RESUMEN
This study compares the clinical performance of three digital mammography system types in a breast cancer screening programme. 28 digital mammography systems from three different vendors were included in the study. The retrospective analysis included 238 182 screening examinations of females aged between 50 and 64 years over a 3-year period. All images were double read and assigned a result according to a 5-point rating scale to indicate the probability of cancer. Females with a positive result were recalled for further assessment imaging and biopsy if necessary. Clinical performance in terms of cancer detection rate was analysed and the results presented. No statistically significant difference was found between the three different mammography systems in a population-based screening programme, in terms of the overall cancer detection rate or in the detection of invasive cancer and ductal carcinoma in situ. This was shown in both prevalent and subsequent screening examination categories. The results demonstrate comparable cancer detection performance for the three imaging system types operational in the screening programme.
Asunto(s)
Neoplasias de la Mama/diagnóstico por imagen , Carcinoma Ductal de Mama/diagnóstico por imagen , Detección Precoz del Cáncer/normas , Mamografía/normas , Detección Precoz del Cáncer/métodos , Femenino , Humanos , Persona de Mediana Edad , Intensificación de Imagen Radiográfica/normas , Sensibilidad y EspecificidadRESUMEN
Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube. Many controversial questions remain concerning the best methods for conducting this process. An International Consensus Conference was held in April 2005 to provide recommendations regarding the management of this process. An 11-member international jury answered five pre-defined questions. 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? The main recommendations were as follows. 1) Patients should be categorised into three groups based on the difficulty and duration of the weaning process. 2) Weaning should be considered as early as possible. 3) A spontaneous breathing trial is the major diagnostic test to determine whether patients can be successfully extubated. 4) The initial trial should last 30 min and consist of either T-tube breathing or low levels of pressure support. 5) Pressure support or assist-control ventilation modes should be favoured in patients failing an initial trial/trials. 6) Noninvasive ventilation techniques should be considered in selected patients to shorten the duration of intubation but should not be routinely used as a tool for extubation failure.
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Insuficiencia Respiratoria/fisiopatología , Desconexión del Ventilador/métodos , Humanos , Insuficiencia Respiratoria/terapia , Insuficiencia del Tratamiento , Trabajo RespiratorioRESUMEN
Insufficiency fractures of the sacrum are not uncommon and usually occur in osteoporotic bone with minimal or unremembered trauma. However, they appear to be relatively under-diagnosed and this pictorial review aims to highlight the condition, discuss the expected imaging features and some of the potential imaging pitfalls. Owing to its relationship with osteoporosis, the majority occur in elderly females and are frequently bilateral, often presenting as low back pain. Plain radiographs are generally normal and both clinician and radiologist need to consider the possibility of sacral insufficiency fracture to allow prompt accurate diagnosis and correct treatment. Lumbar spine MRI is among the first investigations performed and can enable the correct diagnosis to be made. Occasionally the MR appearances can mimic tumour or osteomyelitis. The "H" sign on an isotope bone scan is considered diagnostic in the right clinical setting, but this sign is often not present. CT is useful to confirm the diagnosis and exclude tumour or infection.
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Sacro/lesiones , Fracturas de la Columna Vertebral/diagnóstico , Anciano , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Cintigrafía , Factores de Riesgo , Fracturas de la Columna Vertebral/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodosRESUMEN
In patients with diaphragm paralysis, ventilation to the basal lung zones is reduced, whereas in patients with paralysis of the rib cage muscles, ventilation to the upper lung zones in reduced. Inspiration produced by either rib cage muscle or diaphragm contraction alone, therefore, may result in mismatching of ventilation and perfusion and in gas-exchange impairment. To test this hypothesis, we assessed gas exchange in 11 anesthetized dogs during ventilation produced by either diaphragm or intercostal muscle contraction alone. Diaphragm activation was achieved by phrenic nerve stimulation. Intercostal muscle activation was accomplished by electrical stimulation by using electrodes positioned epidurally at the T(2) spinal cord level. Stimulation parameters were adjusted to provide a constant tidal volume and inspiratory flow rate. During diaphragm (D) and intercostal muscle breathing (IC), mean arterial Po(2) was 97.1 +/- 2.1 and 88.1 +/- 2.7 Torr, respectively (P < 0.01). Arterial Pco(2) was lower during D than during IC (32.6 +/- 1.4 and 36.6 +/- 1.8 Torr, respectively; P < 0.05). During IC, oxygen consumption was also higher than that during D (0.13 +/- 0.01 and 0.09 +/- 0.01 l/min, respectively; P < 0.05). The alveolar-arterial oxygen difference was 11.3 +/- 1.9 and 7.7 +/- 1.0 Torr (P < 0.01) during IC and D, respectively. These results indicate that diaphragm breathing is significantly more efficient than intercostal muscle breathing. However, despite marked differences in the pattern of inspiratory muscle contraction, the distribution of ventilation remains well matched to pulmonary perfusion resulting in preservation of normal gas exchange.
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Diafragma/fisiología , Gases/metabolismo , Músculos Intercostales/fisiología , Oxígeno/sangre , Mecánica Respiratoria/fisiología , Animales , Perros , Modelos AnimalesRESUMEN
This case report concerns a nulliparous female with prolonged vaginal bleeding, where MRI demonstrated a mass with an aggressive, tumour like appearance involving the posterior aspect of the uterus. Histological examination confirmed that this was an adenomyoma. The unusual imaging appearance of this lesion and its differential diagnosis are discussed. Adenomyoma should be considered in the differential diagnosis of aggressive-appearing uterine masses.
Asunto(s)
Adenomioma/diagnóstico , Neoplasias Uterinas/diagnóstico , Adulto , Diagnóstico Diferencial , Femenino , Humanos , Imagen por Resonancia Magnética/métodosRESUMEN
BACKGROUND: As the incidence of diabetic nephropathy increases, especially in minority populations, more simultaneous pancreas-kidney (SPK) transplants are being performed both in the United States and worldwide. The role of matching on SPK outcomes and organ allocation remains controversial. The purpose of this analysis was to determine the influence of HLA matching using currently employed criteria on 5-year SPK graft survival. METHODS: We performed an analysis of all 3,316 SPK transplants performed in the United States reported to the United Network for Organ Sharing (UNOS) between December 31, 1988 and December 31, 1994. Kaplan-Meier unadjusted 1- and 5-year graft survival with log rank comparisons and Cox multivariable regression models that adjusted for 12 confounding variables were used to analyze the influence of HLA matching on outcomes. RESULTS: Despite low-grade HLA or DR matching or high levels of common reactive groups (CREG) mismatching, 1- and 5-year allograft survival rates were 90% and 78% for kidney, and 85% and 75% for pancreas transplantation. CONCLUSIONS: SPK transplantation is associated with excellent outcomes independent of the level of HLA matching. These data support the hypothesis that SPK transplants need not be allocated based on matching criteria, thus minimizing organ ischemia time and promoting a more racially equitable allocation for SPKs in the US today.
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Supervivencia de Injerto/inmunología , Prueba de Histocompatibilidad/métodos , Trasplante de Riñón/inmunología , Trasplante de Páncreas/inmunología , Adulto , Estudios de Cohortes , Diabetes Mellitus Tipo 1/cirugía , Femenino , Antígenos HLA/inmunología , Humanos , Trasplante de Riñón/estadística & datos numéricos , Masculino , Grupos Minoritarios , Análisis Multivariante , Trasplante de Páncreas/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Sistema de Registros , Tasa de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
PURPOSE: Our study develops decision rules to define appropriate intervals at which repeat tests might be indicated for commonly ordered laboratory tests for hospitalized patients. METHODS: The final data set includes 5,632 adult patients admitted to the University of Virginia Hospital between July 1995 and December 1999. These patients had a hospital length of stay of five days or more and had results recorded for three routinely ordered laboratory tests for each of the first five days of their hospitalization. We use the serum potassium test to illustrate our algorithm-based decision rule methodology. RESULTS: Our decision rule begins with testing on the first two days of hospitalization and allows for repeat testing after observation of any non-normal values. The results show that the algorithm-based decision rule would lead to a 34% reduction for serum potassium tests for the first five days of hospitalization. Only one out of the 5,632 patients in our sample had a critical value that occurred only on a non-test day and, thus, was missed by the algorithm. CONCLUSIONS: The algorithm results are encouraging. We demonstrate that the number of tests can be reduced while missing critical values in only a small fraction of patients. Testing algorithms such as these can be used to reduce laboratory test ordering without compromising the quality of patient care.
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Algoritmos , Técnicas de Laboratorio Clínico/estadística & datos numéricos , Técnicas de Apoyo para la Decisión , Adulto , Mal Uso de los Servicios de Salud , Hospitales Universitarios , Humanos , Laboratorios de Hospital/estadística & datos numéricos , Pautas de la Práctica en Medicina , VirginiaRESUMEN
An association may exist between Crohn's disease (CD) and lymphoid/myeloid malignancies. We aimed to evaluate the 2-year cumulative incidence rate of lymphoid/myeloid malignancy among hospitalized CD patients. This is a retrospective cohort study using hospital discharge data from California and Virginia. Cohorts were defined by the presence or absence of a CD diagnosis in all patients discharged during a single calendar year (Year-2). The presence or absence of lymphoid/myeloid malignancy was determined for all hospitalizations during a 4-year period (Year-1 to Year-4) for each member of both cohorts. To obtain a 2-year cumulative incidence rate, patients with lymphoid/myeloid malignancy prior to or at the time of their first admission in Year-2 were excluded. Patients were followed for 8 quarters after this admission for the incidence of lymphoid/myeloid malignancy. Cumulative incidence rates and odds ratios were calculated. The crude 2-year incidence rate of lymphoid/myeloid malignancy among hospitalized CD patients was 3.87/1.000 CD patients (21/5,426; 95% CI = 2.40-5.92). The odds ratio adjusted for age, gender, and race was 2.04 (95% CI = 1.33-3.14, p < 0.001). The 2-year cumulative incidence of lymphoid/myeloid malignancies among hospitalized CD patients is greater than that seen in hospitalized patients without CD. This finding supports the need for further prospective population-based studies.
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Enfermedad de Crohn/complicaciones , Leucemia/complicaciones , Linfoma/complicaciones , Mieloma Múltiple/complicaciones , Factores de Edad , Estudios de Cohortes , Enfermedad de Crohn/epidemiología , Interpretación Estadística de Datos , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Leucemia/epidemiología , Linfoma/epidemiología , Masculino , Persona de Mediana Edad , Mieloma Múltiple/epidemiología , Oportunidad Relativa , Estudios RetrospectivosRESUMEN
BACKGROUND & AIMS: The cost-utility of infliximab is unknown. The aim of this study was to determine the incremental cost-utility (CU(inc)) of medical therapy for Crohn's disease (CD) perianal fistula. METHODS: A Markov model was used to simulate a 1-year treatment period with the following: 6-mercaptopurine and metronidazole [6MP/met] (comparator), 3 infliximab infusions + 6MP/met as second-line therapy (intervention I), infliximab with episodic reinfusion (intervention II), and 6MP/met + infliximab as second-line therapy (intervention III). Utilities were elicited from patients with CD and healthy individuals by standard gamble, and costs were obtained from hospital billing data. Uncertainty was assessed by sensitivity analysis. RESULTS: All strategies had similar effectiveness. Interventions I, II, and III were slightly more effective, but also more costly than 6MP/met (Intervention I: CU(inc) = $355,450/quality-adjusted life-years [QALY]; Intervention II: CU(inc) = $360,900/QALY; Intervention III: CU(inc) = $377,000/QALY). If the cost of infliximab were reduced to $304 per infusion, the CU(inc) for intervention II would be $54,050/QALY. CONCLUSIONS: Based on available data, all strategies had similar effectiveness in our model, but infliximab was much more expensive than 6MP/met. The incremental benefit of infliximab for treating CD perianal fistulae over a 1-year period may not justify the higher cost. Prospective studies directly comparing 6MP/met and infliximab are warranted.
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Anticuerpos Monoclonales/uso terapéutico , Enfermedad de Crohn/tratamiento farmacológico , Fármacos Gastrointestinales/uso terapéutico , Fístula Rectal/tratamiento farmacológico , Adulto , Costos de los Medicamentos , Quimioterapia Combinada , Femenino , Costos de la Atención en Salud , Humanos , Infliximab , Masculino , Mercaptopurina/administración & dosificación , Metronidazol/administración & dosificación , Persona de Mediana EdadRESUMEN
PURPOSE: Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. SUBJECTS AND METHODS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support. We estimated life expectancy based on long-term follow-up of SUPPORT patients. Utilities were estimated using time-tradeoff questions. Costs (in 1998 dollars) were based on hospital fiscal data and Medicare data. RESULTS: Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 dependence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator support was withheld, the median survival was 3 days. Among patients whose estimated probability of surviving at least 2 months from the time of ventilator support ("prognostic estimate") was 70% or more, the incremental cost per quality-adjusted life-year (QALY) saved by providing rather than withholding ventilator support and aggressive care was $29,000. For medium-risk patients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate < or =50%), it was $110,000 per QALY. When assumptions were varied from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76, 000 for medium-risk patients, and from $67,000 to $200,000 for high-risk patients. CONCLUSIONS: Ventilator support and intensive care for acute respiratory failure due to pneumonia or acute respiratory distress syndrome are relatively cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival < or =50%, the cost per QALY is more than threefold greater at >$100,000.
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Cuidados Críticos/economía , Costos de Hospital/estadística & datos numéricos , Neumonía/complicaciones , Respiración Artificial/economía , Síndrome de Dificultad Respiratoria/complicaciones , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , APACHE , Enfermedad Aguda , Anciano , Análisis Costo-Beneficio , Femenino , Humanos , Esperanza de Vida , Masculino , Registro Médico Coordinado , Medicare , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Pronóstico , Años de Vida Ajustados por Calidad de Vida , Insuficiencia Respiratoria/economía , Insuficiencia Respiratoria/microbiología , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVES: The goal of this study was to determine factors associated with receiving cardiologist care among patients with an acute exacerbation of congestive heart failure. BACKGROUND: Because cardiologist care for acute cardiovascular illness may improve care, barriers to specialty care could impact patient outcomes. METHODS: We studied 1,298 patients hospitalized with acute exacerbation of congestive heart failure who were cared for by cardiologists or generalist physicians. Using multivariable logistic models we determined factors independently associated with attending cardiologist care. RESULTS: Patients were less likely to receive care from a cardiologist if they were black (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.35, 0.80), had an income of less than $11,000 (AOR 0.65, 95% CI 0.45, 0.93) or were older than 80 years of age (AOR 0.23, 95% CI 0.12, 0.46). Patients were more likely to receive cardiologist care if they had college level education (AOR 1.89, 95% CI 1.02, 3.51), a history of myocardial infarction (AOR 1.59, 95% CI 1.17, 2.16), a serum sodium less than 133 on admission (AOR 1.96, 95% CI 1.30, 2.95) or a systolic blood pressure less than 90 on admission (AOR 1.97, 95% CI 1.20, 3.24). Patients who stated a desire for life extending care were also more likely to receive care from a cardiologist (AOR 1.40, 95% CI 1.04, 1.90). CONCLUSIONS: After adjusting for severity of illness and patient preferences for care, patient sociodemographic factors were strongly associated with receiving care from a cardiologist. Future investigations are required to determine whether these associations represent unmeasured preferences for care or inequities in our health care system.
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Cardiología/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/clasificación , Insuficiencia Cardíaca/terapia , Pacientes Internos/clasificación , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores Socioeconómicos , Estados Unidos , Recursos HumanosRESUMEN
OBJECTIVE: The objective of this work was to identify similarities and differences in primary attending physicians' (generalists' versus oncologists') care practices and outcomes for seriously ill hospitalized patients with malignancy. DESIGN: This was a prospective cohort study (SUPPORT project). SETTING: Subjects were recruited from 5 US teaching hospitals; data were gathered from 1989 to 1994. SUBJECTS: Included in the study was a matched sample of 642 hospitalized patients receiving care for non-small-cell lung cancer, colon cancer metastasized to the liver, or multiorgan system failure associated with malignancy with either a generalist or an oncologist as the primary attending physician. MEASUREMENTS: Care practices and patient outcomes were determined from hospital records. Length of survival was identified with the National Death Index. Physicians' perceptions of patient's prognosis, preference for cardiopulmonary resuscitation (CPR), and length of relationship were assessed by interview. A propensity score for receiving care from an oncologist was constructed. After propensity-based matching of patients, practices and outcomes of oncologists' and generalists' patients were assessed through group comparison techniques. RESULTS: Generalist and oncologist attendings showed comparable care practices, including the number of therapeutic interventions, eg, "rescue care" and chemotherapy, and the number of care topics discussed with patients/ families. Length of stay, discharge to supportive care, readmission, total hospital costs, and survival rates were similar. For both physician groups, perception of patients' wish for CPR was associated with rescue care (P < 0.03), and such care was related to higher hospital costs (P < 0.000). Poorer prognostic estimates predicted aggressiveness-of-care discussions by both types of physicians. Length of the patient-doctor relationship was associated with oncologists' care practices. More documented discussion about aggressiveness of care was related to higher hospital costs and shorter survival for patients in both physician groups (P < 0.001). CONCLUSIONS: Generalists and oncologists showed similar care practices and outcomes for comparable hospitalized late-stage cancer patients. Physicians' perceptions about patients' preferences for CPR and prognosis influenced decision making and outcomes for patients in both physician groups. Length of relationship with patients was associated only with oncologists' care practices. Rescue care increased hospital costs but had no effect on patient survival. Future studies should compare physicians' palliative care as well as acute-care practices in both inpatient and ambulatory care settings. Patients' end-of-life quality and interchange between physician groups should also be documented and compared.
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Medicina Familiar y Comunitaria/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Oncología Médica/estadística & datos numéricos , Neoplasias/terapia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Adulto , Actitud del Personal de Salud , Femenino , Costos de Hospital/estadística & datos numéricos , Humanos , Masculino , Cuerpo Médico de Hospitales/psicología , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Pronóstico , Estudios Prospectivos , Órdenes de Resucitación , Análisis de SupervivenciaRESUMEN
OBJECTIVE: To develop a model estimating the probability of a patient aged 80 years or older having functional limitations 2 months and 12 months after being hospitalized. DESIGN: A prospective cohort study. SETTING: Four teaching hospitals in the US. PARTICIPANTS: Enrolled patients were nonelective hospital admissions aged 80 years or older who stayed in hospital at least 48 hours. The 804 patients who survived and completed an interview at 2 months and the 450 who completed an interview at 12 months were from the 1266 patients in the Hospitalized Elderly Longitudinal Project (HELP) (76% and 47% of survivors, respectively). Median age of the 2-month survivors was 84.7 years. MEASUREMENTS AND MAIN OUTCOMES: Patient function 2 and 12 months after enrollment was defined by the number of dependencies in Activities of Daily Living (ADLs). Ordinal logistic regression models were constructed to predict functional status. Predictors included demographic characteristics, disease category, geriatric conditions, severity of physiologic imbalance, current quality of life, and exercise capacity and ADLs 2 weeks before study admission. RESULTS: Before admission, 39% of patients were functionally independent in ADLs. Of patients who survived and were interviewed at 2 months, 32% were functionally independent, and at 12 months, 36% were independent. Among patients with no baseline dependencies, 42% had developed one or more limitations 2 months later, and 41 % had limitations 12 months later. The patient's ability to perform activities of daily living at baseline was the most important predictor of functional status at both 2 and 12 months. In a multivariable predictive model, independent predictors of poorer functional status at 2 months included: worse baseline functional status and quality of life; depth of coma, if any; lower serum albumin level; presence of dementia, depression, or incontinence; being bedridden; medical record documentation of need for nursing home; and older age. Model performance, assessed using Somers' D, was 0.61 for 2 months and 0.57 for 12 months (Receiver Operating Characteristic (ROC) area = 0.81 and .79, respectively.) Bootstrap validation of the month 2 model also yielded a Somers' D = 0.60. The models were well calibrated over the entire risk range. The ROC area for prediction of the loss of independence was 0.76 for 2 months and 0.68 for 12 months. CONCLUSIONS: Many older patients are functionally impaired at the time of hospitalization, and many develop new functional limitations. A limited amount of readily available clinical information can yield satisfactory predictions of functional status 2 months after hospitalization. Models like this may prove to be useful in clinical care. This work illuminates a potential method for risk adjustment in research studies and for monitoring quality of care.
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Actividades Cotidianas , Evaluación Geriátrica , Anciano , Anciano de 80 o más Años , Femenino , Hospitalización , Humanos , Modelos Logísticos , Masculino , Pronóstico , Estudios Prospectivos , Calidad de Vida , Estados UnidosRESUMEN
OBJECTIVE: To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older. DESIGN: A prospective cohort study with mortality follow-up using the National Death Index. SETTING: Four teaching hospitals in the US. PARTICIPANTS: Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery. MEASUREMENTS: A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care. RESULTS: A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly. CONCLUSIONS: Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.
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Actividades Cotidianas , Evaluación Geriátrica , Modelos Estadísticos , Análisis de Supervivencia , Anciano , Anciano de 80 o más Años , Femenino , Escala de Coma de Glasgow , Hospitalización , Humanos , Estudios Longitudinales , Masculino , Pronóstico , Estudios Prospectivos , Calidad de Vida , Índice de Severidad de la Enfermedad , Estados UnidosRESUMEN
OBJECTIVE: To identify age group differences in care practices and outcomes for seriously ill hospitalized patients with malignancy. DESIGN: Prospective cohort study (SUPPORT project). SETTING: Five United States teaching hospitals; data was gathered between 1989 and 1994. SUBJECTS: Nine hundred twenty five older (age > or = 65 years), 983 middle aged (age = 45-64 years), and 274 younger (age = 18-44 years) hospitalized patients receiving care for non-small cell lung cancer, colon cancer metastasized to the liver, or multi-organ system failure associated with malignancy. MEASUREMENTS: Care practices and patient outcomes were determined from hospital records. Length of survival was identified using the National Death Index. After adjusting for important variables, including severity of illness (i.e., SUPPORT model estimate for 2-month survival, cancer condition), hospital site, selection to intervention and sociodemographic variables, age group differences in care practices and outcomes were identified using general linear models. RESULTS: Older patients with cancer had lower resource utilization during hospitalization (P < .04) and were less likely to receive cancer-related treatments (i.e., chemotherapy, platelet infusions, scheduled intravenous medications) than middle-aged and young-adult patients in the first week of hospitalization (P < or = .01). More care topics were discussed with older patients and their families then with younger patients and their families (P < .001). Length of stay and total hospital costs were lower for older and middle-aged patients than for younger patients. Although more older patients had discussions about transfer to hospice (P < .001), older patients were no more likely to be discharged with supportive care (inpatient hospice or home with home/ hospice care). Older patients died sooner than middle-aged patients (P < .01). CONCLUSIONS: Patient age influenced care decisions and outcomes. Older patients (age > or = 65 years) received less aggressive care, had more discussions about care decisions, and died sooner than younger patients with cancer. Younger patients had longer stays, higher hospital costs, and greater probability of rehospitalization. Although well over half of patients died within 6 months of hospitalization, few patients in any age group were discharged with supportive care. Future studies should examine age differences in palliation, as well as acute care of cancer patients across inpatient and ambulatory care settings and should assess quality of care at the end of life.
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Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias del Colon/terapia , Neoplasias Pulmonares/terapia , Insuficiencia Multiorgánica/terapia , Calidad de la Atención de Salud , Adulto , Factores de Edad , Anciano , Análisis de Varianza , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Neoplasias del Colon/mortalidad , Neoplasias del Colon/patología , Toma de Decisiones , Femenino , Hospitalización/economía , Humanos , Tiempo de Internación , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/terapia , Neoplasias Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/mortalidad , Estudios Prospectivos , Análisis de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Enteral tube and parenteral hyperalimentation are widely used nutritional support systems. Few studies examine the relation between nutritional support and patient outcomes in seriously ill hospitalized adults. OBJECTIVE: To explore the association between nutritional support and survival in seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: A prospective study of preferences, decision-making, and outcomes. SETTING: Five teaching hospitals PARTICIPANTS: 6298 patients aged 18 or older meeting diagnostic and illness severity criteria. MEASUREMENT: Demographic characteristics, diagnoses, comorbid conditions, acute physiology score, nutritional support, and functional status before hospitalization. RESULTS: A total of 2149 patients received nutritional support. In patients who received artificial nutrition on hospital days 1 or 3 (Cohort 1), enteral feeding was associated with improved survival in coma (hazard: 0.53; 95%CI, 0.42-0.66), and reduced survival in COPD (hazard: 1.57; 95%CI, 1.18-2.08). In patients who were hospitalized on Day 7 and received artificial nutrition on days 1, 3, or 7 (Cohort 2), enteral tube feeding (hazard: 0.35; 95%CI, 0.27-0.46) or hyperalimentation (hazard: 0.58; 95%CI, 0.38-0.90) was associated with improved survival in coma. Tube feeding was associated with decreased survival in acute respiratory failure (ARF) or multiorgan system failure (MOSF) with sepsis (hazard: 1.21; 95%CI, 10.4-1.41), cirrhosis (hazard: 2.15; 95%CI, 1.35-3.42), and COPD (hazard: 1.37; 95%CI, 1.04-1.80). Hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis (hazard: 1.34; 95%CI, 1.12-1.59). CONCLUSIONS: Nutritional support was associated with improved survival in coma. Enteral feeding and hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis. Tube feeding was associated with decreased survival in cirrhosis and COPD. Except for patients in coma, artificial nutrition was not associated with a survival advantage.
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Nutrición Enteral , Cirrosis Hepática/terapia , Insuficiencia Multiorgánica/terapia , Nutrición Parenteral Total , Síndrome de Dificultad Respiratoria/terapia , Adulto , Anciano , Toma de Decisiones , Femenino , Hospitalización , Humanos , Cuidados para Prolongación de la Vida , Cirrosis Hepática/clasificación , Cirrosis Hepática/mortalidad , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/clasificación , Insuficiencia Multiorgánica/mortalidad , Estudios Prospectivos , Síndrome de Dificultad Respiratoria/clasificación , Síndrome de Dificultad Respiratoria/mortalidad , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: To examine factors associated with family satisfaction with end-of-life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision-making. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died. MEASUREMENTS: Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision-making. RESULTS: Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision-making. Factors found to be significantly associated with satisfaction with communication and decision-making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3-3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0, 1.2-3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4-1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1-0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2-0.8). CONCLUSIONS: Satisfaction scores suggest the need for improvement in end-of-life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end-of-life care. An intervention like that used in SUPPORT may help family members.
Asunto(s)
Comunicación , Comportamiento del Consumidor , Familia/psicología , Estado de Salud , Cuidado Terminal/psicología , Anciano , Toma de Decisiones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Clase Social , Cuidado Terminal/economía , Estados UnidosRESUMEN
OBJECTIVE: To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life. STUDY DESIGN: A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Hospitalization for exacerbation of COPD at five US teaching hospitals. PARTICIPANTS: COPD patients who died within 1 year (n = 416) among 1016 enrolled. METHODS: Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier. OUTCOME MEASURES: Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families. RESULTS: One-year survival was 59%, 39% had > or = 3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19-0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40, 0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated. One-quarter of patients had serious pain throughout, and two-thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do-Not-Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%. CONCLUSIONS: Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care.