The premature infant: anesthesia for cesarean delivery.

The influence of anesthetic technique (general [GA] versus epidural [EPI]) on neonatal outcome was assessed for singleton infants of gestational age 32 wk or less, delivered by cesarean section. Neonates were identified from a prospectively collected perinatal database from 1986 to 1991. The independent effect of anesthetic technique on low 1-min Apgar scores after controlling for other risk factors was assessed by ordinal logistic regression. Among the 509 infants studied, 30% had Apgar scores of 0 to 3 at 1 min and 5.9% at 5 min. Among infants delivered with GA, 46.4% had low 1-min and 10.1% had low 5-min Apgar scores as compared to 22.0% and 3.8% for EPI. GA as compared to EPI was associated with higher risk of low (0-3) 1-min score after controlling for confounding factors (relative odds = 2.92, [1.99, 4.27 95% confidence intervals]). Other factors significantly related to low 1-min Apgar scores included malpresentation, maternal diabetes, primiparity, low gestational age, and associated neonatal outcomes (presence of respiratory distress syndrome and intraventricular hemorrhage). When there is a choice to be made in cesarean delivery of the premature infant, EPI is associated with higher 1- and 5-min Apgar scores compared to GA.

Prescribing propensity: influence of life-expectancy gains and drug costs.

OBJECTIVE: To determine whether physician willingness to prescribe drugs for primary prevention of cardiovascular disease is influenced by information about the resultant life-expectancy gains (presented in one of two formats) and about drug costs. MATERIALS AND METHODS: Mailed survey (four versions randomly allocated) asking physicians to assess hypothetical preventive interventions with outcomes expressed either as averaged or as stratified gains in life expectancy (e.g., average gain of 15 weeks, versus 5% of treated patients gain 2 to 6 years, 10% gain up to 2 years, and 85% remain unchanged). Both costs and gains were varied to high and low values. The subjects rated their willingness to prescribe treatments on an 11-point scale from "strongly oppose" to "strongly favor." PARTICIPANTS: Internists randomly selected from two Canadian academic centers (n = 330). RESULTS: 231 usable responses were received (76% of the deliverable questionnaires). For low-yield scenarios typical of very effective primary prevention strategies, the physicians gave significantly higher ratings in response to stratified life-expectancy data than to equivalent averaged data (p < 0.0001). The same trend was not observed for high-yield scenarios (p = NS). The ratings were strongly influenced by cost: 34% of the physicians reversed their treatment decisions in response to a tenfold price increase. Despite this, the rankings of the treatments differed from those expected on the basis of cost-effectiveness criteria (p < 0.0001). CONCLUSIONS: Physician enthusiasm for a therapy designed to prolong life expectancy may be influenced by the format in which that life-expectancy gain is presented. Knowledge of drug cost also affects physicians' choices, but their greater focus on treatment effects causes their rankings to depart from those expected with cost-effectiveness criteria.

Waiting for coronary revascularization in Toronto: 2 years' experience with a regional referral office.

OBJECTIVES: To determine the frequency of major adverse events among patients awaiting coronary revascularization; to assess the match between referring physicians' estimates of urgency, a computer-generated multifactorial urgency rating score and actual waiting times; to determine the changes in waiting times as capacity for bypass surgery increased; and to evaluate the influence of choice of procedure or operator on waiting times. DESIGN: Consecutive case series. SETTING: Greater Toronto region. SUBJECTS: All 571 patients referred to an organized referral office by cardiologists at hospitals without on-site revascularization facilities between Jan. 3, 1989, and June 30, 1991. MAIN OUTCOME MEASURES: Preoperative fatal or nonfatal myocardial infarction; proportions of patients waiting longer than the maximum period recommended for their urgency rating; mean waiting times for various subgroups; and correlations among referring physicians' urgency ratings, computer-generated multifactorial urgency scores and waiting times. RESULTS: Of the 496 patients accepted for a procedure 5 had fatal cardiac events and 3 nonfatal myocardial infarction. Events occurred three times more often in patients with left mainstem disease than in those in other anatomic categories (relative risk [RR] 3.05, 95% confidence interval [CI] 1.48 to 6.27, p = 0.03). Both the computer-generated scores and the referring physicians' scores were correlated with the actual waiting time (r = 0.46 and 0.57 respectively). Waiting times and the proportion of patients with excessive waiting times fell during the study period (p < 0.0001). However, urgent cases were much less likely to be done "on time" than those with a recommended waiting time of more than 2 weeks (RR 0.16, 95% CI 0.11 to 0.25, p < 0.0001). The mean wait for coronary artery bypass grafting (CABG) was 22.73 days if the referral office was allowed to find a surgeon or interventional cardiologist and 35.31 days if one was requested (p = 0.002 after adjustment for urgency scores). CONCLUSIONS: Death of a patient on the waiting list is uncommon in an organized referral system. Patients with left main-stem disease are at higher risk of death than those in other anatomic categories. There were significant correlations between referring physicians' ratings of urgency, multifactorial urgency scores and actual waiting times. Expansion of capacity for CABG led to shorter waiting times, but patients with unstable symptoms continued to wait longer than recommended. Requests for a specific surgeon caused significantly longer delays.

Sex-related differences in coronary revascularization practices: the perspective from a Canadian queue management project.

OBJECTIVE: To assess sex-related differences in coronary revascularization practices in a Canadian setting. DESIGN: Prospective analytic cohort study. SETTING: Regional referral office in Toronto. PATIENTS: A selected but consecutive group of 131 women and 440 men referred by cardiologists for revascularization procedures between Jan. 3, 1989, and June 30, 1991. INTERVENTIONS: Coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). Nurse-coordinators placed the referral with a surgeon or interventional cardiologist at one of three hospitals, who then communicated directly with the referring cardiologist. MAIN OUTCOME MEASURES: Symptom status at referral, procedures requested and performed, and time from referral to procedure. RESULTS: Although the women were more likely than the men to have unstable angina at the time of referral (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.38 to 3.79, p = 0.0006), more women than men (16.8% v. 12.1%) were turned down for a procedure. Significant sex-related differences in practice patterns (p < 0.001) persisted after controlling for age or for the referring cardiologists' perception of expected procedural risk. A stepwise multivariate model showed that anatomy was the main determinant of case management; sex was the only other significant variable (p = 0.016). The referring physicians requested CABG more often for men than for women (p = 0.009), and the men accepted for a procedure were much more likely to undergo CABG than the women (OR 2.40, CI 1.47 to 3.93, p = 0.0002). Although the women undergoing CABG waited shorter periods than the men (p = 0.0035), this difference was attributable to their more severe symptoms. CONCLUSIONS: In this selected group women had more serious symptoms before referral but were turned down for revascularization more often than men. Reduced use of CABG rather than PTCA largely accounted for the sex-related differences in revascularization. Once accepted for a procedure women had shorter waiting times, which was appropriate given their more severe symptoms.

Queueing for coronary surgery during severe supply-demand mismatch in a Canadian referral centre: a case study of implicit rationing.

Queues for in-patient surgery are commonplace in universal health care systems. Clinicians and hospitals usually manage these waiting lists with informal criteria for determining patient priority--a form of implicit rationing. To understand the workings of implicit rationing by queue, we took advantage of a natural experiment in the Canadian province of Ontario. Unprecedentedly severe supply-demand mismatch led to long waiting lists for coronary surgery [CABS] in Ontario during 1987-88. The crisis was resolved by increased funding and widespread adoption of a multifactorial clinical index for patient priority that was developed by an expert panel in 1989. Thus, we audited randomly chosen charts of patients who underwent coronary angiography at four Toronto hospitals during the crisis period, and calculated urgency scores for each case based on the multifactorial index. From 413 charts, 193 eligible patients were identified who proceeded to CABS. Waiting times did correlate with urgency ratings (r = 0.42, P < 0.0001). However, mean wait from catheterization to CABS varied among hospitals by as much as 8 weeks (P < 0.0001 after controlling for urgency scores). At the hospital with shortest queues, waiting times were twice as long for patients catheterized by cardiologists off-site vs those referred by on-site practitioners (P < 0.0001, after controlling for urgency scores); a similar form of bias was found at a second coronary surgery centre (P = 0.056, after controlling for urgency scores). Over half the patients waited longer than the maximum suggested for their category by the expert panel.(ABSTRACT TRUNCATED AT 250 WORDS)

Fish oil in lupus nephritis: clinical findings and methodological implications.

Our objective was to determine the effects of fish oil on renal function, symptoms, and serum lipids in patients with lupus nephritis. A double-blind, randomized crossover trial of fish oil versus placebo (olive oil) was done on 26 patients with confirmed systemic lupus; 21 completed the study. Intervention was fish oil or placebo, 15 g/day, for one year followed by a 10 week wash-out period, and then the reverse treatment for one year. At baseline and six month intervals, we measured platelet membrane fatty acids, indices of renal function, a disease activity index, serum lipid levels, blood pressure, serum viscosity and red cell flexibility. We found that platelet membrane phospholipids were uniformly affected by fish oil supplementation (P < 0.001) but with significant carry-over effects despite a 10 week wash-out period. Glomerular filtration rate and serum creatinine were not affected. A non-significant reduction in mean (SE) 24-hour proteinuria occurred, from 1424.1 mg (442.7) on placebo to 896.7 mg (352.2) on fish oil (P = 0.21). Fish oil lowered serum triglycerides from 1.89 (0.25) mmol/liter to 1.02 (0.11) mmol/liter (P = 0.004). VLDL cholesterol decreased markedly whether patients initially received fish oil or placebo (P = 0.004). The size of the reduction was affected by the order of treatment (P = 0.03), but parallel comparisons were significant before the crossover (P = 0.0006). With the possible exception of bleeding time, no other treatment effects were shown with fish oil. However, treatment order effects were seen in urinary IgG excretion (P = 0.03), whole blood viscosity (P < 0.0001), red cell flexibility (P = 0.004), and bleeding time (P = 0.06). In conclusion, one year of dietary supplementation with fish oil in patients with stable lupus nephritis did not improve renal function or reduce disease activity, but did alter some lipid parameters. Hitherto unreported carry-over effects and treatment order effects caused by the olive oil created a risk of type II error, and bear methodologic consideration in the design of future studies.

Placing patients in the queue for coronary surgery: do age and work status alter Canadian specialists' decisions?

OBJECTIVE: To determine the effects of age and work status on whether and where cardiovascular specialists would place hypothetical patients in the queue for coronary surgery. MATERIALS AND METHODS: Mailed survey presenting a set of clinical scenarios either to be rated on a scale with 7 time frames for urgency of need or to be designated as questionable/inappropriate for intervention. The basic scenario was a patient with mild-moderate stable angina, good left ventricular function, and limited coronary disease; operative risks and stress test results were varied. Three identifiers were used: "45-year-old civil servant gainfully employed"; "45-year-old laborer disabled by angina, faces job loss"; and "75-year-old retiree, angina limits golf." PARTICIPANTS: Cardiologists and cardiac surgeons practicing in five Ontario medical centers (n = 120). RESULTS: There was a 59% response rate (120 usable responses). Large shifts in willingness to intervene occurred in favor of the disabled laborer (p less than 0.0001) and against the retiree (p-value ranges from 0.04 to less than 0.0001, depending on operative risk and stress test results), but not for the employed civil servant. Striking effects (p less than 0.0001) were also evident in ratings of waiting time, with the order of priority being the disabled laborer first, the civil servant second, and the retiree last. The overall mean shift due to work status or age was equal to, or larger than, the mean shift due to clinical factors, such as stress test results, changes in severity of stable angina, and extent of coronary disease. CONCLUSION: Cardiovascular specialists may place considerable weight on age and work status in determining urgency and appropriateness of coronary revascularization. Risk-benefit concerns may partly explain shifting thresholds for intervention, but not differential waiting times. The influence of these factors should be sought in utilization audits and addressed from an ethical perspective.

Adapting to waiting lists for coronary revascularization. Do Canadian specialists agree on which patients come first?

STUDY OBJECTIVES: To assess specialists' adaptation to long waiting lists for coronary revascularization, and their acceptance of a formal queue-ordering schema proposed by an expert panel. DESIGN: Mail survey of practitioners in referral centers using 49 hypothetical case scenarios. Scenarios were rated for maximum acceptable delay prior to coronary surgery, on a scale with seven interventional time frames graded from emergency to three to six months' permissible delay. The survey included the proposed schema and rating system; respondents were invited to differ as they saw fit. HYPOTHETICAL PATIENTS: Assumed uniformly to be middle aged with typical angina, but clinical factors varied, eg, severity and stability of angina, response to medical therapy, coronary anatomy, and noninvasive test results. PHYSICIAN SUBJECTS: There were 122 respondents, for a 60 percent response rate, including a majority of cardiac surgeons and invasive cardiologists on staff in Ontario teaching hospitals. MEASUREMENTS AND RESULTS: Fifty-seven percent rated some scenarios for acceptable waiting times of three to six months; another 39 percent rated their least urgent scenarios to wait six weeks to three months. Interpractitioner agreement was high: for 48/49 scenarios, at least 75 percent of urgency ratings fell within two contiguous points on the scale. Symptom status was the dominant determinant of waiting time, with mean maximum acceptable wait of 74 days for patients with mild-moderate stable angina but three days for those receiving parenteral nitroglycerin (p less than 0.00001). About half the ratings matched those predicted based on the original panel's consensus criteria; 90 percent were within one scale point. CONCLUSIONS: Specialist practitioners in Ontario have adapted to waiting lists for coronary artery bypass surgery/percutaneous transluminal coronary angioplasty, and assess the priority of hypothetical patients in similar ways and in reasonable accord with formal queue-ordering criteria. This behavior may help mitigate the impact of resource constraints, allowing delay of services for those with less acute need--a potential contrast to delayed access in America based on low income or lack of insurance.