The value of peer support for self-management of diabetes among veterans in the Empowering Patients In Chronic care intervention.

AIM: To examine the value of peer support in the self-management of diabetes among veterans in an integrated health care system. METHODS: We conducted semi-structured in-depth interviews with veterans and clinicians 6 months after their participation in Empowering Patients in Chronic Care (EPIC), a group-based diabetes intervention with a peer-support component. Interviews elicited clinicians' narratives of how peer support unfolded in the groups and veterans' experiences of giving and receiving support from their peers. Data analysis was guided by principles of framework analysis using Heisler's peer-support model. RESULTS: Findings support Heisler's peer-support model and provide evidence supporting professional-led group visits with peer exchange. Clinicians and veterans endorsed informational and emotional support received in EPIC groups. Clinicians often referred to EPIC as an open forum or a support group where veterans could both give and receive help. Veterans noted the benefits of shared problem-solving and the support they received. Clinicians and veterans perceived the peer-support component of EPIC as facilitating increased empowerment in terms of self-efficacy, increased perceived social support and increased understanding of self-care. Ultimately, many veterans acknowledged that their participation in EPIC facilitated improved health-related quality of life, improved health behaviours and improved chronic disease control. CONCLUSIONS: Findings emphasize the value of peer support in managing chronic illness. Peer-support programmes may address veterans' unique challenges and have the potential to improve physical and mental health.

Impact of marital status on outcomes in hospitalized patients. Evidence from an academic medical center.

BACKGROUND: Prior studies have described the importance of social support on long-term patient outcomes. Few studies have investigated the impact of social support on outcomes in hospitalized patients. OBJECTIVE: To examine the relationship between marital status, an important aspect of social support, and several hospital outcomes. METHODS: Patients included 40,820 adult medical and surgical patients discharged from a midwestern academic medical center during 1988 through 1991, of whom 21,291 were unmarried and 19,529 were married. Using multivariable regression analyses, we compared the following outcomes in married and unmarried patients: rate of in-hospital death, rate of nursing home discharge, length of stay, and hospital charges. Severity of illness was measured using a previously validated commercial method. RESULTS: Admission severity of illness was higher in unmarried than married patients; 40% of unmarried patients had moderate or high severity compared with 32% of married patients. In a series of multivariable analyses, controlling for severity of illness, age, gender, race, and diagnosis, the risk of nursing home discharge was more than 2.5 times greater for unmarried than for married patients (multivariable odds ratio, 2.67; 95% confidence interval, 2.33 to 3.06), while the risk of in-hospital death for unmarried compared with married patients was higher among surgical patients (odds ratio, 1.30; 95% confidence interval, 1.06 to 1.58) but not among medical patients (odds ratio, 0.98; 95% confidence interval, 0.84 to 1.15). In additional analyses, multivariable models estimated that hospital charges and length of stay were 5% and 8% higher (P < .001), respectively, for unmarried than for married patients. In a series of stratified analyses, the above differences among unmarried patients tended to be greater for patients who were never married than for patients who were widowed, divorced, or separated. CONCLUSION: The findings suggest that marital status was an independent risk factor for several important hospital outcomes. This adds to our understanding of the importance of social support and other nonbiological factors on outcomes in hospitalized patients. This also has implications for the design of hospital-based interventions to improve patient outcomes and for the development of equitable prospective and capitated hospital payment formulas.

Efficacy of delayed or discontinuous FK506 administrations on nerve regeneration in the rat sciatic nerve crush model: lack of evidence for a conditioning lesion-like effect.

We examined whether the nerve regenerative property of FK506 exhibits a 'window-of-opportunity' corresponding to the time of injury for maximal efficacy in the sciatic nerve crush model. FK506 (5 mg/kg, s.c.) was administered over the 18-day period of study according to three dosage regiments: delayed (days 9-17), discontinuous (days 0-8) and continuous (days 0-17) administrations. Quantitation of axonal calibers and the extend of myelination in the soleus nerve at 18 days demonstrated that both delayed and discontinuous administrations were equally effective, arguing against a 'window-of-opportunity' for FK506 nerve regenerative effect. However, both protocols were less effective than continuous administration indicating that the compound needs to be given during the entire regenerative period to elicit maximal efficacy.

Using severity-adjusted mortality to compare performance in a Veterans Affairs hospital and in private-sector hospitals.

The objective of this study was to compare hospital mortality in Veterans Affairs (VA) and private-sector patients. The study included 5016 patients admitted to 1 VA hospital. Admission severity of illness was measured using a commercial methodology that was developed in a nationwide database of 850,000 patients from 111 private-sector hospitals. The method uses data abstracted from patients' medical records to predict the risk of death in individual patients, based on the normative database. Analyses compared actual and predicted mortality rates in VA patients. VA patients had higher (P < .05) severity of illness than private-sector patients. The observed mortality rate in VA patients was 4.0% and was similar (P = .09) to the predicted risk of death (4.4%; 95% confidence interval 4.0-4.9%). In subgroup analyses, actual and predicted mortality rates were similar in medical and surgical patients and in groups stratified according to severity of illness, except in the highest severity stratum, in which actual mortality was lower than predicted mortality (57% vs 73%; P < .001). We found that in-hospital mortality in 1 VA hospital and a nationwide sample of private-sector hospitals were similar, after adjusting for severity of illness. Although not directly generalizable to other VA hospitals, our findings nonetheless suggest that the quality of VA and private-sector care may be similar with respect to one important and widely used measure.

The relationship of gender and in-hospital death: increased risk of death in men.

OBJECTIVES: The prognostic importance of gender in hospitalized patients has been poorly studied. The current study compared in-hospital death rates between men and women after adjusting for severity of illness. DESIGN: Retrospective cohort study. PATIENTS: 89,793 eligible patients with 6 common nonsurgical diagnoses who were discharged from 30 hospitals in Northeast Ohio in 1991 to 1993. METHODS: Admission severity of illness (ie, predicted risk of death) was calculated using multivariable models that were based on data abstracted from patients' clinical records (ROC curve areas, 0.83-0.90). In hospital death rates were then adjusted for predicted risks of death and other covariates using logistic regression analysis. RESULTS: Adjusted odds of death were higher (P < 0.05) in men, compared with women, for 4 diagnoses (stroke [OR, 1.60]; obstructive airway disease [OR, 1.38]; gastrointestinal hemorrhage [OR 1.32]; pneumonia [OR, 1.18]) and similar for two diagnoses (congestive heart failure [OR, 1.12]; and acute myocardial infarction [OR, 0.97]). These differences were somewhat attenuated by excluding patients discharged to skilled nursing facilities or other hospitals from analysis; nonetheless, the odds of death in men remained higher for 3 diagnoses. CONCLUSIONS: The findings indicate that inhospital death rates are generally higher in men than in women, after adjusting for severity of illness. In addition, the risk of in-hospital death in men and women was influenced by diagnosis. These differences may reflect gender-related variation in the utilization of hospital services, the effectiveness of care, over- or underestimation of severity of illness, or biological differences in men and women.

Impact of interhospital transfers on outcomes in an academic medical center. Implications for profiling hospital quality.

The purpose of this article is to determine whether a widely implement ed method of severity adjustment underestimated the risk of death and other outcomes among interhospital transfers (ie, patients transferred from other acute care hospitals) and to examine the impact of this potential bias on hospital outcomes profiles. The retrospective cohort study was conducted at a midwestern academic medical center with 40,820 adult medical and surgical patients from 1988 to 1991, of whom 38,946 were direct admissions and 1,874 were interhospital transfers. Hospital mortality, length of stay, and total charges in interhospital transfers and direct admissions were compared using multivariable regression methods that adjusted for admission severity of illness and other potential covariates (age, type of health insurance, diagnosis, emergent admission). Severity of illness was measured using the Medis-Groups methodology. Admission severity of illness was directly related (P<0.001) to rates of in-hospital death, length of stay, and charges, and was higher among interhospital transfers; 49% of transfers had moderate to high severity, compared with 35% of direct admissions (P<0.001) However, in a logistic regression model adjusting for severity and other covariates, the risk of in-hospital death was nearly two times (multivariable odds ratio, 1.99; 95% confidence interval [CI], 1.64-2.42) higher in transfers than in direct admissions. In linear regression models, length of stay and charges were 1.47 (95% CI, 1.42-1.53) and 1.40 (95% CI, 1.35-1.44) times higher, respectively, in transfers. Results were consistent in medical and surgical admissions, when examined separately, and among individual diagnostic categories. Based on their findings, the authors estimate that, independent of quality of care, severity adjusted mortality and length of stay would appear 17% and 8% higher, respectively, for hospitals in which 20% of patients were interhospital transfers than for hospitals in which 2% of patients were transfers. In an academic medical center, interhospital transfers had poorer severity adjusted outcomes than patients admitted directly. Failure to account for transfer status may produce biased performance profiles and, therefore, may create disincentives for hospitals to accept transfers from other acute care facilities.

Racial variation in predicted and observed in-hospital death. A regional analysis.

OBJECTIVE: To compare observed, predicted, and risk-adjusted hospital mortality rates in white and African-American patients and to determine whether, as prior studies suggest, African-American patients would have higher predicted risks of death and similar or higher risk-adjusted mortality. DESIGN: Retrospective cohort study. SETTING: Thirty hospitals in northeast Ohio. PATIENTS: A total of 88205 eligible patients consecutively discharged in the years 1991 through 1993 with the following 6 diagnoses: acute myocardial infarction, congestive heart failure, obstructive airways disease, gastrointestinal hemorrhage, pneumonia, and stroke. METHODS: We measured predicted risks of death at admission for each diagnosis using validated multivariable models based on standard clinical data abstracted from patients' medical records. We then adjusted in-hospital mortality rates in white and African-American patients for predicted risk of death and other covariates using logistic regression analysis. MAIN OUTCOME MEASURES: Predicted risk of death at admission and observed hospital mortality in white and African-American patients. RESULTS: Predicted risks of death were lower (P<.001) in African Americans for 4 of the 6 diagnoses. Adjusted odds of hospital death were lower (P<.01) in African Americans for 2 of the 6 diagnoses (congestive heart failure and obstructive airways disease) and similar for the other 4 diagnoses. For all diagnoses, in aggregate, the adjusted odds of hospital death were 13% lower in African-American compared with white patients (multivariable odds ratio, 0.87; 95% confidence interval, 0.80-0.94). Findings were similar if further adjustments were made for differences in length of stay, site of hospitalization, or discharge triage practices. CONCLUSION: Contrary to our a priori hypotheses, predicted risks of death and risk-adjusted mortality rates were generally lower in African-American patients. Our finding of lower predicted risk may reflect racial differences in hospital admission practices or in access to outpatient care. However, our findings suggest that, once hospitalized, African-American patients attained similar or better outcomes, as measured by an important measure--hospital mortality.

Immunophilin FK506-binding protein 52 (not FK506-binding protein 12) mediates the neurotrophic action of FK506.

The neurotrophic property of the immunosuppressant drug FK506 (tacrolimus) is believed to depend on the 12-kDa FK506-binding protein (FKBP-12). Here, we show that FK506 maintains its neurotrophic activity in primary hippocampal cell cultures from FKBP-12 knockout mice. In human neuroblastoma SH-SY5Y cells, the neurotrophic action of FK506 (10 pM to 10 nM) is completely prevented by the addition of a monoclonal antibody (50-100 nM) to the immunophilin FKBP-52 (also known as FKBP-59 or heat shock protein 56), a component of mature steroid receptor complexes. By itself, the FKBP-52 antibody is also neurotrophic. The neurotrophic activity of dexamethasone (50 nM) is potentiated by FK506, whereas that of beta-estradiol (50 nM) is not altered, suggesting a common mechanisms of action. Geldanamycin (which disrupts mature steroid receptor complexes) is also neurotrophic (0.1-10 nM), whereas it reduces the neurotrophic activity of FK506 and steroid hormones (dexamethasone and beta-estradiol). Conversely, 20 mM molybdate (which prevents the disruption of mature steroid receptor complexes) decreases the neurotrophic activity of FK506, FKBP-52 antibody, dexamethasone, and beta-estradiol. In rats, FK506 (10 mg/kg s.c.) augments the regenerative response of regenerating motor and sensory neurons to nerve injury as shown by its ability to increase the axotomy-induced induction of c-jun expression. A model is proposed to account for the neurotrophic action of both neuroimmunophilin ligands (FK506) and steroid hormones. Components of steroid receptor complexes represent novel targets for the rational design of new neurotrophic drugs.

Variations in risk-adjusted cesarean delivery rates according to race and health insurance.

OBJECTIVE: To assess the association between race and insurance and Cesarean delivery rates after adjusting for clinical risk factors that increase the likelihood of cesarean delivery. DESIGN: Retrospective cohort study in 21 hospitals in northeast Ohio. SUBJECTS: 25,697 women without prior cesarean deliveries admitted for labor and delivery January 1993 through June 1995. METHODS: Demographic and clinical data were abstracted from patients' medical records. The risk of cesarean delivery was adjusted for 39 maternal and neonatal risk factors that were included in a previously developed risk-adjustment model using nested logistic regression analysis. MAIN OUTCOME MEASURES: Odds ratios for cesarean delivery in nonwhite patients relative to whites and for patients with government insurance or who were uninsured relative to patients with commercial insurance. RESULTS: The overall rate of cesarean delivery was similar in white and nonwhite patients (15.8% and 16.1%, respectively), but rates varied (P < 0.001) according to insurance (17.0%, 14.2%, 10.7% in patients with commercial insurance, government insurance, and without insurance, respectively). However, after adjusting for clinical factors, the adjusted odds ratio (OR) of cesarean delivery was higher in nonwhite patients (OR = 1.34; 95% CI: 1.14-1.57; P < 0.001), but similar for patients with government insurance (OR = 1.01; 95% CI: 0.90-1.14; P = 0.84) and lower for uninsured patients (OR = 0.65; 95% CI, 0.41, 1.03; P = 0.067), albeit not statistically significant. In analyses stratified according to quintiles of predicted risk of cesarean delivery, racial differences were largely limited to patients in the lower risk quintiles. However, differences in odds ratios for uninsured patients were seen across the risk quintiles, although odds ratios were not statistically significant. CONCLUSION: After adjusting for clinical factors, race and insurance status may independently influence the use of cesarean delivery. The higher rates in nonwhites and lower rates in the uninsured may reflect differences in patient preferences or expectations, differences in physician practice, or unmeasured risk factors. The lower odds of cesarean delivery in uninsured women, particularly women at high risk, may raise the issue of underutilization of services and warrants further study.

Racial variation in the use of do-not-resuscitate orders.

OBJECTIVE: To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample. MEASUREMENTS: Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82-0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates. MAIN RESULTS: In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p <.001). Rates of orders were also lower ( p <. 001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower ( p <.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days. CONCLUSIONS: The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.

Preoperative risk factors for 30-day mortality after elective surgery for vascular disease in Department of Veterans Affairs hospitals: is race important?

PURPOSE: Racial variation in health care outcomes is an important topic. Risk-adjustment models have not been developed for elective abdominal aortic aneurysm repair (AAA), lower extremity bypass revascularization (LEB), or lower extremity amputation (AMP). Earlier studies examining racial variation in mortality and morbidity from AAA, LEB, or AMP were limited to administrative data. This study determined risk factors for mortality after surgery for vascular disease and determined whether race is an important risk factor. METHODS: Data in this prospective observational study were obtained from the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program. Detailed demographic and clinical data were collected prospectively from patients' medical records by trained nurse reviewers. Eligible patients were those 18 years and older who underwent elective AAA, LEB, or AMP at one of 44 VA medical centers performing both vascular and cardiac surgery (phase I; October 1991 to December 1993) and at one of these 44 or 79 additional VA medical centers performing vascular but not cardiac surgery (phase II; January 1994 to August 1995). The independent association of several preoperative factors with the 30-day postoperative mortality rate was examined with stepwise logistic regression analysis for AAA, LEB, and AMP. Models were developed in the combined 44 VA medical centers and validated in the 79 VA medical centers. The independent association of race with the 30-day postoperative mortality rate was examined after controlling for important preoperative risk factors for each operation. RESULTS: More than 10,000 surgical operations were examined, and 5, 3, and 10 independent preoperative predictors of 30-day mortality rate were identified for AAA, LEB, and AMP, respectively. The observed mortality rate for patients undergoing AAA was higher (7.2% vs 3.2%; P =.02) in African American patients than in white patients in the 44 VA medical centers, although the differences were not significant in LEB and AMP or at the additional 79 hospitals. After important preoperative risk factors were controlled, there was no difference in 30-day mortality rates between African American patients and white patients. CONCLUSION: We identified several important preoperative risk factors for 30-day mortality rate in three vascular operations. From the results of this study, race was determined not to be an independent predictor of mortality.