A Comparison of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Pain Assessment in Advanced Dementia Scale (PAINAD).

BACKGROUND: There is currently no gold standard instrument for assessing pain in severely cognitively impaired adults who are unable to provide self-report. AIMS: To determine interrater reliability of the PACSLAC and PAINAD in assessing pain behaviors in patients with the same pain stimulus, determine the consistency of the reliable changes between and within the instruments and assess nurse preference for either instrument. DESIGN: A single-group, within-subjects repeated-measures design was implemented. SETTING: The study took place in a small suburban hospital. PARTICIPANTS/SUBJECTS: Pain levels were observed at 24, 48, and 72 hours postsurgery using two instruments: Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Pain Assessment in Advanced Dementia Scale (PAINAD). These instruments were selected because they are among the most commonly recommended tools for clinical use. Interrater reliability was analyzed along with reliable changes in pain for each period, and the study concluded with the nurse raters completing a preference survey. METHODS: A convenience sample of 30 patients was used with a diagnosis of severe dementia rendering the patient unable to reliably express pain, 60+ years of age, recovering from hip fracture surgery. RESULTS: Greater interrater reliability was found for the PACSLAC, with reliable change potentially affected by the type and level of pain medication. The nurses' preference for the tool was split. CONCLUSIONS: The results of this study indicate that the PACSLAC may be the more reliable tool over the PAINAD; however, rater training and familiarity with the tool is critical.

Associations between local government expenditures and low birth weight incidence: Evidence from national birth records.

Local governments play an integral role in providing public services to their residents, yet the population health benefits are frequently overlooked, especially when services are outside the traditional health domain. With data from the U.S. Census of Governments and national birth records (spanning from 1992 to 2014), we examined whether local government expenditures on parks and recreation services (PRS) and housing and community development (HCD) predicted county low birth weight outcomes (population incidence and black-white disparities). Hypotheses were tested using bias-corrected county-by-period fixed effects models in a sample of 956 U.S. counties with a total of 3619 observations (observations were defined as three-year pooled estimates), representing 24 million births. Adjusting for prior county low birth weight incidence, levels of total operational, health, and hospital expenditures, and time-varying county sociodemographics, an increase in per capita county PRS expenditures of $50 was associated with 1.25 fewer low birth weight cases per 1000. Change in county HCD expenditures was not associated with low birth weight incidence, and, contrary to hypotheses, neither expenditure type was linked to county black-white disparities. Further examination of the benefits to birth outcomes from increasing parks and recreation services is warranted.

Impact of patient symptoms and caregiving tasks on psychological distress in caregivers for head and neck cancer (HNC).

OBJECTIVE: To determine the association of caregiving task burden and patient symptom burden with psychological distress among caregivers of head and neck cancer (HNC) patients. METHODS: Adults with HNC and their primary caregivers were included. Patient symptom burden was assessed with the Vanderbilt Head and Neck Symptom Survey-2.0. Caregiving task burden was quantified as task number and task difficulty/distress using the HNC Caregiving Task Inventory. Psychological distress was measured with the Profile of Mood States-Short Form. Two-step clustering analysis was conducted for patient symptom burden, caregiving task burden, and psychological distress. Associations of the resultant clusters of task burden and patient symptoms with caregiver distress were tested using logistic regressions. RESULTS: Eighty-nine HNC caregivers and 84 patients were included. Among patients, two clusters of symptom burden were found (51% mod-high, 49% low). Among caregivers, two clusters of caregiving task burden (40% mod-high, 60% low) and caregiver psychological distress (40% mod-high, 60% low) were found. Caregivers with mod-high task numbers and task difficulty/distress reported higher levels of psychological distress. After controlling for caregiver number of tasks, respective difficulty/distress, and patient symptom burden, caregiver perceived task difficulty/distress had the strongest association with caregiver psychological distress (adjusted OR = 3.83; 95% CI, 1.0-14.64; P = 0.049). CONCLUSIONS: Psychological distress in HNC caregivers is associated with caregiving task burden, with caregivers experiencing high task difficulty/distress at greatest risk. Further study of the caregiver and task characteristics leading to psychological distress should inform supportive interventions for HNC patients and caregivers.

Cafeteria assessment for elementary schools (CAFES): development, reliability testing, and predictive validity analysis.

BACKGROUND: Strategies to reduce childhood obesity and improve nutrition include creating school food environments that promote healthy eating. Despite well-documented health benefits of fruit and vegetable (FV) consumption, many U.S. school-aged children, especially low-income youth, fail to meet national dietary guidelines for FV intake. The Cafeteria Assessment for Elementary Schools (CAFES) was developed to quantify physical attributes of elementary school cafeteria environments associated with students' selection and consumption of FV. CAFES procedures require observation of the cafeteria environment where preparation, serving, and eating occur; staff interviews; photography; and scoring. METHODS: CAFES development included three phases. First, assessment items were identified via a literature review, expert panel review, and pilot testing. Second, reliability testing included calculating inter-item correlations, internal consistency (Kuder-Richardson-21 coefficients), and inter-rater reliability (percent agreement) based on data collected from 50 elementary schools in low-income communities and 3187 National School Lunch Program participants in four U.S. states. At least 43% of each participating school's students qualified for free- or reduced-price meals. Third, FV servings and consumption data, obtained from lunch tray photography, and multi-level modeling were used to assess the predictive validity of CAFES. RESULTS: CAFES' 198 items (grouped into 108 questions) capture four environmental scales: room (50 points), table/display (133 points), plate (4 points), and food (11 points). Internal consistency (KR-21) was 0.88 (overall), 0.80 (room), 0.72 (table), 0.83 (plate), and 0.58 (food). Room subscales include ambient environment, appearance, windows, layout/visibility, healthy signage, and kitchen/serving area. Table subscales include furniture, availability, display layout/presentation, serving method, and variety. Inter-rater reliability (percent agreement) of the final CAFES tool was 90%. Predictive validity analyses indicated that the total CAFES and four measurement scale scores were significantly associated with percentage consumed of FV served (p < .05). CONCLUSIONS: CAFES offers a practical and low-cost measurement tool for school staff, design and public health practitioners, and researchers to identify critical areas for intervention; suggest low- and no-cost intervention strategies; and contribute to guidelines for cafeteria design, food presentation and layout, and operations aimed at promoting healthy eating among elementary school students.

Nurse-Delivered Symptom Assessment for Individuals With Advanced Lung Cancer.

OBJECTIVES: To assess an intervention derived from self-regulation theory (SRT) to promote well-being for individuals with advanced lung cancer. SAMPLE & SETTING: 45 adults with advanced lung cancer who were receiving chemotherapy at an ambulatory cancer center. METHODS & VARIABLES: Participants were randomized to the intervention group or usual care control group. Feasibility assessment focused on recruitment, retention, design, methods, and fidelity. Outcome measures of quality of life, symptoms, and distress were collected at four time points. The main research variables were symptoms, quality of life, and distress. RESULTS: The participation rate was 79%, and the retention rate was 62%. Participant loss was most often because of progressive disease and occurred early in the study. High fidelity was noted for delivery of the intervention as planned and outcome data collection by telephone. The mean number of interventions delivered was 5.5 of a planned 8. A high level of acceptability was reported for participants completing the intervention. IMPLICATIONS FOR NURSING: Although delivering the SRT-derived intervention with fidelity was possible, feasibility findings do not warrant intervention replication in this population.

The carry-over effects of school gardens on fruit and vegetable availability at home: A randomized controlled trial with low-income elementary schools.

This group-randomized controlled trial examines the effects of a school garden intervention on availability of fruits and vegetables (FV) in elementary school children's homes. Within each region, low income U.S. schools in Arkansas, Iowa, New York, and Washington State were randomly assigned to intervention group (n = 24) or waitlist control group (n = 22). Children were in grades 2, 4, and 5 at baseline (n = 2768). The garden intervention consisted of both raised-bed garden kits and a series of grade-appropriate lessons. FV availability at home was measured with a modified version of the GEMS FJV Availability Questionnaire. The instrument was administered at baseline (Fall 2011) and throughout the intervention (Spring 2012, Fall 2012, Spring 2013). Analyses were completed using general linear mixed models. The garden intervention led to an overall increase in availability of low-fat vegetables at home. Among younger children (2nd grade at baseline), the garden intervention led to greater home availability of vegetables, especially, low-fat vegetables. Moreover, for the younger group, garden intervention fidelity (GIF) or robustness predicted home availability of fruit, vegetables, and low-fat vegetables. School gardens have potential to affect FV availability in the home environment.

Preliminary evaluation of reliability and validity of head and neck external lymphedema and fibrosis assessment criteria.

PURPOSE: Measurement of head and neck external lymphedema and fibrosis (LEF) is challenging. To address this gap, we developed the Head and Neck External Lymphedema and Fibrosis (HN-LEF) Assessment Criteria. This article aimed to report preliminary data on reliability and validity of the HN-LEF Assessment Criteria. METHODS: Sixty head and neck cancer (HNC) patients who were ≥3-month post cancer therapy were recruited. Study measures included 1) demographic/medical data; 2) LEF physical examination completed independently by two staff members for interrater reliability (intrarater reliability completed by one of them); and 3) grayscale ultrasound examination of the head and neck skin. Reliability estimates used percent agreement and Kappa statistic. Validity was assessed via Spearman correlations of physical examination findings with ultrasound measurements. RESULTS: Fifty-one out of 60 HNC patients completed both physical examination and ultrasound assessments. Interrater reliability: 91.0% agreement (Kappa = 0.81, p < 0.001) on the presence of types of LEF; 84.9% agreement regarding the grade of LEF (Kappa = 0.70, p < 0.001) across all anatomic sites. Intrarater reliability: 96.1% agreement for type of LEF; and 91.4% agreement for grade across all sites. Ultrasound examination demonstrates characteristics and patterns for different types of LEF (particularly in the cheek, submental, and neck regions). CONCLUSIONS: The study provided initial reliability and validity data for a clinician-reported tool evaluating external LEF in the HNC population. These preliminary findings demonstrate that the tool had good reliability. Associations with the ultrasound examination results demonstrate that the tool validly captures soft tissue changes at select sites. Further validation of the tool is warranted.

Immersion in Evidence-Based Practice Fellowship Program: A Transforming Experience for Staff Nurses.

The aim of this study was to explore professional and personal changes staff nurses experience during and after a 1-year evidence-based practice program. Focus groups were conducted with staff who completed an evidence-based practice fellowship program. Five themes emerged from the focus groups: support, resources, knowledge, opportunity, and empowerment. A 1-year fellowship program provides essential elements needed for organizational structural empowerment. Sense of empowerment helps to explain outcomes of fellowship programs and successes of graduates.

Rural middle school nutrition and physical activity environments and the change in body mass index during adolescence.

BACKGROUND: For rural adolescents, schools are among the few places where environmental interventions can promote health outside of the home. The goal of this study was to assess the nutrition and physical activity (N&PA) environments of schools attended by a birth cohort and examine the association with change in body mass index (BMI) from sixth to eighth grade. METHODS: Using data from adolescents of a rural New York State birth cohort (N = 281), we used linear mixed models to identify N&PA environments associated with change in BMI. We also examined family income trajectory as a potential modifier to consider how the association between school environment and change in BMI might differ depending on income. RESULTS: We found considerable heterogeneity in environments within and between schools. Among students with low-income trajectories, reductions in BMI z-scores were associated with school environments that promote better physical education (PE) and general (non-PE, non-sport) physical activity. Schools with better sports environments were associated with reductions in BMI for some students, but not lower-income students. CONCLUSIONS: School environments may have differing effects on students depending on their socioeconomic status. Strategies are needed to identify and address barriers that impair low-income students' access to health-promoting school resources.

Development and preliminary testing of head and neck cancer related external lymphedema and fibrosis assessment criteria.

PURPOSE: To develop assessment criteria for evaluating and documenting status of external lymphedema and fibrosis in patients with head and neck cancer (HNC). METHODS: This was a two-phase instrument development study. In Phase I, initial assessment criteria for head and neck external lymphedema and fibrosis were generated based on a conceptual framework developed to describe the continuum of lymphedema - fibrosis in HNC patients. The initial Head and Neck External Lymphedema and Fibrosis (HN-ELAF) Assessment Criteria with three components were revised based on expert feedback. In Phase II, a pilot study was conducted to evaluate the revised assessment criteria through direct physical examination of 30 HNC patients with facial swelling and/or scar-like tissue >3 months post-treatment. The following statistical methods were used to evaluate interrater reliability in Phase II: simple percent agreement, the Kappa statistic, and the concordance correlation coefficient. Then, a post-test revision was made to further modify the tool based on the results of the pilot test. RESULTS: In Phase I, the initial HN-ELAF was revised including deleting Grade 0 (subclinical disease) and two components (i.e., symptoms and functional impairments). The revised HN-ELAF Assessment Criteria demonstrated good content/face validity. In Phase II, the assessment criteria had an acceptable interrater reliability, e.g., 83% exact agreement on grading lymphedema and fibrosis severity; and kappa = 0.75 (p < .001). The assessment criteria were further modified including three dimensions: type, severity, and anatomical sites of lymphedema and fibrosis. CONCLUSIONS: Validation of the modified HN-ELAF Assessment Criteria in larger sample sizes is ongoing.

The healthy start partnership: an approach to obesity prevention in young families.

This article investigates the impact of community-based interventions developed by the Healthy Start Partnership (HSP) to promote healthy body weights in families. Intercept surveys were conducted to monitor community exposure. A nonconcurrent, no treatment control design was used to assess population-level weight outcomes. Control (n = 219) and intervention (n = 276) cohorts of pregnant women were recruited and followed until 6 months postpartum. Data were collected through 2 self-administered questionnaires and medical record audits. Results indicate community residents were exposed to interventions. However, little evidence of positive effects of interventions on weight outcomes was found for mothers or infants.

Assessment of external lymphedema in patients with head and neck cancer: a comparison of four scales.

PURPOSE/OBJECTIVES: To compare available grading and staging scales that measure external lymphedema in patients with head and neck cancer (HNC) and to assess problems and gaps related to these tools. DESIGN: Cross-sectional. SETTING: A comprehensive cancer center in Tennessee. SAMPLE: 103 participants post-HNC treatment. METHODS: Four scales were used to evaluate study participant external lymphedema status, including the Common Terminology Criteria for Adverse Events (CTCAE) Lymphedema Scale (version 3.0), American Cancer Society Lymphedema Scale, Stages of Lymphedema (Földi's Scale), and the CTCAE Fibrosis Scale (version 3.0). MAIN RESEARCH VARIABLES: Occurrence rate, severity of lymphedema, and components and descriptors of each scale. FINDINGS: The prevalence and severity of external lymphedema differed based on the tools. Each tool had an identified limitation. Current theory postulates a continuum between lymphedema and fibrosis, but only the Földi's Scale adequately reflected that concept. CONCLUSIONS: None of the available scales clearly captured all the important characteristics of external lymphedema in patients with HNC. A need exists to develop a clearly defined and validated scale of external lymphedema in the HNC population. IMPLICATIONS FOR NURSING: Oncology nurses should take an active role in addressing issues related to lymphedema assessment in patients post-HNC treatment; however, new assessment tools need to be developed for clinical use. KNOWLEDGE TRANSLATION: Early identification and accurate documentation of head and neck lymphedema are critically important to prevent lymphedema progress. However, existing grading criteria failed to capture important characteristics of external head and neck lymphedema. More research efforts need to be made to address this under-recognized issue.

Vanderbilt Head and Neck Symptom Survey version 2.0: report of the development and initial testing of a subscale for assessment of oral health.

BACKGROUND: The prevalence, severity, and functional implications of adverse oral health outcomes attributed to head and neck cancer therapy are largely undefined. We report development of an oral health outcome subscale for the Vanderbilt Head and Neck Symptom Survey (VHNSS). METHODS: Oral health outcome questions were formulated through literature review and consultation with an expert panel. Questions were incorporated into the VHNSS resulting in a 50-item survey, scored 0 (none) to 10 (severe). The tool was administered to 70 subjects who completed radiation to assess for feasibility. RESULTS: Patient acceptance was high with a completion time <10 minutes. A full range of scores was noted for 46 of 50 questions. Oral health symptom burden was high early and late posttreatment. CONCLUSIONS: The VHNSS version 2.0 was feasible and could be completed in a timely manner. Validation studies are ongoing. The high prevalence of adverse oral health outcomes warrants further study.

Cancer pain management in ambulatory care: can we link assessment and action to outcomes?

PURPOSE: Good cancer pain control requires appropriate assessment and treatment. The purpose of this study was to examine the relationships among physician, nurse practitioner, and nurse knowledge, documentation of assessment, treatment, and pain reduction in cancer patients seen in ambulatory settings. METHOD: The study method included an assessment of pain knowledge of providers (physicians, nurse practitioners, and nurses) who worked in cancer clinics and a retrospective review of patients' records treated for cancer-related pain in their clinics. Fifty-eight providers from eight cancer clinics completed the knowledge questionnaire; 56 patient records were reviewed for assessment, treatment, and outcome data. Pain relief, the outcome, was obtained from documentation at the next clinic visit. RESULTS: Of the 54 patient records that documented pain relief at the next clinic visit, 61.9% reported no relief. Chi square analysis revealed clinics with a higher level of pain knowledge documented a greater number of elements of an ideal pain assessment (p = 0.03) but was unrelated to treatment and pain relief reported. Assessment and treatment were unrelated to reported pain relief at the next clinic visit. CONCLUSION: These data suggest that providers' pain knowledge is related to pain assessment but not treatment or outcome. In addition, these data showed no relationship between assessment, treatment prescribed, and pain relief in these ambulatory settings.

Environmental volunteering and health outcomes over a 20-year period.

PURPOSE: This study tested the hypothesis that volunteering in environmental organizations in midlife is associated with greater physical activity and improved mental and physical health over a 20-year period. DESIGN AND METHODS: The study used data from two waves (1974 and 1994) of the Alameda County Study, a longitudinal study of health and mortality that has followed a cohort of 6,928 adults since 1965. Using logistic and multiple regression models, we examined the prospective association between environmental and other volunteerism and three outcomes (physical activity, self-reported health, and depression), with 1974 volunteerism predicting 1994 outcomes, controlling for a number of relevant covariates. RESULTS: Midlife environmental volunteering was significantly associated with physical activity, self-reported health, and depressive symptoms. IMPLICATIONS: This population-based study offers the first epidemiological evidence for a significant positive relationship between environmental volunteering and health and well-being outcomes. Further research, including intervention studies, is needed to confirm and shed additional light on these initial findings.

Reliability and validity of the Vanderbilt Head and Neck Symptom Survey: a tool to assess symptom burden in patients treated with chemoradiation.

BACKGROUND: We describe the development and validation of the Vanderbilt Head and Neck Symptom Survey (VHNSS), which was designed to screen for tumor- and treatment-specific symptoms in patients with head and neck cancer undergoing concurrent chemoradiation (CCR). METHODS: Using a 2-step card sort method, we identified high-impact and high-frequency toxicities in patients with head and neck cancer treated with CCR. This resulted in a 28-item questionnaire which scores symptoms on a 0 to 10 scale (none to severe). The tool was validated using data collected from 5 supportive care studies comprising a total sample of 332 patients with head and neck cancer. RESULTS: Responses to the VHNSS items demonstrated a very consistent pattern (Cronbach's alpha = 0.943) with each item contributing substantially to the global index. Five symptom subscales were identified including "Nutrition," "Pain," "Voice," "Swallow," and "Mucous/Dry Mouth." Each of the cluster scores demonstrated good internal consistency. The pattern of associations between the VHNSS and established tools indicated appropriate convergence and divergence. Comparison of global and subscale scores and objective measure were also in the expected direction providing further evidence of validity. CONCLUSIONS: The findings provide support that the VHNSS is a valid and reliable tool to assess head and neck-specific symptom burden and function loss. Further research to evaluate this screening tool as a part of a systems approach to supportive care is warranted.

The Vanderbilt Professional Nursing Practice Program, part 3: managing an advancement process.

Consistency of performance standards across multiple clinical settings is an essential component of a credible advancement system. Our advancement process incorporates a central committee, composed of nurses from all clinical settings within the institution, to ensure consistency of performance in inpatient, outpatient, and procedural settings. An analysis of nurses advanced during the first 18 months of the program indicates that performance standards are applicable to nurses in all clinical settings. The first article (September 2003) in this 3-part series described the foundation for and the philosophical background of the Vanderbilt Professional Nursing Practice Program (VPNPP), the career advancement program underway at Vanderbilt University Medical Center. Part 2 described the development of the evaluation tools used in the VPNPP, the implementation and management of this new system, program evaluation, and improvements since the program's inception. The purpose of this article is to review the advancement process, review the roles of those involved in the process, and to describe outcomes and lessons learned.

The Vanderbilt Professional Nursing Practice Program: part 1: Growing and supporting professional nursing practice.

Professional practice programs are designed to attract, retain, and reward nurses. This three-part series will describe Vanderbilt's performance-based career advancement system, the Vanderbilt Professional Nursing Practice Program (VPNPP). Part 1 outlines the overall program's foundation, philosophical background, and basic structure. The VPNPP is built upon Benner's work, distinguishing among four levels of practice: novice, competent, proficient, and expert. Work by many in the organization identified the expected behaviors for nurses at each level, which were then used to develop clear process evaluation criteria. Part 2 will examine the performance measurement and evaluation system created to support the program. The process of advancing within the program will be described in part 3.

Single-center comparison of laparoscopic pyeloplasty, Acucise endopyelotomy, and open pyeloplasty.

PURPOSE: To compare Acucise endopyelotomy (Applied Medical, Irvine, California), laparoscopic pyeloplasty, and open pyeloplasty in the treatment of ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS: A retrospective review of all adult patients undergoing surgical correction of UPJ obstruction between December 1999 and August 2001 at Vanderbilt University Medical Center was performed. Patients undergoing UPJ correction with Acucise endopyelotomy (N = 9), laparoscopic pyeloplasty (N = 16), and open pyeloplasty (N = 7) were compared in regard to demographic information, operative data, recovery parameters, cost data, and outcome (as determined by diuretic renography, the Whitaker test, or both). RESULTS: Success rates of 56%, 94%, and 86% were obtained for Acucise endopyelotomy, laparoscopic pyeloplasty, and open pyeloplasty, respectively. There were no differences between the Acucise endopyelotomy and laparoscopic pyeloplasty groups in age, American Society of Anesthesiology (ASA) score, length of follow-up, estimated blood loss (EBL), hospital stay, total hospital cost, or analgesic requirement. The Acucise patients demonstrated shorter operating times (1.7 v 3.3 hours; P < 0.001) and time to oral intake (7.9 v 16 hours; P = 0.008) than the laparoscopic pyeloplasty group. When the laparoscopic pyeloplasty patients were compared with the open pyeloplasty patients, there was no difference in operative time, EBL, time to oral intake, or total hospital costs. The laparoscopically treated patients demonstrated significantly lower analgesic requirements (27.2 v 124.2 mg of morphine sulfate equivalent; P = 0.02) and shorter hospital stays (1.4 v 3.0 days; P = 0.03) than the open surgery patients. The Acucise patients demonstrated shorter operative time (1.7 v 3.4 hours; P < 0.001), shorter hospital stay (1.3 v 3.0 days; P = 0.02), and lower analgesic requirement (22.4 v 124.2 mg of morphine sulfate equivalent; P = 0.02) than the open surgery patients. CONCLUSIONS: Laparoscopic pyeloplasty achieves a success rate equal to that of open pyeloplasty while providing a recovery similar to that obtained with Acucise endopyelotomy and is gaining popularity as the treatment of choice for UPJ obstruction.

Single-center comparison of purely laparoscopic, hand-assisted laparoscopic, and open radical nephrectomy in patients at high anesthetic risk.

BACKGROUND AND PURPOSE: The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications. PATIENTS AND METHODS: All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnett's T for pairwise comparisons. RESULTS: The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN ($6089 v $7678; P = 0.57) and open surgery ($6089 v $7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12). CONCLUSIONS: Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.