Prediction of in-hospital cardiopulmonary arrest outcome.

Clinical and demographic characteristics of 122 patients undergoing cardiopulmonary resuscitation were retrospectively collected to develop a predictive model for immediate success of resuscitation (restoration of pulse and blood pressure). The project focused on objective measurement of parameters available before resuscitation was performed. Variables included age, diagnoses, objective severity of illness, laboratory data, and clinical course variables. A four-variable model was developed using logistic regression to predict resuscitation success immediately after resuscitation. The four predictive before arrest factors were age between 40 and 70 years, scheduled for surgery, location of arrest in an intensive care unit, and before arrest PO2 greater than 8 mm Hg. The model had an accuracy of 69%, sensitivity of 76%, and specificity of 61%.

Impact of continued geriatric outpatient management on health outcomes of older veterans.

BACKGROUND: Although previous trials have proved inpatient-based geriatric assessment to be beneficial, to our knowledge, the effectiveness of outpatient geriatric assessment has not been established. We examined the effectiveness of an outpatient geriatric evaluation and management (GEM) clinic. METHODS: Hospitalized veterans aged 65 years or older with impairment of activities of daily living, chronic disease, polypharmacy, or two or more hospitalizations in the previous year were randomized to an outpatient GEM team clinic (n = 60) or usual care (n = 68). After an initial comprehensive assessment, they received long-term management in the geriatric clinic. Principal outcomes included health status (mortality, hospitalizations, health perception, and medications), function (activities of daily living, instrumental ADL, and social activity), affect (Center for Epidemiologic Studies-Depression test score and life satisfaction), and cognition (Mini-Mental State examination score). RESULTS: At randomization, no significant differences were noted between the groups. The average age of the patients was 71 years (range, 65 to 93 years). At 1 year following randomization, GEM clinic patients compared with subjects receiving usual care had significantly improved health perception, took fewer medications despite increased number of diagnoses, reported greater social activity, had improved Center for Epidemiologic Studies-Depression scale scores, and had higher life satisfaction scores. There was a trend toward improved performance of activities of daily living for GEM clinic patients. The GEM clinic patients had a 54% lower mortality (6.8% vs 14.9%). Overall, no differences were observed in the total number of hospitalizations between the groups. CONCLUSIONS: The combination of long-term management following comprehensive outpatient assessment significantly improved aspects of health status (including health perception and medications), function (including social activity), and affect (including depression and life satisfaction) for older veterans and may influence mortality and function.

Nonpharmacologic intervention to reduce blood pressure in older patients with mild hypertension.

BACKGROUND: Although nonpharmacologic interventions are widely recommended in the therapy of high blood pressure in older adults, surprisingly little data exist to confirm the efficacy of these interventions in older persons. METHODS: We conducted a randomized, controlled clinical trial in persons aged 60 to 85 years with a diastolic blood pressure of 85 to 100 mm Hg. The experimental arm was a nonpharmacologic intervention combining weight reduction, sodium restriction, and increased physical activity. The nonpharmacologic intervention consisted of eight weekly group and two individual sessions during the intensive phase, followed by four monthly group sessions during the maintenance phase. The control group received no treatment during the study. Blood pressure was assessed by certified technicians (blinded to group assignment) using random zero sphygmomanometers. RESULTS: Of 56 participants randomized, 47 completed the entire 6-month trial (21 in the intervention group and 26 in the control group). Attendance at the intervention sessions was excellent. The intervention group lost more weight (-2.1 kg) over 6 months than the control group (+0.3 kg). Trends for decreasing 24-hour urine sodium excretion in both the intervention and control groups, with greater trend in the intervention group, were not statistically significant. The intervention group experienced more reduction in systolic and diastolic blood pressure than did the control group (mean differences between groups at 6 months, 4.2/4.9 mm Hg, respectively). CONCLUSIONS: Our data indicate that a nonpharmacologic intervention will lower systolic and diastolic blood pressure levels in older people with borderline or mild elevations of diastolic blood pressure.

Impact of race and age on the effects of regionalization of cardiac procedures in the Department of Veterans Affairs Health Care System.

Previous studies have demonstrated that regionalization of resources for cardiac catheterization, percutaneous coronary artery angioplasty (PTCA), and coronary artery bypass graft surgery (CABG) reduces the rate of procedure use. It was hypothesized that the impact of regionalization would be greater for the elderly and for African-Americans than for other populations. Discharge medical records of 30,901 patients admitted to a Veterans Affairs (VA) medical center between October 1, 1993, and September 30, 1994, with a diagnosis of coronary artery disease were analyzed. The presence of a cardiac catheterization laboratory in the patients' local VA facility significantly increased the likelihood of undergoing catheterization, PTCA, and CABG, as determined by odds ratios and associated confidence limits estimated by logistic regression techniques. The presence of a cardiac surgical facility also significantly increased the likelihood of having the procedures. The odds ratios estimating the effects of resource availability were significantly greater for the subgroup of patients aged > or =70 years than for the younger subgroup for catheterization, PTCA, and CABG and for African-Americans than for white patients for PTCA and CABG. Thus, within the VA health care system, regionalization of cardiac procedures has a significant impact on utilization rates of tertiary cardiac procedures. These differences are significantly greater for the elderly and for African-Americans than for the general population.

Prevalence and predictors of regularly scheduled prescription medications of newly admitted nursing home residents.

OBJECTIVE: The purpose of this study was to identify the prevalence and predictors of commonly prescribed regularly scheduled medications. DESIGN: Data were collected on the first day following nursing home admission in this non-experimental study. SETTING: A stratified, proportional probability sample of eight nursing homes in a large Mid-South city participated in this study. PARTICIPANTS: A consecutive sample of 574 new and readmitted nursing home residents who did not refuse participation. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Data were collected on regularly scheduled prescription medications and resident and nursing home characteristics. RESULTS: Residents without a diagnosis of dementia were more likely to receive cardiovascular medications (Odds Ratio = 2.34; 95% CI = 1.56-3.49), and white residents were more likely to receive cardiovascular medications (Odds Ratio = 1.74; 95% CI = 1.19-2.53) or central nervous system medications (Odds Ratio = 1.72; 95% CI = 1.18-2.51). Older residents were less likely to receive central nervous system medications (Odds Ratio = 0.97 per year; 95% CI = 0.96-0.99), and females were more likely to receive cardiovascular medications (Odds Ratio = 1.89; 95% CI = 1.30-2.75). CONCLUSIONS: Resident characteristics were the most important predictors for cardiovascular and central nervous system medication prescriptions of new and readmitted nursing home residents.

Health status gender differences of newly admitted black nursing home residents.

OBJECTIVES: To investigate gender differences in health status of newly admitted black nursing home residents on the day following admission. DESIGN: Descriptive and comparative cross-sectional study of black residents drawn from a larger prospective longitudinal study on health and functional status of new nursing home residents interviewed on the first full day after admission. SETTING: Eight southern nursing homes: three not-for-profit, three for-profit, one county government-operated, and one federal government-operated. Homes ranged in size from 110 to 575 beds and were licensed for skilled and intermediate care. PARTICIPANTS: Black nursing home residents (N = 224) aged 60 years and older as admitted sequentially to nursing homes. MEASUREMENTS: Health status was assessed by the Short Portable Mental Status Questionnaire, as a measure of mental status, and the Scaled Outcome Criteria, as a measure of ability to perform activities of daily living (ADLs). Morbidity was assessed by the number of medical diagnoses, number of prescribed medications, and the medical diagnoses of hip fracture, dementia, and cancer. Resident classification data assessed the source of entry to the nursing home, payer source, and level of care required. Demographic data assessed included age, education, marital status, and number of living children. RESULTS: Both black men (n = 126) and women (n = 98) newly admitted to the nursing home had health and social deficits. Moreover, women, although not significantly different from men in average age, were more impaired in six of eight ADLs, including grooming, dressing, feeding, ambulating, transferring, and defecating. Women were also less likely to be married. No gender differences were found for five other health status variables, four other demographic variables, five resident classification variables, or five measures of morbidity. CONCLUSION: These data on southern black nursing home residents provide evidence that among older black nursing home residents, women have greater care needs than men. Findings illustrate the need to consider gender in planning nursing home care of black older residents, black women may be at greater risk for health status alterations and require more frequent health status monitoring and intervention.

The experience of living-dying in a nursing home: self-reports of black and white older adults.

PURPOSE: The purpose of this study was to describe and compare the experiences, needs, priorities, and concerns reported by black and white nursing home residents during the living-dying interval. The living-dying interval is defined as the time between the knowledge of one's impending death and death itself. DESIGN: This qualitative study was part of a larger ethnographic project. Residents participated in from one to four individual, in-depth, semi-structured, audiotaped interviews. SETTING: Residents lived in two large county-financed nursing homes that have historically provided care to indigent black and white older adults. PARTICIPANTS: Purposive sampling was used to identify eight black and five white residents with terminal cancer diagnoses who could serve as rich resources about the experience of living-dying in a nursing home. MEASURES: Residents were asked open-ended questions about how things have been and what would make things better; what comforts them and would make them more comfortable; what dying means to them; and what things are important for nursing staff to know. RESULTS: Verbatim transcripts of the interviews were coded using QRS NUD-IST software. Codes were placed in categories, categories were reviewed for common and different concepts, themes, and patterns, and a conceptual model was developed. The model identified six care needs: (1) day-to-day living; (2) inadequate pain relief for black residents; (3) difficulty chewing and swallowing; (4) importance of religious activities; (5) giving care to others; and (6) appreciation of respectful and prompt care. Residents validated all components of the conceptual model. CONCLUSION: Black and white terminally ill residents focused on the quality of living rather than on dying, and black residents may be undertreated for pain. Important care needs for pain and religion are not routinely addressed by the Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) triggers.

Admission health status differences of black and white indigent nursing home residents.

OBJECTIVE: To compare the health status of newly admitted lower socioeconomic status (SES) southern black (n = 81) and white (n = 53) nursing home residents. DESIGN: The study data were part of a larger prospective study on the health of newly admitted nursing home residents. SETTING: A 575-bed, government-funded nursing home providing care for indigent residents in a large southern city. PARTICIPANTS: Newly admitted black and white nursing home residents aged 60 and older. MEASUREMENTS: Mental status was measured using the Short Portable Mental Status Questionnaire, activities of daily living by Scaled Outcome Criteria, and medical status by medical diagnoses and medications. MAIN RESULTS: Blacks entering the nursing home were more cognitively and functionally impaired and had 3.7 years less education than white residents, but average age was not significantly different for black and white residents. CONCLUSIONS: Many common health status measures showed no significant black-white differences for institutionalized older adults when region and SES were constants. However, mental status, self-care activities, and marital status were significantly different. These findings indicate a possible impact of lifelong poverty or low educational attainment on the increased disability of indigent black older adults. Black residents in our study had less spousal support to remain in the community.

Interdisciplinary geriatric primary care evaluation and management: two-year outcomes.

BACKGROUND: The long-term efficacy of interdisciplinary outpatient primary care Geriatric Evaluation and Management (GEM) has not been proven. This article focuses on results obtained during the 2 years of the study. METHODS: In this 2-year randomized clinical trial, at the Veterans Affairs Medical Center, Memphis, TN, 128 veterans, age 65 years and older, were randomized to outpatient GEM or usual care (UC). Two-year follow-up analyses are based on the 98 surviving individuals. Study outcome measurements included health status, function, and quality of life including affect, cognition, and mortality. RESULTS: At 2 years, there were positive intervention effects for eight of 1 outcome measures, five of which had attained significance at 1 year. GEM subjects, compared with UC subjects, had significantly greater improvement in health perception (P = .001), smaller increases in numbers of clinic visits (P = .019) and instrumental activities of daily living (IADL) impairments (P = .006), improved social activity (P<.001), greater improvement in Center for Epidemiologic Studies-Depression (CES-D) scores (P = .003), general well-being (P = .001), life satisfaction (P<.001), and Mini-Mental State Exam (MMSE) scores (P = .025). There were no significant treatment effects in activities of daily living (ADL) scores (P = .386), number of hospitalizations (P = .377), or mortality (P = .155). CONCLUSIONS: These findings suggest that a primary care approach that combines an initial interdisciplinary comprehensive assessment with long-term, interdisciplinary outpatient management may improve outcomes for targeted older adults significantly. Findings suggest further that outcomes may continue to improve over time and that the GEM care model provides an effective way to manage health care of older adults.

Influence of diagnostic classification on outcomes and charges in geriatric assessment and rehabilitation.

OBJECTIVE: To determine if diagnostic classification is associated with different outcomes from treatment on a geriatric assessment unit (GAU) compared with usual care for elderly patients with acute illnesses. STUDY DESIGN: Reanalysis after post-hoc diagnostic classification of a randomized clinical trial with one year follow up. SETTING: Community hospital with rehabilitation facility. SUBJECTS: A total of 155 subjects, mean age 78 years and 78% female, of whom 58 subjects had a rehabilitation classification of their diagnoses and 97 had a medical or surgical classification. OUTCOME MEASURES: Mortality, nursing home use, activities of daily living, and charges for subsequent medical services. RESULTS: Mortality was decreased in persons with a rehabilitation classification who had received the GAU intervention. The GAU increased point-prevalence residence in the community for persons with a rehabilitation classification. For persons with a medical-surgical classification, the GAU intervention was associated with decreased cumulative use of nursing homes. However, GAU intervention was also associated with trends for increased charges in both diagnostic classification groups, even when adjusted for differential survival. CONCLUSION: Greater benefit from the GAU intervention on mortality and maintenance of residence in the community was observed in a group with a rehabilitation classification when compared with a group with a medical-surgical classification. These improved outcomes in the rehabilitation group were not accompanied by decreased charges for later medical services that could compensate for initial rehabilitation charges.

Prevalence of undiagnosed non-insulin-dependent diabetes mellitus and impaired glucose tolerance in a cohort of older persons with hypertension.

OBJECTIVE: To determine the prevalence of undiagnosed non-insulin-dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in a cohort of older persons with hypertension. To examine the usefulness of screening for NIDDM in this study population. DESIGN: Cross-sectional study. SETTING: University of Tennessee, Memphis and the General Clinical Research Center (GCRC). PATIENTS: Ninety-five participants in the Trial of Nonpharmacologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study. MEASUREMENTS: A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels was performed before the beginning of the TONE intervention. RESULTS: In this cohort, 43 participants (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had IGT, and 11 (11.6%) had undiagnosed NIDDM. The positive predictive value for NIDDM of a fasting glucose > or = 115 mg/dL in our participants was 57%. Hyperinsulinemia occurred in only one participant, a subject in the IGT group. CONCLUSIONS: Our data demonstrate that undiagnosed NIDDM is common in our cohort of older persons who are being treated for essential hypertension and that impaired glucose tolerance may be more common than in the general population of the same age. Further, our data show that the vast majority of this older, obese, hypertensive cohort did not have fasting hyperinsulinemia. We also infer that a fasting glucose alone has a low positive predictive value for screening of NIDDM in our older cohort. As the prevalence of NIDDM and impaired glucose tolerance in older hypertensive patients in the general population is unknown, we believe that further investigation is needed to characterize the relationship of hypertension, glycemic status, and hyperinsulinemia in the general population.

Discrepancies in recording systolic blood pressure of elderly persons by ambulatory blood pressure monitor.

Agreements between auscultatory blood pressure measurements and recordings of the Suntech Accutracker II ambulatory blood pressure monitor (ABPM) were examined in 103 participants ages 23 through 91 to estimate influence of age on accuracy of automated recordings. Simultaneous auscultation by two technicians and recording by the ABPM were compared. Technicians demonstrated close agreement in auscultation of blood pressure. Mean systolic blood pressure measured by ABPM was 5.6 mm Hg lower and mean ABPM diastolic blood pressure was 6.3 mm Hg lower than average auscultatory blood pressure measured by technicians (P less than .0001). Discrepancies in systolic blood pressure measurements between technicians and ABPM were associated with age and systolic blood pressure. The age effect, controlled for gender and race, was a 0.15 mm Hg increase in systolic blood pressure discrepancy per year of age. Discrepancies in diastolic blood pressure measurements were associated with race but not with age or body size measurements. Automated recordings of blood pressure by this ABPM may have systematic bias compared to auscultation which exceeds current standards for ABPM instrumentation. For systolic blood pressure, this bias increases with age and may affect interpretation of ABPM recordings in elderly persons.

Black and white female nursing home residents: does health status differ?

BACKGROUND: There will be greater numbers of Black female nursing home residents in the future, but past emphasis has been on the study of Black older adults in the community. The purpose of this study was to assess the health status stability of newly admitted female nursing home residents and to analyze Black-White differences in health status and health status stability. METHODS: Health status (mental status, activities of daily living [ADLs], self-reported mood, self-reported health) of Black (n = 98) and White (n = 260) female nursing home residents was evaluated during their first two weeks of residence. Time, race, and their interaction effects on health status were analyzed using repeated measures multivariate analysis of variance. RESULTS: All health status data showed stability or improvement, but there were significant race differences in both health status and health status stability. Black female residents had worse mental status and worse ADLs, and reported less alert mood, less tired mood, and better health. Race differences in stability were evident for hygiene, dressing, ambulation, and transferring ADLs: Black female residents were less likely to show improvements over time. CONCLUSION: Black female residents are an at-risk population for special care needs in nursing homes.

Accuracy and bias of licensed practical nurse and nursing assistant ratings of nursing home residents' pain.

BACKGROUND: This study evaluated the accuracy of licensed practical nurses' (LPN) and nursing assistants' (NA) Minimum Data Set (MDS) pain ratings of nursing home residents and evaluated the bias in pain ratings associated with residents' race, gender, mental status, function, depression, or disruptive behavior. METHODS: Data were obtained on the same day directly from residents, LPNs, and NAs by trained interviewers in two safety-net nursing homes. A total of 252 residents were included in this study: 79% were Black, and 60% were men. MDS items J2a and J2b evaluated pain frequency and pain intensity during the last 7 days (weekly pain frequency and weekly pain intensity). A parallel question evaluated pain intensity on the day of the interview (daily pain intensity). MDS data were obtained for the MDS Cognition Scale, the MDS Activities of Daily Living-Long Form Scale, the MDS Depression Rating Scale, and the MDS Disruptive Behavior Scale. RESULTS: Kappa coefficients documented fair to good resident-LPN (K =.70,.56, and.50) and resident-NA (K =.72,.58, and.60) agreement for weekly pain frequency, weekly pain intensity, and daily pain intensity ratings. LPNs and NAs underestimated residents' weekly pain frequency (p <.001 for LPNs, and p <.001 for NAs), weekly pain intensity (p <.001 for LPNs, and p <.001 for NAs), and daily pain intensity (p <.001 for LPNs, and p =.002 for NAs). LPNs underestimated weekly and daily pain intensity more than NAs did (p =.016 for weekly pain intensity, and p =.035 for daily pain intensity). LPN and NA pain ratings were not biased by resident race, gender, mental status, function, depression, or disruptive behavior. CONCLUSIONS: Results documented that (i) LPNs and NAs underestimated residents' pain frequency and pain intensity, (ii) NAs were more accurate than LPNs for pain intensity, and (iii) resident characteristics did not bias LPN or NA pain ratings.

Accuracy of nurse aides' functional health assessments of nursing home residents.

BACKGROUND: Nurse aides provide assessments of nursing home residents' functional health for use in care planning and quality assurance. Nurse practitioner assessments can serve as a standard for analysis of nurse aides' accuracy. This study compared nurse aide to nurse practitioner assessments of nursing home residents' functional health with regard to possible bias and extent of correlation. METHODS: Nurse aides' accuracy in assessing nursing home residents' activities of daily living was evaluated by comparisons to assessments performed by a master's-prepared nurse practitioner using four functional assessment instruments: the Barthel Index, the Katz Index of Activities of Daily Living, the Multidimensional Observation Scale for Elderly Subjects, and the Scaled Outcome Criteria. Data were collected in a 159-bed nonprofit nursing home licensed for skilled and intermediate care. Residents had a wide variety of functional and cognitive abilities and disabilities. Ninety-six nursing home residents provided data for the study. Functional health assessments by 24 nurse aides, each assessing 4 different nursing home residents, were compared to those of 1 nurse practitioner. Statistical analysis of accuracy used paired samples t-tests and Pearson product moment correlation coefficients. RESULTS: Nurse aide assessments and nurse practitioner assessments were highly correlated. Most functional health assessments evidenced no significant nurse aide bias. When bias was present it usually resulted from nurse aides electing more optimistic choices when using an assessment instrument that offered fewer response levels for rating residents. CONCLUSIONS: Nurse aides can accurately use well-calibrated instruments to assess nursing home residents' functional health. Demonstration of assessment accuracy in nurse aides, who provide the majority of direct care for nursing home residents, documented a valuable clinical resource for planning and evaluating resident care.

Does syndrome X exist in hypertensive elderly persons with impaired glycemic control?

BACKGROUND: This report focuses on the glycemic state in relation to insulin and lipid levels of a cohort of elderly hypertensive persons to estimate the prevalence of syndrome X. METHODS: A cross-sectional study was performed at the University of Tennessee, Memphis, and the General Clinical Research Center (GCRC) on 95 participants in the Trial of Nonpharmacologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study. A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels and a fasting lipid profile were obtained. RESULTS: In this sample of healthy elderly participants with hypertension who were taking an antihypertensive medication, 43 (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had impaired glucose tolerance (IGT), and 11 (11.6%) had undiagnosed non-insulin-dependent diabetes mellitus (NIDDM). Fasting hyperinsulinemia occurred in only one participant, who was in the IGT group. Hypertriglyceridemia and low high density lipoprotein (HDL) occurred in four persons, none of whom had hyperinsulinemia. Persons in the NIDDM and IGT groups had decreased beta cell function compared to persons in the NGT group, but did not have increased peripheral insulin resistance as estimated from the OGTT data. CONCLUSIONS: Our data demonstrated that in this cohort of elderly hypertensive participants with a high prevalence of central obesity, impaired glycemic control was common, but was not associated with fasting hyperinsulinemia or peripheral insulin resistance. Furthermore, we conclude that syndrome X essentially did not occur in these participants and postulate that the primary etiology for their impaired glycemic control is beta cell dysfunction. Further research is needed to elucidate these relationships.

Does workplace health promotion decrease medical claims?

We examined the relationship between workplace health promotion and medical claims in 38 textile plants, considering also the effects of demographic and contextual variables (i.e., average worker age, sex ratio, racial composition, plant product, and access to medical services). Number of claims per worker varied threefold among plants but was independent of plant workforce's sex ratio, racial composition, and access to medical services. Worker age predicted claims; in a linear regression model, age, sex, race, plant product, and access explained 23% of variance in claims. Health promotion was also related to claims, and its inclusion in the model (with interaction terms involving plant product) explained 54% of variance in claims, with the deletion of race, sex, and access from the reduced model. We concluded that effective health promotion must address the contexts of different types of plant product.

A clinical index for predicting visual acuity after cataract surgery.

We developed a clinical index for predicting postoperative visual acuity of cataract patients and cross-validated it using data from 182 patients aged 70 years and older. The index consisted of four statistically combined indicators: age, preoperative visual acuity, frequency of reading, and comorbidity. Validation of the index included comparisons to two standard technical instruments for measurement of retinal visual acuity. For the clinical index, 72% of predictions were accurate within one Snellen line of postoperative visual acuity compared to 37% using a laser interferometer and 33% using a potential acuity meter. Testing of the clinical index's external validity using data from 111 patients in a different ophthalmology clinic disclosed 61% of predictions accurate within one Snellen line.

Stability of performance of activities of daily living using the MDS.

The Minimum Data Set (MDS) requires assessment of performance of activities of daily living (ADLs) by newly admitted nursing home residents over all shifts for a 7-day period, for a total of 21 assessments. This study evaluated within-subject equivalence of multiple assessments of 42 residents' admission MDS ADL performance. Friedman two-way analysis of variance for ranks documented no significant within-subject differences among repeated measurements for all 13 MDS ADL variables. Thus, fewer than 21 assessments may accurately assess ADL performance.

Trends in burnout and related measures of organizational stress among leaders of Department of Veterans Affairs medical centers.

Psychological burnout significantly and detrimentally affects individuals and the organizations for which they work. Leaders with burnout often display characteristics that are the opposite of those required to implement major organizational change. This study was undertaken to assess the level of psychological burnout of leaders of the Department of Veterans Affairs (VA) medical centers during a period of rapid change. The objective was to quantify trends in the level of burnout and associated measures of psychological stress. Surveys of medical center directors, associate medical center directors, and chiefs of staff of each VA medical center were conducted in 1989, 1992, and 1997 to evaluate burnout, role characteristics, and job satisfaction. Burnout was measured using the Maslach Burnout Inventory and scored using the phase model of burnout. Findings demonstrated higher prevalences of more advanced levels of burnout in the 1992 and 1997 surveys than in the 1989 survey. Role clarity, perceived adequacy of resources to complete assigned tasks, and several measures of job satisfaction were lower in the 1997 survey compared to the earlier survey data. Therefore, psychological burnout and other indicators of stress increased during the 1989 to 1997 study period. These findings suggest cause for concern as the largest integrated healthcare system in the United States undertakes major organizational change to meet present and future challenges.