work situation' (-13.3%). The proportion of respondents who were highly dissatisfied (score 1-2) increased the most for 'administrative burden' (+8.9%) and 'social status and respect' (+5.0%). CONCLUSIONS: Doctors' satisfaction with most aspects of their professional lives has decreased sharply during the past decade. This trend may be linked, tentatively, with specific policy changes.

Self-assessment of intercultural communication skills: a survey of physicians and medical students in Geneva, Switzerland.

BACKGROUND: Physicians working with multicultural populations need to know how to elicit the patient's understanding of the illness; determine the patient's sociocultural context and identify any issues that might affect care; communicate effectively across patient-provider social and cultural differences; and collaborate effectively with an interpreter. Skills self-assessment can contribute to identifying training needs and monitoring skills development in these areas. METHODS: As part of a larger study exploring the knowledge, attitudes and practices of Geneva physicians and medical students regarding the care of immigrant patients, we asked respondents to self-rate their ability to perform a range of common yet challenging intercultural communication tasks. RESULTS: Overall, respondents rated themselves less competent at intercultural tasks than at basic medical skills and less competent at specific intercultural communication skills than at general intercultural skills. Qualified doctors (as opposed to students), those with greater interest in caring for immigrants, and those who rarely encountered difficulties with immigrants rated themselves significantly more competent for all clinical tasks. Having a higher percentage of immigrant patients and previous cultural competence training predicted greater self-rated intercultural communication skills. CONCLUSION: Our self-assessment results suggest that students and physicians should be provided with the opportunity to practice intercultural skills with immigrant patients as part of their cultural competence training. To strengthen the validity of self-assessment measures, they should ideally be combined with more objective methods to assess actual skills.

Using clinical vignettes to assess doctors' and medical students' ability to identify sociocultural factors affecting health and health care.

BACKGROUND: Methods are needed for assessing clinicians' cultural knowledge frameworks. METHOD: We used a mail survey containing four short clinical vignettes to explore respondents' ability to identify sociocultural factors affecting health and health care. Participants included 299 physicians working at the University Hospitals of Geneva, 156 private physicians, and all 134 local medical students in their clinical years. Twenty-one sociocultural "domains" were identified through inductive coding of responses. For each vignette, we obtained the sum of codes as a measure of the respondent's awareness of sociocultural factors that might affect care in this particular situation. As internal consistency was reasonably high (0.68), we computed a single total score as the sum of responses given to all four vignettes. RESULTS: Reponses correlated with factors that might be expected to impact clinicians' awareness of sociocultural factors affecting care. Medical students, females, respondents who had received cultural competence training, those with greater interest in caring for immigrant patients, and those with high self-assessed skills at exploring psychosocial and migration-related issues scored higher on the vignettes. CONCLUSIONS: Brief clinical vignettes appear to be a relevant and feasible method for exploring physicians' knowledge of social and cultural factors affecting health and health care.

Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT.

OBJECTIVES: To evaluate an algorithm integrating ultrasound and low-dose unenhanced CT with oral contrast medium (LDCT) in the assessment of acute appendicitis, to reduce the need of conventional CT. METHODS: Ultrasound was performed upon admission in 183 consecutive adult patients (111 women, 72 men, mean age 32) with suspicion of acute appendicitis and a BMI between 18.5 and 30 (step 1). No further examination was recommended when ultrasound was positive for appendicitis, negative with low clinical suspicion, or demonstrated an alternative diagnosis. All other patients underwent LDCT (30 mAs) (step 2). Standard intravenously enhanced CT (180 mAs) was performed after indeterminate LDCT (step 3). RESULTS: No further imaging was recommended after ultrasound in 84 (46%) patients; LDCT was obtained in 99 (54%). LDCT was positive or negative for appendicitis in 81 (82%) of these 99 patients, indeterminate in 18 (18%) who underwent standard CT. Eighty-six (47%) of the 183 patients had a surgically proven appendicitis. The sensitivity and specificity of the algorithm were 98.8% and 96.9%. CONCLUSIONS: The proposed algorithm achieved high sensitivity and specificity for detection of acute appendicitis, while reducing the need for standard CT and thus limiting exposition to radiation and to intravenous contrast media.

Exploration of health dimensions to be included in multi-attribute health-utility assessment.

OBJECTIVE: Measurement of health utility is important for quality improvement, but instruments vary in their content. Multi-attribute health utility measures typically assess a small number of health problems, e.g. the EuroQoL EQ-5D questionnaire explores five dimensions of health. We aimed to examine whether a small number of dimensions explains a sufficient amount of variance in self-perceived health, and what can be gained from adding additional dimensions. DESIGN: Cross-sectional mail survey that explored health utility and self-perceived health. SETTING: General resident population of French-speaking Switzerland. PARTICIPANTS: Non-institutionalized adults. MAIN OUTCOME MEASURES: EQ-5D (which measures mobility, self-care, usual activities, pain/discomfort, anxiety/depression and a visual analogue health scale between 0 and 100 (VAS)). A subsample rated five additional health dimensions (sleep, memory/concentration, energy/fatigue, sight/hearing, contacts with others). RESULTS: In total, 349 adults returned the extended 10-item questionnaire. All added items were strongly and significantly associated with the VAS for perceived health. The proportion of variance explained (R(2)) in the VAS was 0.47 for the original EQ-5D items (adjusted for attenuation: 0.65), 0.47 for the new items (adjusted for attenuation: 0.65) and 0.56 for the 10 items together (adjusted for attenuation: 0.78). Forty-four percent of the respondents who had a perfect health utility on the EQ-5D reported at least one problem in the new health dimensions. CONCLUSION: Self-perceived health among the general public is influenced by more health dimensions than are typically measured in a multi-attribute health-utility instrument.

Desire for autonomy in health care decisions: a general population survey.

OBJECTIVE: To examine factors associated with desire for autonomy in health care decisions in the general population. METHODS: Mailed survey of 2348 residents of Geneva, Switzerland. Participants answered questions on a scale measuring their desire for autonomy in health care decisions. The scale was scored between 0 (lowest desire for autonomy) and 100 (highest desire for autonomy). RESULTS: On average the respondents favoured shared or active involvement in medical decisions (mean score 62.0, SD 20.9), but attitudes varied considerably. In the multivariate model, factors associated with a higher desire for autonomy included female gender, younger age, higher education, living alone, reporting an excellent global health and - a new observation compared to previous studies - having made several medical decisions in the past 6 months. CONCLUSIONS: The attitudes of the general public appear to be consistent with the model of shared decision making. However, people vary considerably in their desire for autonomy. PRACTICE IMPLICATIONS: An explicit assessment of each individual's desire for autonomy may improve the decision-making process. Such an assessment should be repeated regularly, as familiarity with medical decisions may increase the desire for autonomy.

What doctors think about the impact of managed care tools on quality of care, costs, autonomy, and relations with patients.

BACKGROUND: How doctors perceive managed care tools and incentives is not well known. We assessed doctors' opinions about the expected impact of eight managed care tools on quality of care, control of health care costs, professional autonomy and relations with patients. METHODS: Mail survey of doctors (N = 1546) in Geneva, Switzerland. Respondents were asked to rate the impact of 8 managed care tools on 4 aspects of care on a 5-level scale (1 very negative, 2 rather negative, 3 neutral, 4 rather positive, 5 very positive). For each tool, we obtained a mean score from the 4 separate impacts. RESULTS: Doctors had predominantly negative opinions of the impact of managed care tools: use of guidelines (mean score 3.18), gate-keeping (2.76), managed care networks (2.77), second opinion requirement (2.65), pay for performance (1.90), pay by salary (2.24), selective contracting (1.56), and pre-approval of expensive treatments (1.77). Estimated impacts on cost control were positive or neutral for most tools, but impacts on professional autonomy were predominantly negative. Primary care doctors held more positive opinions than doctors in other specialties, and psychiatrists were in general the most critical. Older doctors had more negative opinions, as well as those in private practice. CONCLUSIONS: Doctors perceived most managed care tools to have a positive impact on the control of health care costs but a negative impact on medical practice. Tools that are controlled by the profession were better accepted than those that are imposed by payers.

General population reference values for the French version of the EuroQol EQ-5D health utility instrument.

OBJECTIVE: To provide reference values for the French version of the EQ-5D and verify its capacity to discriminate between subgroups. METHODS: General population mail survey in French-speaking Switzerland that included the EQ-5D instrument (five items rated on three levels as no problem, moderate problem, severe problem, and a visual analog health scale between 0 and 100) and descriptive variables. RESULTS: Questionnaires were returned by 1956 adults (response rate 52.1%). Three of the five items had important "ceiling" effects (proportions with no problem: mobility 92.1%, self-care 97.6%, usual activities 91.2%), the other two less so (pain/discomfort 54.3%, anxiety/depression 68.1%). Four health states represented the majority of the population: no health problem (41.8%), moderate pain/discomfort only (21.0%), moderate anxiety/depression only (11.5%), moderate pain/discomfort and moderate anxiety/depression only (13.2%). The mean health utility was 0.83 (SD 0.15) on a scale between 0 and 1 and the mean visual analog score 81.7 (SD 15.5); the two were correlated (Pearson r 0.63, P < 0.001). Health utility scores were lower among women, older respondents, those with basic education, users of health services, and those with lower self-reported health status. The pattern was similar for the visual analog score except that women reported slightly higher ratings than men. CONCLUSION: The EQ-5D performed as expected in a French-speaking general population sample. Reference values by sex and age group may facilitate the interpretation of results obtained in clinical settings.

[Fee schedules and cost containment]. / Tarifs, forfaits et economicité.

Medical fee schedules are controversial. In this paper we examine the reasons that justify the imposition of fee schedules in the presence of a socially financed health insurance system, and examine the ways of constructing a medical fee schedule. The weakness of fee-for-service tariffs is that they do not allow a control of health care costs if the volume of services is unchecked. Current solutions to this problem--audit of doctors' average cost per case, freeze on new medical practices, or the insurers' discretion in choosing the doctors they reimburse--have multiple drawbacks. Alternatives to fee-for-service payment--such as flat fees, or payment based on the quality of medical services--are discussed.

Use of a computer-based simulated consultation tool to assess whether doctors explore sociocultural factors during patient evaluation.

RATIONALE, AIMS AND OBJECTIVES: The delivery of patient-centred care to diverse populations requires that doctors identify sociocultural factors that may affect care. We adapted a computer-based simulated consultation tool and tested its utility for assessing whether doctors explore sociocultural factors during a patient evaluation, and whether they include such information in their case conclusions and follow-up recommendations. METHODS: We developed two detailed patient 'stories' that involved sociocultural issues that doctors needed to identify and consider for adequate clinical management. They were incorporated into an existing 'Virtual Internet Patient Simulation' (VIPS) program designed to test clinical reasoning skills. Doctors and medical students (n = 618) were invited to access the program via Internet. For each consultation, participants were assigned a sociocultural score, corresponding to the number of sociocultural domains explored. Scores were then compared with subjective ratings of participants' performance by expert doctors. RESULTS: 118 respondents completed at least one virtual consultation (19%), 92 conducted both. The mean number of sociocultural dimensions explored by doctors (i.e. sociocultural score) was 3.9 (standard deviation 2.6) for case 1, and 5.2 (standard deviation 2.3) for case 2. The two sociocultural scores were moderately correlated (Spearman r = 0.65, P < 0.001). Sociocultural scores correlated positively with experts' subjective ratings of participants' performance (Spearman r = 0.84 for case 1 and 0.78 for case 2, both P < 0.001). CONCLUSIONS: The adapted computer-based simulated consultation tool provided a feasible means to assess doctors' exploration of sociocultural issues during a clinical evaluation. Further validation of this method should be conducted by comparing VIPS results with other skills assessment methods such as objective structured clinical examination or direct observation of clinical performance.

A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility.

BACKGROUND: Early identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time. METHODS: We conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort. RESULTS: Prediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patient's partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score > or = 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results. CONCLUSION: A simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning.

CD4-guided scheduled treatment interruptions compared with continuous therapy for patients infected with HIV-1: results of the Staccato randomised trial.

BACKGROUND: Stopping antiretroviral therapy in patients with HIV-1 infection can reduce costs and side-effects, but carries the risk of increased immune suppression and emergence of resistance. METHODS: 430 patients with CD4-positive T-lymphocyte (CD4) counts greater than 350 cells per muL, and viral load less than 50 copies per mL were randomised to continued therapy (n=146) or scheduled treatment interruptions (n=284). Median time on randomised treatment was 21.9 months (range 16.4-25.3). Primary endpoints were proportion of patients with viral load less than 50 copies per mL at the end of the trial, and amount of drugs used. Analysis was intention-to-treat. This study is registered at ClinicalTrials.gov with the identifier NCT00113126. FINDINGS: Drug savings in the scheduled treatment interruption group, compared with continuous treatment, amounted to 61.5%. 257 of 284 (90.5%) patients in the scheduled treatment interruption group reached a viral load less than 50 copies per mL, compared with 134 of 146 (91.8%) in the continued treatment group (difference 1.3%, 95% CI-4.3 to 6.9, p=0.90). No AIDS-defining events occurred. Diarrhoea and neuropathy were more frequent with continuous treatment; candidiasis was more frequent with scheduled treatment interruption. Ten patients (2.3%) had resistance mutations, with no significant differences between groups. INTERPRETATION: Drug savings with scheduled treatment interruption were substantial, and no evidence of increased treatment resistance emerged. Treatment-related adverse events were more frequent with continuous treatment, but low CD4 counts and minor manifestations of HIV infection were more frequent with scheduled treatment interruption.