Familial aggregation of low birth weight among whites and blacks in the United States.

BACKGROUND: Studies have shown that the birth weight of infants is correlated with the birth weights of their siblings and their mothers. We investigated whether the birth weights of mothers and index children were jointly associated with the risk of low birth weight in the siblings of the index children. METHODS: We used data on the live-birth cohort of the 1988 National Maternal and Infant Health Survey. The analysis included 1691 white and 1461 black mothers, each of whom had two or more live-born, singleton children. Multiple logistic regression with generalized-estimation equations was used to assess the risk of low birth weight among an index child's siblings. Four groups were studied: that in which neither the mother nor the index child had low birth weight (group 1), that in which only the mother had low birth weight (group 2), that in which only the index child had low birth weight (group 3), and that in which both the mother and the index child had low birth weight (group 4). There was adjustment for other maternal and infant covariates. RESULTS: Among white siblings in groups 1, 2, 3, and 4, 3.6, 8.3, 21.2, and 38.9 percent, respectively, had low birth weight, as compared with 8.0, 19.0, 31.1, and 57.1 percent of black siblings. When group 1 was used as the reference group, the adjusted odds ratios (and 95 percent confidence intervals) for low birth weight in groups 2, 3, and 4 were 2.5 (1.4 to 4.3), 6.8 (4.7 to 9.8), and 15.4 (9.2 to 25.5), respectively, among white siblings and 2.6 (1.8 to 3.8), 4.7 (3.5 to 6.4), and 13.9 (9.2 to 20.9) among black siblings. These associations were consistently found for birth weights below 1500 g and those ranging from 1500 to 2499 g in both races and after stratification for the mother's age, parity, education, cigarette-smoking status, and weight and height before pregnancy and the infant's sex. CONCLUSIONS: Although selection and recall biases cannot be excluded with certainty, our data suggest a strong familial aggregation of low birth weight among both whites and blacks in the United States.

Predicting in-hospital mortality. The importance of functional status information.

Monitoring risk-adjusted outcomes is the centerpiece of efforts to ensure health care quality. Because data collection is expensive, questions arise concerning what information is essential to adjust for risk. This investigation used retrospective analysis of existing, computerized clinical databases containing laboratory test results, information on chronic coexisting conditions, and nursing evaluations of functional status to predict in-hospital mortality. We studied persons admitted to one tertiary teaching hospital between 1987 and 1992 for cerebrovascular disease or pneumonia. Predictive models for each of the conditions were developed using logistic regression; the results were validated with split samples. We compared the predictive value of the nursing functional status assessments and the clinical laboratory data. For each study condition, the functional status data had as much prognostic information as the laboratory data. Specifically, a nurse's report that a patient required total assistance for bathing was the best single predictor of in-hospital mortality in the models for patients with either cerebrovascular disease or pneumonia. If hospitals admit patients with different levels of functional impairment, it is important to account for these differences before comparing outcomes across facilities. Assessments of functional status are a simple, inexpensive measure that may have considerable value.

In-hospital mortality for surgical repair of congenital heart defects: preliminary observations of variation by hospital caseload.

OBJECTIVE: To examine the impact of hospital caseload on in-hospital mortality for pediatric congenital heart surgery. DESIGN: Population-based, retrospective cohort study. SETTING: Acute care hospitals in California and Massachusetts. PATIENTS: Children undergoing surgery for congenital heart disease, identified by the presence of procedure codes indicating surgical repair of a congenital heart defect in computerized statewide hospital discharge abstract databases. Cases were grouped into four categories based on the complexity of the procedure. MAIN OUTCOME MEASURES: Adjusted odds ratios (OR) for in-hospital death were estimated using generalized estimating equations that account for the intra-institutional correlation among patients. RESULTS: A total of 2833 cases at 37 centers were identified. Compared with centers performing > 300 cases per year, after controlling for patient characteristics, centers performing < 10 cases per year had an OR for in-hospital death of 7.7 (95% confidence interval (CI) [1.6-37.8]); 10 to 100 cases, OR = 2.9 (95% CI [1.6-5.3]); 101 to 300 cases, OR = 3.0 (95% CI [1.8-4.9]). Independent risk factors for mortality included procedure complexity category (P < .0001), use of cardiopulmonary bypass (P < .0001), young age at surgery (P = .001), and transfer from another acute care hospital (P < .0001). Few differences were found by hospital caseload in length of stay or total hospital charges. CONCLUSIONS: For children with a congenital heart defect who underwent surgery in California in 1988 or Massachusetts in 1989, the risk of dying in-hospital was much lower if the surgery was performed at an institution performing > 300 cases annually. This study was limited by the absence of clinical detail in discharge abstract databases. If these findings are corroborated by other studies, health care delivery strategies that direct children requiring surgical correction of congenital heart defects to high-volume centers may substantially reduce overall mortality.

Costs of potential complications of care for major surgery patients.

We examined computerized hospital discharge abstract data from 372,680 major surgery patients admitted to 404 California acute care hospitals in 1988 to identify potential complications of care. At least one potential in-hospital complication occurred for 10.8% of patients. Patients with complications were older and more likely to die in-hospital (9.4% compared to 1.0%, P < 0.0001). On average, patients with complications had longer stays (13.5 versus 5.4 days, p < 0.0001) and higher total charges ($30,896 versus $9,239, p < 0.0001). After adjusting for demographic, clinical, and hospital factors, patients with potential complications averaged $16,023 higher total hospital charges than uncomplicated patients. Complications were associated with 96.6% (95% confidence interval = 95.2%, 98.0%) higher hospital charges after adjusting for these factors. Across all patients, complications were related to over $647 million in additional total hospital charges for these major surgery patients.

Chronic conditions and risk of in-hospital death.

OBJECTIVE: This study examined the relationship of in-hospital death and 13 conditions likely to have been present prior to the patient's admission to the hospital, defined using secondary discharge diagnosis codes. DATA SOURCES AND STUDY SETTING: 1988 California computerized hospital discharge abstract data, including 24 secondary diagnosis coding slots, from all general, acute care hospitals. STUDY DESIGN: The odds ratio for in-hospital death associated with each of 13 chronic conditions was computed from a multivariable logistic regression using patient age and all chronic conditions to predict in-hospital death. DATA EXTRACTION: All 1,949,276 general medical and surgical admissions of persons over 17 years of age were included. Patients were assigned to four groups according to the mortality rate of their reason for admission; some analyses separated medical and surgical hospitalizations. PRINCIPAL FINDINGS: Overall mortality was 4.4 percent. For all cases, mortality varied by chronic condition, ranging from 5.3 percent for coronary artery disease to 18.6 percent for nutritional deficiencies. The odds ratios associated with the presence of a chronic condition were generally highest for patients in the rare mortality group. Although chronic conditions were more commonly listed for medical patients, the associated odds ratios were generally higher for surgical patients, particularly in lower mortality groups. CONCLUSIONS: Studies examining death rates need to consider the influence of chronic conditions. Chronic conditions had a particularly significant association with the likelihood of death for admission types generally associated with low mortality rates and for surgical hospitalizations. The accuracy and completeness of discharge diagnoses require further study, especially relating to chronic illnesses.

Identifying complications of care using administrative data.

The Complications Screening Program (CSP) is a method using standard hospital discharge abstract data to identify 27 potentially preventable in-hospital complications, such as post-operative pneumonia, hemorrhage, medication incidents, and wound infection. The CSP was applied to over 1.9 million adult medical/surgical cases using 1988 California discharge abstract data. Cases with complications were significantly older and more likely to die, and they had much higher average total charges and lengths of stay than other cases (P < 0.0001). For most case types, 13 chronic conditions, defined using diagnosis codes, increased the relative risks of having a complication after adjusting for patient age. Cases at larger hospitals and teaching facilities generally had higher complication rates. Logistic regression models to predict complications using demographic, administrative, clinical, and hospital characteristics variables, had modest power (C statistics = 0.64 to 0.70). The CSP requires further evaluation before using it for purposes other than research.

Using administrative data to screen hospitals for high complication rates.

Medicare's Peer Review Organizations (PROs) now are required to work with hospitals to improve patient outcomes. Which hospitals should be targeted? We used 1988 California discharge data to identify hospitals with higher-than-expected rates of complications in six adult, medical-surgical patient populations. Relative hospital complication rates generally were correlated across clinical areas, although correlations were lower between medical and surgical case types. Higher relative rates of complications were associated with larger size, major teaching facilities, and provision of open heart surgery, as well as with coding more diagnoses per case. Complication rates generally were not related significantly to hospital mortality rates as calculated by the Health Care Financing Administration. Different hospitals may be chosen for quality review depending on the method used to identify poor outcomes.

The utility of severity of illness information in assessing the quality of hospital care. The role of the clinical trajectory.

This research explored whether differentiating patients whose severity of illness worsened, improved, or remained the same over the hospital stay is a good screen for quality of care. The hypothesis was that substandard care is more likely to occur among patients who have worsened. Severity was measured using the Computerized Severity Index (CSI) and MedisGroups in 233 patients who had experienced acute myocardial infarction and 279 who had undergone coronary artery bypass graft who were admitted to four New England hospitals in 1987. Deaths and patients with discharge diagnoses indicating iatrogenic events and complications were oversampled. Potential quality problems were identified through explicit screening criteria applied by nurse researchers and implicit physician reviews. Acute myocardial infarction patients who worsened had higher rates of potential quality problems than other patients (CSI, P = 0.06; MedisGroups, P = 0.01). For the CSI, the 49.4% of patients who worsened captured 70.6% of the potentially substandard care; for MedisGroups, the 35.6% of patients who worsened also encompassed 70.6% of the problematic cases. For coronary artery bypass graft, results varied depending on how severity and quality were defined. The CSI performed better using implicit physician review to identify problematic care (P = 0.00), capturing 76.5% of substandard cases among the 41.6% of patients who worsened. In contrast, MedisGroups did better using explicit quality screens (P = 0.04), grouping 60.5% of the problematic cases among the 47.0% of patients who worsened. After removing in-hospital deaths from consideration, a worsening trajectory was generally associated with a higher fraction of potential quality problems among live discharges. This preliminary study suggests that examining changes in illness severity may be a useful screen for substandard hospital care, but its utility could vary by condition and by how quality problems are defined.

Predicting in-hospital mortality. A comparison of severity measurement approaches.

Hospital mortality statistics derived from administrative data may not adjust adequately for patient risk on admission. Using clinical data collected from the medical record, this study compared the ability of six models to predict in-hospital death, including one model based on administrative data (age, sex, and principal and secondary diagnoses), one on admission MedisGroups score, and one on an approximation of the Acute Physiology Score (APS) from the revised Acute Physiology and Chronic Health Evaluation (APACHE II), as well as three empirically derived models. The database from 24 hospitals included 16,855 cases involving five medical conditions, with an overall in-hospital mortality rate of 15.6%. The administrative data model fit least well (R-squared values ranged from 1.9-5.5% across the five conditions). Admission MedisGroups score and the proxy APS score did better, with R-squared values ranging from 4.9% to 25.9%. Two empirical models based on small subsets of explanatory variables performed best (R-squared values ranged from 18.5-29.9%). The preceding models had the same relative performances after cross-validation using split samples. However, the high R-squared values produced by the full empirical models (using 40 or more explanatory variables) were not preserved when they were cross-validated. Most of the predictive clinical findings were general physiologic measures that were similar across conditions; only a fifth of predictors were condition-specific. Therefore, an efficient approach to risk-adjusting in-hospital mortality figures may involve adding a small subset of condition-specific clinical variables to a core group of acute physiologic variables. The best predictive models employ condition-specific weighting of even the generic clinical findings.

The impact of a physician's warning on recovery after alcoholism treatment.

OBJECTIVE: To study whether alcoholic workers had seen physicians during the year they were identified by their company, whether they recalled physicians' warnings about drinking, and whether such warnings affected outcomes 2 years later. DESIGN: Workers were interviewed at intake and 2 years later: subgroups who did and did not see physicians and who did and did not recall warnings were compared. SETTING: A company-union employee assistance program. PARTICIPANTS: Two hundred problem drinkers, newly identified on the job, predominantly male, blue-collar workers. OUTCOMES: Drinking, drunkenness, average daily alcohol consumption, and impairment score. RESULTS: Among the 200 participants, 74% saw physicians in the index year; only 22% recalled warnings. Recall of a warning was associated with liver disease, continued drinking while ill, supervisors' job warnings, older age, and marijuana use. Two years later, those warned were more likely to be abstaining, and sober, and were less impaired. CONCLUSIONS: Recalling a physician's warning at intake into alcoholism treatment was associated with better prognosis 2 years later. However, among this group of employees whose drinking was serious enough to be identified on the job, fewer than a quarter recalled physicians' warnings, even though more than three quarters had seen physicians in the year preceding intake.

A randomized trial of treatment options for alcohol-abusing workers.

BACKGROUND: Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options. METHODS: We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period. RESULTS: All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment. CONCLUSIONS: Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.

Admission and mid-stay MedisGroups scores as predictors of hospitalization charges.

This study examines the ability of MedisGroups, a severity measure based on clinical data abstracted from the medical record, to predict hospitalization charges. MedisGroups measures severity both on admission and approximately 1 week into the hospital stay. The data base contained 23,361 admissions of Medicare beneficiaries in six conditions from 836 hospitals in seven states between January 1985, and May 1986. In all six conditions, higher admission and mid-stay severity scores were generally associated with higher charges. Across the six conditions, the R2 values for predicting charges using diagnosis-related group (DRG) class ranged from 0.06 to 0.32 using trimmed data. Adding admission MedisGroups scores to DRG class produced R2 values ranging from 0.09 to 0.33, while adding mid-stay scores yielded R2 values from 0.15 to 0.41, and adding both admission and mid-stay scores produced R2 levels ranging from 0.17 to 0.42. Very little of the superior predictive power of the mid-stay score could be attributed to its serving as a proxy for length of stay.

Associations between alcohol and cocaine use in a sample of problem-drinking employees.

Increases in cocaine use have created a new and challenging cohort of problem drinkers with dual or multiple addictions. As part of a randomized trial comparing alternative alcoholism treatments at a 10,000-employee industrial plant, we interviewed 224 new alcoholic clients of an employee assistance program (EAP); 40% used cocaine during the 6 months just prior to EAP intake. Compared to employees reporting no recent cocaine use, the cocaine users were younger, less often married and reported heavier drinking and more alcohol-related problems, on the job and off. Even after controlling for demographic and occupational factors, and drinking indicators, cocaine users reported more binges (being drunk 24 hours or more), more blackouts (marginally significant, p = .06), more absenteeism and more warnings about unacceptable job performance. Alcoholic EAP clients who use cocaine appear to engage in riskier drinking and to have more trouble on the job than do those who report no cocaine use, and this seems to be a difference specifically attributable to their use of cocaine.

DSM-III disorders in a large sample of psychiatric patients: frequency and specificity of diagnoses.

This study examined certain nosological features of DSM-III axis I diagnostic categories and subcategories as applied to 11,292 general psychiatric patients presenting for care, using a semistructured assessment procedure. The most frequently used major categories were affective, substance use, childhood-onset, and adjustment disorders. Secondary diagnoses were given to 26% of the patients. Male patients predominated in the categories of impulse-control, psychosexual, and substance use disorders, and female patients predominated in the categories of anxiety, affective, and somatoform disorders. Of the 329 five-digit subcategories available in DSM-III, 296 (90%) were actually used. Sixteen percent of the patients were given unspecific primary diagnoses.

Multiaxial characterization of depressive patients.

A review of the literature on the comprehensive description of depressive patients revealed prominent concern with syndromic subtypes, course of illness, and personality factors, followed by severity, concomitant physical disorders, psychosocial stressors, and adaptive functioning. The descriptive value of multiaxial approaches for depression was illustrated through the application of an extended DSM-III formulation to all 3455 depressive (bipolar depression, major depression, dysthymic disorder, and atypical depression) and 7837 nondepressive patients of all ages and sexes presenting for evaluation and care at the Psychiatric Institute of the University of Pittsburgh during a period of 53 months. Twenty-six percent of the depressive patients received an additional diagnosis in axis I, the most frequent of which were substance use disorder, anxiety disorder, and condition not attributable to a mental disorder. In axis II, depressive patients presented a differentially higher frequency of dependent personality disorder and the "anxious/fearful" cluster of personality disorders. In axis III, 47% of the depressive vs. 40% of the nondepressive patients had a positive diagnosis of physical illness, with a significantly higher frequency among depressive patients attained by acquired hypothyroidism, migraine, essential hypertension, unspecified abdominal hernia, and unspecified arthropathies. Specific stressors differentially more frequent among depressive patients were those of conjugal, parenting, and occupational types and those reflecting the impact of physical illness. Overall stressor severity was at severe, extreme, or catastrophic levels for 42% of the depressive and 31% of the nondepressive patients. The highest level of adaptive functioning in the past year was good, very good, or superior for 44% of the depressive and 29% of the nondepressive patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Descriptive validity of DSM-III depressions.

There are five categories of psychiatric disorders in DSM-III that embrace depressive moods: adjustment disorder with depressed mood (group 1), bipolar depression (group 2), major depression (group 3), dysthymic disorder (group 4), and atypical depression (group 5). A large sample of patients seen in a metropolitan university psychiatric referral center, with these categories as primary diagnoses in axis I, constitute the subjects studied (N = 2988). The study includes a comparison of the cross-sectional clinical properties of these patients, including an inventory of psychopathological symptoms, entries in axes II to V (i.e., as described in DSM-III, plus a sixth axis measuring current adjustment) and immediate dispositions rendered by clinicians. This study addresses the descriptive validity of DSM-III diagnostic categories of depression. A clustering of depressions based on a continuum of severity is uncovered as well as unique features of certain subtypes that point to categorical aspects of DSM-III mood disorders. The nature and implication of these findings are discussed.

International experience with DSM-III.

The authors investigated various aspects of the international use of and experience with DSM-III through a consultation by mail sponsored by the World Psychiatric Association. The respondents were 175 expert diagnosticians nominated as such by the national psychiatric associations of 52 countries spanning all continents. The United States diagnostic system was used by 72% of the participants, only slightly less than the internationally official International Classification of Diseases, Injuries, and Causes of Death, ninth revision (ICD-9) (77%). Furthermore, DSM-III was perceived to be considerably more useful than the current international classification manual. The leading difficulties encountered with DSM-III involved problematic boundaries or definitions of diagnostic categories and the lack of suitable categories in some cases. The most frequent recommendations offered for the advancement of diagnostic systems included the improvement of patient evaluation procedures, the greater use and refinement of multiaxial diagnosis, and the empirical validation of diagnostic systems.