Association between functional status and use and effectiveness of beta-blocker prophylaxis in elderly survivors of acute myocardial infarction.

OBJECTIVES: To examine whether physical and cognitive impairments explain low use of beta-blockers in elderly patients and whether functionally impaired older adults have improved survival if a beta-blocker is prescribed at hospital discharge. DESIGN: Cross-sectional and retrospective cohort study. SETTING: Acute care hospitals in the United States. PARTICIPANTS: National cohort of 45,370 elderly acute myocardial infarction survivors, with no chart-documented contraindications to beta-blocker treatment. MEASUREMENTS: The main outcome measures were beta-blocker prescription at hospital discharge and 1-year survival. RESULTS: Fifty percent (n=22,683) of eligible patients were prescribed a beta-blocker at discharge. Older age and functional impairments (incontinence, mobility impairment, and cognitive impairment) were independently associated with decreased use of beta-blockers. The odds ratios for prescribing a beta-blocker at hospital discharge were 0.82 (95% confidence interval (CI)=0.77-0.86), 0.63 (95% CI=0.56-0.71), and 0.40 (95% CI=0.32-0.51) for persons with one, two, and three impairments, respectively, compared with those with no impairments. In survival analysis, patients prescribed a beta-blocker were 21% less likely than nonrecipients to die within 1 year of follow-up (relative risk=0.79, P=.0001). Similar survival benefit was observed in patients with and without functional impairments. CONCLUSION: This study shows a strong association between functional impairment and the use of beta-blockers after acute myocardial infarction in elderly patients. The results suggest that increasing use of beta-blockers in this group provides an opportunity to improve outcomes.

A comparison of three rating scales for measuring subjective phenomena in clinical research. II. Use of experimentally controlled visual stimuli.

BACKGROUND: In a previous study of three types of global scales we found that verbal rating scales were particularly reliable for rating auditory stimuli. We now wanted to check the performance of the scales for rating experimentally controlled visual stimuli. METHODS: We used a prospective, experimentally controlled, clinimetric study, which was conducted at the Department of Psychiatry of the Autonomous University of Puebla Medical School in the state capital city of Puebla, Mexico. A total of 20 fifth-year medical students participated in the study. Visual stimuli consisted of 15 cards with five different intensities on the gray-to-black scale, administered randomly in three sessions to each subject. With regard to main outcome measurement, validity and consistency indices were determined for visual analog scale (VAS), numerical rating score (NRS), and verbal rating scale (VRS) to rate visual stimuli. RESULTS: For validity, correlation coefficients between scales and reference standard were high, especially in VRS (r=0.902). For consistency, VRS had highest kappa value (k(w)=0.71) for interobserver variability. CONCLUSIONS: Three instruments could be hierarchically ranked for their indices of validity and consistency. Being more consistent than VAS and NRS, VRS merits more frequent usage in clinical research.

Comparison of three rating scales for measuring subjective phenomena in clinical research. I. Use of experimentally controlled auditory stimuli.

BACKGROUND: An interest in measuring subjective phenomena such as pain, nausea, anxiety, etc. has led clinicians to develop three types of ratings: the visual analog scale (VAS); the verbal rating scale (VRS), and the numeric rating score (NRS). These ratings are regarded as global scales because they lack criteria to demarcate diverse dimensions or categories that comprise each scale. The purpose of this study was to evaluate validity and consistency of usage for these scales. Criterion for validity consisted of an experimentally controlled intensity for auditory stimuli. METHODS: We conducted a prospective, experimentally controlled, clinimetric study at the Audiology Department at the Hospital of Puebla Autonomous University (in Puebla State, Mexico). Participants included 25 medical students, two psychology students, and three practicing physicians. Interventions consisted of pure 1,000 Hz tones in five different intensities applied for 3 sec with a 1-min interval between stimuli at three sessions for each observer. Main outcome measure was validity and consistency of usage for VAS, VRS, and NRS scales. RESULTS: Correlation coefficients between scale results and standard stimuli were 0.818 for VAS, 0.735 for NRS, and 0.796 for VRS. Mean weighted kappa indices for intraobserver agreement were 0.70, 0.59, and 0.65, respectively, for scales with five categories each. Mean weighted kappa indices for inter-observer variability were 0.61, 0.48, and 0.54 for VAS, NRS, and VRS again with five categories each. CONCLUSIONS: The three instruments appeared reasonably accurate, with VAS having highest scores. VRS appeared sufficiently consistent to be regarded as providing reliable scientific information.

Quality-of-life measurements: origin and pathogenesis.

Despite extensive growth in recent years, the field of "quality-of-life" appraisal still evokes debate about basic perception of the concept and is accompanied by a plethora of indexes for measurement. One prime reason for the problems is that the measurements have been transferred from two separate sources - medical health status indexes and social-science population indexes - neither of which was designed for appraising the particular personal distinctions of the way people feel about their own quality of life. When regulatory and commercial incentives were offered for measuring patients' quality of life, it became appraised with the indexes available from the medical and psychosocial sources, even though neither set of indexes was specifically intended for that purpose. They are not developed from the basic principle that a person's "quality of life" is a state of mind, not a state of health, which is uniquely perceived by that person, and which will not be appropriately appraised unless the most cogent personal components are allowed suitable expressions. An approach that lets patients state their own opinions directly can offer the "face validity" or "common sense" that now seems absent from the generally applied measurements.

Is "quality of care" being mislabeled or mismeasured?

According to Francis Peabody, "The secret of the care of the patient is in caring for the patient." This secret has been well guarded in current approaches to measuring "quality of care." The measurements have concentrated on performance of approved technical procedures, such as the appropriate ordering of diagnostic tests, pharmaceutical agents, or surgery, but have generally ignored traditional components of caring, such as relieving pain or other symptoms, improving functional capacity, and assuaging anxiety or distress. By ordering the pertinent technical procedures, a health care system, institution, or clinician can get excellent ratings for "quality of care," despite gross violations of human caring. Although offering desirable assurance that the best procedures are being used, the current measurements need a more accurate label, such as "quality of technical performance." If the process of caring is to be emphasized and appraised appropriately, new methods will be required. They can be developed to identify specific activities in caring and perhaps to include evaluations of accomplishment for what patients say they want done.

Effect of gestational and passive smoke exposure on ear infections in children.

OBJECTIVE: To estimate the relative risk for otitis media (OM) in children from environmental tobacco smoke (passive exposure), maternal smoking during pregnancy (gestational exposure), or both. DESIGN: Analysis of data from a national cross-sectional health survey, utilizing questionnaire information and serum cotinine measurements. PARTICIPANTS: Children younger than 12 years (N = 11 728) in the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988-1994. MAIN OUTCOME MEASURES: Occurrence and recurrence of ear infections. RESULTS: The cumulative incidence of ear infections was 69%. Of all participants, 38% were exposed to passive smoke, 23% were exposed to gestational smoke, and 19% were exposed to combined passive and gestational smoke. The occurrence of any ear infection was not increased by passive smoke exposure (adjusted risk ratio [RR], 1.01; 95% confidence interval [CI], 0.95-1.06), but was slightly increased by gestational (adjusted RR, 1.08; 95% CI, 1.01-1.14) and combined (adjusted RR, 1.07; 95% CI, 1.00-1.14) smoke exposures. The risk of recurrent ear infections (> or = 6 lifetime episodes) was significantly increased with combined smoke exposure (adjusted RR, 1.44; 95% CI, 1.11-1.81). Other risk factors for ear infection identified in multivariable analysis were race/ethnicity, poverty-income ratio of 2.00 or more, attendance in day care, history of asthma, and presence of allergic symptoms. CONCLUSIONS: Passive smoke exposure was not associated with an increased risk of ever developing an ear infection in this study. The increased risk found with gestational and combined smoke exposures has marginal clinical significance. For recurrent ear infections, however, combined smoke exposure had a clinically and statistically significant effect.

The state of the art.

KIE: The physician-author traces the physical and mental decline of his 96-year-old mother during the past six years. Despite her stated readiness to die and against the wishes of her family, her medical attendants have aggressively treated all episodes of acute illness. Feinstein deplores the attitudes of his profession, which pursues a "vigorous therapy that benefits no one except its own satisfaction in thwarting death, regardless of the consequences."^ieng