Selecting a generic measure of health-related quality of life for use among older adults. A comparison of candidate instruments.

Selecting an outcomes assessment instrument requires knowledge of their relative merits, especially head-to-head comparisons. The authors compare health-related quality-of-life (HRQOL) instruments among older adults for their psychometric properties and subject burden, specifically the Sickness Impact Profile (SIP) and Medical Outcomes Study Short-Form 36 (SF-36). Subjects were 282 of 373 eligible older adults (75.6% response) ranging in age from 65 to 96. SIP scores demonstrated a strong skew toward low (good health) scores with a mean of 11.1% (+/- SD 11.5) on the Total SIP index score. Similar components of the SIP and SF-36 were moderately to strongly correlated. The SIP suffered from a ceiling (good health) scaling effect, and the SF-36 scales also demonstrated some scaling extremes. These results demonstrate the relative scaling limits, especially the ceiling effect, of the SIP compared to the SF-36, and in general, the SF-36 is preferred for use among community-living older adults.

Epidemiology of sepsis syndrome in 8 academic medical centers.

CONTEXT: Sepsis syndrome is a leading cause of mortality in hospitalized patients. However, few studies have described the epidemiology of sepsis syndrome in a hospitalwide population. OBJECTIVE: To describe the epidemiology of sepsis syndrome in the tertiary care hospital setting. DESIGN: Prospective, multi-institutional, observational study including 5-month follow-up. SETTING: Eight academic tertiary care centers. METHODS: Each center monitored a weighted random sample of intensive care unit (ICU) patients, non-ICU patients who had blood cultures drawn, and all patients who received a novel therapeutic agent or who died in an emergency department or ICU. Sepsis syndrome was defined as the presence of either a positive blood culture or the combination of fever, tachypnea, tachycardia, clinically suspected infection, and any 1 of 7 confirmatory criteria. Estimates of total cases expected annually were extrapolated from the number of cases, the period of observation, and the sampling fraction. RESULTS: From January 4, 1993, to April 2, 1994, 12759 patients were monitored and 1342 episodes of sepsis syndrome were documented. The extrapolated, weighted estimate of hospitalwide incidence (mean+/-95% confidence limit) of sepsis syndrome was 2.0+/-0.16 cases per 100 admissions, or 2.8+/-0.17 per 1000 patient-days. The unadjusted attack rate for sepsis syndrome between individual centers differed by as much as 3-fold, but after adjustment for institutional differences in organ transplant populations, variation from the expected number of cases was reduced to 2-fold and was not statistically significant overall. Patients in ICUs accounted for 59% of total extrapolated cases, non-ICU patients with positive blood cultures for 11%, and non-ICU patients with negative blood cultures for 30%. Septic shock was present at onset of sepsis syndrome in 25% of patients. Bloodstream infection was documented in 28%, with gram-positive organisms being the most frequent isolates. Mortality was 34% at 28 days and 45% at 5 months. CONCLUSIONS: Sepsis syndrome is common in academic hospitals, although the overall rates vary considerably with the patient population. A substantial fraction of cases occur outside ICUs. An understanding of the hospitalwide epidemiology of sepsis syndrome is vital for rational planning and treatment of hospitalized patients with sepsis syndrome, especially as new and expensive therapeutic agents become available.

Correction of posterior crossbite.

Posterior teeth exhibiting a transverse discrepancy are said to be in crossbite. This abnormal bucco-lingual relationship is usually viewed as affecting one side, but it is really a bilateral problem. There is a multifactorial etiology for this. Early diagnosis by the treating dentist is essential for proper treatment. If not detected early, surgically assisted rapid palatal expansion is needed to correct the transverse discrepancy. Through a series of osteotomies, along with orthodontic appliance therapy, it can be corrected. On such case is presented here. The three main objectives of this treatment are to correct the posterior crossbite; to reduce crowding, and to form a stable occlusion. As shown by this case example, surgically assisted rapid palatal expansion is a safe and effective means of correcting posterior crossbites.

1995 Fast Track: cost reduction and improvement.

To respond to a cost reduction crisis, Strong Memorial Hospital implemented an aggressively managed program of accelerated improvement teams. "Fast-track" teams combined the application of many management tools (total quality management, breakthrough thinking, reengineering, etc.) into one problem-solving process. Teams and managers were charged to work on specific cost reduction strategies. Teams were given additional instruction on interpersonal skills such as communication, teamwork, and leadership. Paradoxically, quality improvement in our hospital was advanced more through this effort at cost reduction than had previously been done in the name of quality itself.

Test-retest performance of a mailed version of the Medical Outcomes Study 36-Item Short-Form Health Survey among older adults.

OBJECTIVES: This study reports the reliability, internal consistency, and response patterns for a mailed version of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) among older adults. METHODS: The SF-36 surveys were mailed to patients living in the community aged 65 years and older who were enrolled in two primary care practice clinics. Comorbidity scores also were assigned to patients based on their diagnoses from computerized clinic encounter forms using Deyo et al's modification of the Charlson Index. Subjects repeated the SF-36 by mail after 1 months. RESULTS: Four-hundred twenty-two subjects were mailed surveys and 253 returned them (60.0%). Missing items further reduced the number of subjects with scores on all SF-36 scales. A total of 186 subjects completed both base-line and retest SF-36 surveys. Intraclass correlation coefficients generally were high and ranged from 0.648 to 0.868. Internal consistency of scales also was high (0.802 to 0.924). Mean SF-36 scale scores decreased significantly with increasing comorbidity levels. CONCLUSIONS: The SF-36 demonstrated good retest reliability and internal consistency among these older adults and also showed a strong relationship to an external measure of comorbidity/health status. Mailed surveys pose a problem of response among older adults, a problem not unique to the SF-36, and methods for increasing response are needed when personal interviews are not feasible.

The appropriateness of coronary artery bypass graft surgery in academic medical centers. Working Group of the Appropriateness Project of the Academic Medical Center Consortium.

OBJECTIVE: To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases. DESIGN: Retrospective, randomized medical record review. SETTING: 12 Academic Medical Center Consortium hospitals. PATIENTS: Random sample of 1156 patients who had had isolated CABG surgery in 1990. MAIN OUTCOME MEASURES: 1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review. RESULTS: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain. CONCLUSIONS: The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review.

Equine pelvic flexure myoelectric activity during fed and fasted states.

The pelvic flexure is the midpoint of the equine large colon that marks the junction of dorsal and ventral components. Previous studies of intraluminal pressure in this region indicate that it could be an important motility control center. The present study was undertaken to expand our knowledge of normal myoelectric activity around the pelvic flexure region. Eight bipolar silver wire electrodes were surgically fixed at 5-cm intervals to the colonic serosa of five adult horses, starting 30 cm oral to the pelvic flexure on the left ventral colon and ending 15 cm aboral to the pelvic flexure on the left dorsal colon (LDC). Recordings of myoelectric activity were done after feed had been withheld for 20 h or when the horses had been allowed to eat hay up to the time of the recording session. The activity was recorded on a polygraph, digitized, processed through a commercial graphics software package, and stored on magnetic tape for later analysis. Action potential activity was basically separated into long spike bursts (LSB) that were > or = 4 s duration and short spike bursts (SSB) that were < 4 s duration and quantified by a software program developed exclusively for the equine large intestine.(ABSTRACT TRUNCATED AT 250 WORDS)

Are hospital quality improvement and public accountability compatible?

BACKGROUND: The goals of public accountability and quality improvement are compatible in theory but not necessarily in practice. Both concepts emphasize the customer. However, those working toward these two goals design systems with quite different roles and relationships between the providers and consumers of health care. Superficial interactions obstruct meaningful dialogue about how to build a better system meeting both sets of goals. ISSUES: Current practices of public accountability and quality improvement have fundamentally different paradigms concerning the roles and responsibilities of those who provide and those who consume health care. CONCLUSIONS: There are at least three ways to improve the current relationship between public accountability and quality improvement. First, optimizing the design and performance of each effort would be an improvement since the goals are highly compatible. Neither ideal currently meets its own expectations, creating distrust among the proponents of each when reality falls short. Second, the two efforts could be coordinated through joint community-level planning and sharing. Finally and optimally, the two concepts could be made part of the same community-level cooperative system, an approach that offers the greatest opportunity for achieving shared goals.

Use of Chinese herbal medicine in veterinary science: history and perspectives.

Veterinary acupuncture has been receiving greater acceptance in veterinary medicine communities throughout the world in recent years. The American Veterinary Medical Association, for example, is beginning to accept acupuncture as a form of veterinary treatment. Another branch of traditional Chinese veterinary practice, herbal medicine, deserves similar recognition throughout the veterinary world. While herbal medicine carries a strong reputation for healing potential in the Orient, this treatment system is new to Western veterinary practices. Chinese herbal medicine should be incorporated into wider veterinary practice only after close scientific examination of these techniques. The authors examine the reasons for investigating Chinese herbal medicine, including the historical background, strategies of development, research plans and prospects for the use of Chinese herbal medicine in veterinary sciences. Potentially, this could lead to a unique combination of traditional and modern medicines, and to links whereby veterinary findings might acquire applications in human medicine.

An auricular acupuncture treatment for idiopathic canine epilepsy: a preliminary report.

A new canine auricular acupuncture point for the treatment for epilepsy is introduced. The new acupoint was used with a previously reported canine auricular acupoint (van Neikerk and Eckersley, 1988) for the treatment of epilepsy in five dogs. The testimonial results of these five cases indicate that the technique is worthy of scientific investigation, and controlled research is proposed. Only testimonial evidence currently supports its application, yet this innocuous treatment is recommended for use in all cases of canine epilepsy. The traditional Chinese medical explanation for the treatment is described, and hypothetical Western physiology is presented.

Reporting tools for clinical quality improvement.

To support clinical quality improvement (QI), effective quality analysis tools are essential. New strategies that we have incorporated into our routine assessment activities include comparative screening, clinical process benchmarking tables, and run charts for key quality indicators. To target areas for improvement, we use comparative screening. We have access to clinical data for 11 comparable medical centers. Currently, these data are used to identify our ranking relative to the others for mortality, readmission, and length of stay. Diagnosis-related groups and ICD-9-CM clusters serve as clinical groupings with defined minimal case volume requirements to ensure meaningful comparisons. These comparative reports permit our clinical leaders and hospital administrators to focus QI activities. Clinical process benchmarking involves peer-to-peer interfacility communication to identify those factors that create outstanding clinical performance. We successfully have used this tool to support process improvement in cardiac-surgery, administration of patient controlled analgesia, and respiratory therapy. Interdisciplinary QI teams identify the key investigative questions. Team members then contact their counterparts at similar facilities, which differ from our hospital in quality, based on empirical evidence or through comparative screening. The information that is obtained is collated in a tabular format, along with our own information, to permit easy identification of key clinical processes associated with better outcomes. Key quality and utilization goals at our hospital include reducing unplanned readmissions by 10%, achieving a 5% lower average length of stay, and not exceeding Health Care Financing Administration expected mortality rates in any clinical area.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of the traditional Chinese versus transpositional zangfu organ association acupoint locations in the horse.

The traditional Chinese (TC) and transpositional (TP) methods of animal acupoint location result in different acupoint charts. Representative TC and TP equine zangfu organ shu-association acupoint charts are compared to each other and to a human chart. Despite their differences, practitioners of both methods appear to achieve equally effective therapeutic results--a phenomenon termed "traditional Chinese/transpositional equal efficacy" (TTEE). Common veterinary acupuncture practices, traditional Chinese medical theory, spinal cord anatomy, and a preliminary equine "association segment" chart are proposed to explain TTEE. The differences between the charts indicate that all documented animal acupoint locations should be explicitly described.

Acupuncture for reproductive disorders.

The use of acupuncture to treat reproductive disorders can produce excellent results. Two proposed physiologic mechanisms for its effects on the reproductive system include an endorphin-mediated mechanism affecting the hypothalamic-pituitary-gonadal endocrine axis and a direct effect on gonadal paracrine and autocrine control of steroidogenesis. This chapter discusses reproductive disorders from both western and traditional Chinese perspectives, and details the use of acupuncture for the treatment of eight specific categories of reproductive dysfunction.

Clinical evaluation of stenosis of the carotid bifurcation with magnetic resonance angiographic techniques.

We evaluated the images of 60 carotid artery bifurcations in 31 patients suspected to have carotid artery disease who underwent invasive carotid angiography and combined two-dimensional, phase-sensitive and a gradient-echo magnetic resonance angiography. The phase scans consisted of seven serial projections that were obtained at 20 degrees intervals (11.0 minutes) around the carotid bifurcation; the gradient-echo (GRASS) scans were composed of 11 axial images (2.4 minutes) acquired through the bifurcation. The two magnetic resonance angiographic techniques yielded complementary pieces of information and were used together to compare magnetic resonance angiography with invasive angiography. Comparison of magnetic resonance and invasive angiograms of the 60 carotid arteries shows that the sensitivity (86%) and specificity (92%) of the magnetic resonance angiographic techniques we used to diagnose clinically significant carotid stenosis approach but do not reach those of invasive angiography.

Evaluation of the carotid artery bifurcation: comparison of magnetic resonance angiography and digital subtraction arch aortography.

Thirty-four carotid artery bifurcations were examined using both magnetic resonance angiography (MRA) and digital subtraction arch aortography to determine their accuracy when compared to selective carotid angiography. The sensitivity of MRA was 73% and its specificity was 91% when compared with selective carotid angiography. The sensitivity of arch aortography was 27% and its specificity was 100%.

A hospital payment system with incentives for improvement in quality of care: first lessons.

A demonstration program of five member hospitals of the Rochester Area Hospitals Corporation in Rochester, New York, is introducing two major changes into traditional quality assurance programs in hospitals: (1) a shift of focus from structure and process to outcomes and (2) replacement of punitive approaches with a positive, reward-oriented approach. Relying on the MedisGroups information system to measure outcomes and on statistical techniques to identify variations in hospitals' performance, the demonstration offers financial awards in the form of a payment adjustment incorporated into the hospital reimbursement system, based on each hospital's outcomes compared to both an external and a local standard. The authors report the first experiences with the demonstration and the prospects for continuous improvement of quality of care.