Predictors of death following ICU discharge.

In order to study possible predictors of early after-discharge mortality (EADM), 700 consecutive patients discharged alive from three intensive care units (ICUs) were followed up 2 months after their admission. The observed mortality was 7.3%. Univariate analysis indicated a strong statistically significant association of the following variables with mortality: initial simplified acute physiological score (SAPS) greater than 10, therapeutic intervention score in the first 24 h of admission greater than 20, age greater than or equal to 65, length of stay in the ICU greater than 10 days, and low educational level. The multiple logistic regression analysis included as predictive independent variables the SAPS, organs or systems failure, age, and length of stay. The model built upon these four variables was able to identify a group of patients at high risk (21-46%) of EADM. We conclude that some simple variables can be used as useful markers of patients groups at high risk of EADM.

Socioeconomic status and severity of illness on admission in acute myocardial infarction patients.

The objective of this research is to test the hypothesis of the existence of an association between socioeconomic status and severity of illness of the patients admitted to the hospital with acute myocardial infarction. The design was a retrospective cohort study of consecutive patients admitted to the coronary care unit with the diagnosis of acute myocardial infarction in six public hospitals from the Spanish region of Valenciá. A total of 369 patients admitted to the intensive care units of the participating hospitals were studied. The socioeconomic status was measured using an ad hoc index based upon the occupational level, income and educational level of the patient. The patients below the 20% percentile were considered as disadvantaged, and the patients whose Killip class on admission was 3 or 4 were considered as complicated. The effect of potential confounders was controlled using unconditional logistic regression analysis. The results were validated in an independent but comparable population of 331 patients. The disadvantaged patients showed a higher prevalence of open cardiac failure on admission (Killip classes 3 or 4) than the remainder (crude odds ratio = 3.1, 95% confidence interval between 1.57 and 6.1). The association between socioeconomic status and severity of illness persisted after controlling for important covariates (age, diabetes mellitus, gender and marital status): adjusted odds ratio = 2.4, 95% confidence interval between 1.1 and 5.2. These results were highly consistent with those in the validation group. Our results suggest that socioeconomic status is an independent predictor of the severity of illness on admission to coronary care units in acute myocardial infarction patients. These results are consistent with the existence of a low accessibility of patients in the lower socioeconomic levels.

[Prognosis of myocardial infarction in women. Effect of the therapeutic effort and the socioeconomic status]. / Pronóstico del infarto de miocardio en mujeres. Efecto del esfuerzo terapéutico y del nivel socioeconómico.

The causes of the high mortality of acute myocardial infarction in women as compared with men are controversial. The objective of this study is to assess the role of the therapeutic effort and socioeconomic factors on the genesis of this excess of mortality. We studied, using a retrospective cohort design, 491 men and 124 women admitted with the diagnosis of acute myocardial infarction. As a group, women were older (69 versus 61 years of age, p < 0.00001), showed a higher prevalence of cardiac failure on admission (44% versus 26%; p = 0.00008) and a higher mortality in the coronary care unit (29.3% versus 12.9%; p = 0.00002). In addition, the women showed an unfavorable socioeconomic profile and received a lower relative therapeutic effort, as assessed by the Therapeutic Intervention Scoring System. There was statistical interaction between gender and marital status, with a higher mortality in the unmarried male, comparable to that of women. Within the married group, the excess of mortality in women persisted after adjusting for age and Killip group (adjusted odds ratio = 2.48, 95% confidence interval between 1.26 and 4.89). None of the studied socioeconomic variables was independently associated to mortality, once age, Killip group and marital status were taken into account. After adjusting for therapeutic effort, the differences between men and women increased. Women admitted with acute myocardial infarction show a poor short-term prognosis that is not explained by their socioeconomic profile nor by the differences in therapeutic effort.

[Effect of social factors on quality of life of survivors of myocardial infarction]. / Efecto de los factores sociales sobre la calidad de vida de los supervivientes de un infarto de miocardio.

BACKGROUND: The aim of this study was to analyze the effect of the social environment on the quality of life of the survivors of an acute myocardial infarction. METHODS: A prospective cohort study was carried out with telephone follow up of patients admitted in the Intensive Care Units of six public hospitals in the region of Valencia (Spain). Three hundred eighty consecutive patients admitted for acute myocardial infarction were studied being followed a median of 3.4 years. Follow up was complete in 91.6% of the cases. RESULTS: The global quality of life was good. The component most affected was that of physical activity. Following control of the effect of the biologic and health care covariables, the quality of life was inversely and independently associated with age, female sex, low educative level and foreigness. CONCLUSIONS: Unequality was found in regard to the quality of life based on the socioeconomic level of survivors of acute myocardial infarction.

[Age as a prognostic factor in intensive care]. / La edad como factor pronóstico en cuidados intensivos.

In order to define the prognostic impact of the age of critical patients as well as its association with the initial severity of illness (SAPS index) and therapeutic effort (TISS index), we studied 1.102 patients older than 14 years admitted consecutively to 3 general intensive care units. The oldest patients (more than 65 years) showed a higher mean SAPS (11.00 versus 8.58, p less than 0.0001) and mortality (odds ratio = 1.99, p less than 0.0001) than the younger ones. The association between age and mortality showed a "dose-response" pattern, even after controlling for the effect of initial severity (p less than 0.0001). The effect of age was stronger in the groups of patients with low SAPS (odds ratio = 2.94, p = 0.0007) or admitted for acute myocardial infarction (odds ratio = 3.28, p less than 0.0001). The oldest group showed a lower TISS/SAPS ratio and a shorter stay in the intensive care unit than younger patients, suggesting a low relative therapeutic effort in the latter. The differential therapeutic effort did not explain, however, the mortality excess in the oldest group, because the gradient of mortality increased after adjusting for TISS/SAPS ratio (adjusted odds ratio = 2.42, p less than 0.0001).

[Differences in therapeutic effort because of the socioeconomic level of patients with acute myocardial infarction]. / Diferencias de esfuerzo terapéutico en razón del nivel socioeconómico en pacientes con infarto agudo de miocardio.

OBJECTIVES: To assess the hypothesis of the existence of differential therapeutic effort according to the socioeconomic status of the patients admitted to the hospital by acute myocardial infarction. PATIENTS AND METHODS: We study retrospectively 592 patients admitted to the intensive care units from six public hospitals from the Spanish region of Valencia, using data from two cohort studies focused on the study of in-hospital inequalities in health. The socioeconomic status was measured using the British occupational classification. The therapeutic effort predicted for the severity of illness was determined using a regression model that included the logarithm of Therapeutic Intervention Scoring System (TISS) score as the dependent variable and Simplified Acute Physiology Score (SAPS) score and Killip group as predictors. The patients whose observed TISS was 3 or more pointless than predicted were considered as infra-treated. The effect of potential confounders was controlled using unconditional logistic regression analysis. RESULTS: The proportion of infra-treated patients was inversely related to socioeconomic status chi 2 for tendency = 4.31, P = 0.0378). The logistic regression analysis showed a negative association between age and therapeutic effort (p < 0.0001) but not between therapeutic effort and socioeconomic status, after controlling the effect of age (p = 0.2150). DISCUSSION: Our results suggest that older patients receive less relative therapeutic effort, measured by TISS score, than younger patients. The differential therapeutic effort observed in the crude analysis seem attributable to the higher age of the patients in the lower socioeconomic strata.