Concordance of proxy-perceived change and measured change in multiple domains of function in older persons

OBJECTIVES: To compare proxy perceptions about change over 6 months in physical, instrumental, affective, and cognitive functioning of older persons with computed change in patient self-report and performance and patient's own perceptions about change. DESIGN: Prospective study. SETTING: Recovery from hip fracture that occurred in community-dwelling persons in Baltimore, Maryland, in 1990-91. The recovery from the sixth to the 12th month postfracture was observed. PARTICIPANTS: One hundred forty-one hip fracture patients aged 65 and older and a self-designated proxy for each. MEASUREMENTS: For specific tasks of physical and instrumental functioning, proxy perception of change over the previous 6 months asked in the 12th month postfracture was compared with change in criterion measures (subject self-report and observed performance) from the sixth to the 12th month postfracture. For global change over the previous 6 months in each area of functioning, proxy perception was compared with the subject's own perception in the 12th month postfracture. RESULTS: Agreement between proxy perceptions of change and change in criterion measures was poor. There was a general pattern for proxies to overstate improvement and understate deterioration in comparison with change observed in criterion measures for specific tasks of physical and instrumental functioning. Proxies' global perceptions reported subjects improving less and deteriorating more than patients' own perceptions. CONCLUSION: Proxy perceptions about task-specific and global changes in subjects' functional health over a short period of time are systematically different from patient report and observed performance.     

Health-related quality of life after elective surgery

Objective:  To examine the responsiveness of the 36-Item Short Form Health Survey (SF-36) to clinical changes in three surgical groups and to study how health-related quality of life (HRQL) changes with time among patients who undergo total hip arthroplasty, thoracic surgery for treatment of non-small-cell lung cancer, or abdominal aortic aneurysm (AAA) repair. Design:  Prospective cohort study with serial evaluations of HRQL preoperatively and at 1, 6, and 12 months after surgery. Setting:  University tertiary care hospital. Patients:  Of 528 patients, more than 50 years of age, who were admitted for these elective procedures, 454 (86%) provided preoperative health status data and are members of the study cohort. At 12 months after surgery, 439 (93%) of the cohort was successfully contacted and 390 (90%) provided follow-up interviews. Measurements and main results:  The Medical Outcomes Study SF-36, the Specific Activity Scale, five validated health transition questions, and a 0 to 100 scale measure of global health were used to assess changes in health status at 1, 6, and 12 months after surgery. Change in health status as measured by the SF-36 demonstrated that physical function and role limitations due to physical health problems were worse 1 month after these three surgeries. However, by 6 months after surgery, most patients experienced significant gains in the majority of the dimensions of health, and these gains were sustained at 12 months after surgery. Longitudinal changes in the SF-36 were positively associated with responses to the five health transition questions, to changes on the Specific Activity Scale and global health rating question, and to clinical parameters for persons who had AAA repair. These findings indicate that the SF-36 has evidence of validity and is responsive to expected changes in HRQL after elective surgery for these procedures. Conclusions:  For the total hip arthroplasty patients, responsiveness was greatest for the SF-36 scales that measure physical constructs. However, for the two other procedures and at various points of recovery, significant changes were observed for all eight subscales, suggesting that responsiveness was dependent on the type of surgery and the timing of follow-up, and that multidimensional measures are needed to fully capture changes in HRQL after surgery. Funded in part by a grant from the Agency for Health Care Policy and Research (1RO1-HS06573). Dr. Mangione is the recipient of a Clinical Investigator Award (1K08-AG00605) from the National Institute on Aging, and is an awardee of the Robert Wood Johnson Foundation Generalist Physicians Faculty Scholars Program (029250).     

Health status and health-related quality of life associated with von Willebrand disease

Von Willebrand disease (VWD) is the commonest inherited disorder of hemostasis and the majority of women with this disorder experience excessive uterine bleeding. Yet very little information is available on the health-related quality of life (HRQL) in individuals with VWD. To test the a priori hypotheses that these individuals will have poorer HRQL than members of the general population, and that this burden of morbidity will correlate with the severity of VWD, a cross-sectional study was undertaken of a population-based cohort in a regional hemophilia program in Ontario, Canada. A survey was made of individuals over 13 years of age with VWD who self-reported their health status using a standard 15 item questionnaire. The responses were converted to levels in the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3) health status classification systems to form multi-element vectors from which single attribute morbidity and overall HRQL utility scores were determined. As a group, individuals with VWD were shown to have poorer HRQL than members of the general population and those with Type 2 disease carried a greater burden of overall morbidity than those with Type 1 disorder. Morbidity was evident mainly in the attributes of emotion, cognition with pain. A striking difference was observed between males and females, with the latter having overall HRQL utility scores similar to those reported previously for HIV positive, severe hemophiliacs. It is possible that this remarkable burden of morbidity reflects chronic iron deficiency associated with menorrhagia. A national study has been proposed to address this likelihood as it offers an opportunity for effective therapeutic intervention (iron supplementation) with a concomitant gain in health status and HRQL.     

Effect of hip fracture on mortality in elderly women: the EPIDOS prospective study

OBJECTIVES: To assess whether the occurrence of a hip fracture is associated with an increased risk of mortality even after taking into account age and prefracture health status and whether this increased risk of mortality persists beyond the first 6 months after the fracture. DESIGN: A prospective study of risk factors for hip fracture. SETTING: Five French areas: Amiens, Lyon, Montpellier, Paris, and Toulouse. PARTICIPANTS: The cohort consisted of 7,512 volunteer ambulatory women aged 75 and older who were recruited from voter registration lists. Women who had a history of hip fracture or bilateral hip replacement were excluded. MEASUREMENTS: The baseline examination included a functional and clinical examination and a questionnaire on life style and treatments. Thereafter, women were followed every 4 months for 4 years to record the occurrence of fractures and deaths. A multivariable proportional hazards model was used to determine the association between hip fracture (treated as a time-dependent variable) and mortality, after adjustment for age and baseline health status. RESULTS: During a mean+/-standard deviation follow-up of 3.9+/-0.9 years, 338 women had a first hip fracture, and their postfracture mortality rate was 112.4 per 1,000 woman-years, compared with 27.3 per 1,000 woman-years for the 6,115 women who did not have any fracture (P<.001). After adjusting for age and baseline health status, women with hip fracture were more than twice as likely to die (95% confidence interval (CI)=1.6-2.8). This increased risk appeared more pronounced in the first 6 months (relative risk (RR)=3.0, 95% CI=1.9-4.7) than after (RR=1.9, 95% CI=1.6-2.2) (P=.09). CONCLUSION: In ambulatory elderly women, the occurrence of a hip fracture is associated with an increased risk of death, even after prefracture health status is taken into account. Although the effect of the fracture is stronger in the first 6 months, it persists for several years thereafter, which suggests that prevention of hip fracture and improved care after the fracture may contribute to increase life expectancy in addition to preserving quality of life.     

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial

OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission. DESIGN: Controlled trial based on assignment by convenience. SETTING: Trauma ward in a university hospital. PARTICIPANTS: One hundred seventy‐one people with hip fracture aged 65 and older. INTERVENTION: Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture. MEASUREMENTS: End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery. RESULTS: Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between‐group differences could be documented for mortality, new nursing home admission, or readmission rate. CONCLUSION: This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more‐intensive approach with more‐direct control over patient management, more‐specific recommendations, and more‐intense education would be effective.     

Patients with hip fracture: subgroups and their outcomes

OBJECTIVES: To present several alternative approaches to describing the range and functional outcomes of patients with hip fracture. DESIGN: Prospective study with concurrent medical records data collection and patient and proxy interviews at the time of hospitalization and 6 months later. SETTING: Four hospitals in the New York metropolitan area. PARTICIPANTS: Five hundred seventy-one hospitalized adults aged 50 and older with hip fracture between July 1997 and August 1998. MEASUREMENTS: Rates of return to function in four physical domains, mortality, and nursing home residence at 6 months. Cluster analysis was used to describe the heterogeneity among the sample and identify variations in 6-month mortality, nursing home residence, and level of functioning and to develop a patient classification tree with associated patient outcomes at 6 months postfracture. RESULTS: In locomotion, transfers, and self-care, 33% to 37% of patients returned to their prior level of function by 6 months, including those needing assistance, but only 24% were independent in locomotion at 6 months. Cluster analysis identified eight patient subgroups that had distinct baseline features and variable outcomes at 6 months. The patient classification tree used four variables: atypical functional status (independent in locomotion but dependent in other domains); nursing home residence; independence/dependence in self-care; and age younger than 85 or 85 and older that identified five subgroups with variable 6-month outcomes that clinicians may use to predict likely outcomes for their patients. CONCLUSION: Patients with hip fracture are heterogeneous with respect to baseline and outcome characteristics. Clinicians may be better able to give patients and caregivers information on expected outcomes based on presenting characteristics used in the classification tree.     

Problems in using health survey questionnaires in older patients with physical disabilities. Can proxies be used to complete the SF-36?

BACKGROUND: The SF-36 Health Survey questionnaire has been proposed as a generic measure of health outcome. However, poor rates of return and high levels of missing data have been found in elderly subjects and, even with face-to-face interview, reliability and validity may still be disappointing, particularly in cognitively impaired patients. These patients may be the very patients whose quality of life is most affected by their illness and their exclusion will lead to biased evaluation of health status. A possible alternative to total exclusion is the use of a proxy to answer on the patient's behalf, but few studies of older people have systematically studied patient-proxy agreement. OBJECTIVE: To compare the agreement between patients, lay and professional proxies when assessing the health status of patients with the SF-36. METHODS: The SF-36 was administered by interview to 164 cognitively normal, elderly patients (Mini-mental State Examination 24 or more) referred for physical rehabilitation. The SF-36 was also completed by a patient-designated lay proxy (by post) and a professional proxy. Agreement between proxies and patients was measured by intraclass correlation coefficients (ICCs), and a bias index. RESULTS: Professional proxies were better able to predict the patients' responses than were the lay proxies. Criterion levels of agreement (ICC 0.4 or over) were attained for four of the eight dimensions of the SF-36 by professional proxies, but for only one dimension by lay proxies. In professional proxies, the magnitude of the bias was absent or slight (<0.2) for six of the eight dimensions of the SF-36 with a small (0.2-0.49) negative bias for the other two. Lay proxies showed a negative bias (i.e. they reported poorer function than did the patients themselves) for seven of the eight dimensions of the SF-36 (small in two and moderate (0.5-0.79) in five). CONCLUSIONS: For group comparisons using the SF-36, professional proxies might be considered when patients cannot answer reliably for themselves. However, in the present study, lay proxy performance on a postal questionnaire showed a strong tendency to negative bias. Further research is required to define the limitations and potentials of proxy completion of health status questionnaires.     

Prospective evaluation of preferences and quality of life in women with hip fractures

OBJECTIVE: Hip fractures are a major cause of morbidity for older women, which result in impaired health related quality of life (HRQOL). Few studies have prospectively evaluated the effect of hip fractures in women on HRQOL with different health state preference measures. We compared how 4 different preference measures change in women post-hip fracture and evaluated the responsiveness of the preference measures. We also compared HRQOL in women with recent hip fractures to a control sample at baseline and to normative Canadian data at followup. METHODS: Health status measures [the Medical Outcomes Study Short Form-36 (SF-36)] and preferences (direct and indirect) of women over age 50 years with hip fractures were measured at baseline and at 3 and 9 months. Baseline preferences [Health Utilities Index (HUI), Feeling Thermometer, Standard Gamble, and SF-36] were obtained from women without hip fractures for comparison. Independent sample t tests were used to compare baseline scores of fracture and nonfracture controls. Correlations between preference and health status measures were assessed and repeated measures ANOVA was used to assess change in health status and preferences over time. RESULTS: Health status and preference measures were lower in women with hip fractures in comparison to nonfracture controls. After 9 months, the SF-36, HUI, Feeling Thermometer, and SF-6D scores improved significantly. Values for the SF-36 remained lower than an age-matched normative sample. The HUI and SF-6D were sensitive to change over time, but the Standard Gamble was not. CONCLUSION: HRQOL and preference measures improve over time in women with recent hip fractures, with the majority of the change occurring in the initial 3 months. Our results suggest that the HUI and SF-6D are valid measures to assess change over time post-hip fracture.     

Quality of life and social integration after allogeneic hematopoietic SCT

In total, 124 adult patients in remission after allogeneic hematopoietic SCT (HSCT) participated in a cross-sectional study to assess health-related quality of life (HRQL). Assessment of HRQL was carried out using two questionnaires: the (EORTC QLQ-C30) and the Functional Assessment of Cancer Therapy (FACT) with specific modules for BMT (FACT-BMT). Transplanted patients differed from healthy controls in many HRQL-related dimensions in the EORTC QLQ-C30: social functioning 73.4 versus 85.8, P<0.0001; role functioning 74.6 versus 83.3, P<0.004; physical functioning 83.9 versus 89.9, P<0.001; emotional functioning 72.2 versus 82.8, P<0.0001 but were not significant for global HRQL 71.2 versus 75.3, P<0.03. In total, 60% of the patients returned to work after HSCT; 31% part time and 29% full time. Age at HSCT and employment status were significantly associated with HRQL. Other factors such as disease and disease stage and especially the occurrence of late complications did not impact the perception of HRQL. This study suggests that the perception of HRQL after HSCT differs from the general population. Issues to increase work-related capabilities and improve social support need to be addressed.     

The relationship between body mass index and health-related quality of life: comparing the EQ-5D, EuroQol VAS and SF-6D

BACKGROUND: No other studies have compared the relationship between body mass index (BMI) and health-related quality of life (HRQL) on more than one utility measure. Estimating the HRQL effects of obesity on a (common) utility scale enables the relative cost-effectiveness of interventions designed to alleviate obesity to be estimated. OBJECTIVE: To examine the relationship between BMI and HRQL according to the EQ-5D, EuroQol visual analogue scale (EQ-VAS) and SF-6D. METHODS: Patients aged >/=45 years at one UK general practice were asked to complete the EQ-5D, EQ-VAS, SF-36 questionnaire (used to derive the SF-6D), and information on their characteristics and co-morbidity. Body mass index was categorized according to the World Health Organization (WHO) recommendations. Regression analysis was used to compare the HRQL of normal BMI patients to the HRQL of patients in other BMI categories, while controlling for patient characteristics and co-morbidity. RESULTS: A total of 1865 patients responded (67%), mean BMI 26.0 kg/m(2), 16% obese (BMI>/=30). Patients with back pain, hip pain, knee pain, asthma, diabetes or osteoarthritis were also significantly more likely to be obese. After controlling for other factors, compared to normal BMI patients, obese patients had a lower HRQL according to the EQ-5D (P<0.01), EQ-VAS (P<0.001) and SF-6D (P<0.001). Pre-obese patients were not estimated to have a significantly lower HRQL, and underweight patients were only estimated to have a significantly lower HRQL according to the SF-6D. These results arose because, on the EQ-5D, obese patients were found to have significantly more problems with mobility and pain, compared to physical functioning, social functioning and role limitations on the SF-6D. Whereas, according to the SF-6D, underweight patients had significantly more problems on the dimension of role limitation. CONCLUSION: The EQ-5D, EQ-VAS and SF-6D were in agreement that, relative to a normal BMI, obesity is associated with a lower HRQL, even after controlling for patient characteristics and co-morbidity. These three measures are thereby sensitive to the HRQL effects of obesity and can be used to estimate the cost-effectiveness of interventions designed to alleviate obesity.     

The structure of physical health status. Comparing proxies and self-respondents

Because gerontological studies often need to rely on the use of proxy respondents, the comparability of proxy and self-respondents is of particular interest. However, it is often impossible to evaluate response agreement between proxy and self-respondents because the necessary data are not available. This study addresses the problem by using a model of health status to evaluate differences between proxy and self-respondents regarding the conceptualization of health status. The model included three dimensions of physical health: chronic illness, functional limitations, and subjective health. Three groups of respondents who differ regarding proxy status and/or physical health status were compared. A subset of matched self-respondents (n = 146) was selected to be comparable in objective health status to respondents who have proxies (n = 140). The third group consisted of physically healthier self-respondents (n = 1,425). Data came from the Study of Well-Being of Older People in Cleveland, OH. No support was found for the expectation that proxies and self-respondents would weight objective health information differently when providing summary statements of subjective health. The results suggest that proxies rely on a conceptualization similar to self-respondents when providing information about another person's health.     

Epidemiology of hip and knee pain and its impact on overall health status in older adults

OBJECTIVES: To obtain prevalence rates of hip and knee pain in elderly people and compare combinations of symptoms with overall health status. METHODS: We performed a cross-sectional postal survey of a random sample of 5500 Oxfordshire residents aged 65 yr and older. Prevalence estimates were based on the screening question: 'During the past 12 months, have you had pain in or around either of your hip/knee joints on most days for one month or longer?' Overall health status was assessed with the SF-36 questionnaire. RESULTS: The response rate was 66.3% (3341/5039 eligible people), and was highest (approximately reverse similar 72%) for the 65-74 yr age-group. The percentage reporting hip pain was 19.2% [95% confidence interval (CI) 17.9-20.6], and 32.6% (95% CI 31.0-34.3) reported knee pain. The percentage reporting hip and knee pain was 11.3%, and 40.7% reported hip or knee pain. Less than half (48%) of the symptomatic respondents had unilateral problems affecting one hip or knee joint only. SF-36 scores worsened as the number of symptomatic hip and knee joints increased (P<0.001 for physical function, physical role limitation and bodily pain). CONCLUSIONS: Patterns of hip and knee symptoms are complex in older people. Amongst the symptomatic, most have more than one hip/knee affected. This has implications for treatment and health status measurement. In the absence of hip and knee symptoms, general health status scores of elderly people are similar to those of people aged under 65 yr.     

Intermediate results of health related quality of life after vertical banded gastroplasty

OBJECTIVES: The purpose of this study is to evaluate (a) health-related quality of life (HRQL) after vertical banded gastroplasty (VBG) (Mason) and (b) predictors of HRQL. SUBJECTS: Eighty-two consecutive patients were assessed preoperatively and then after 6, 12 and 24 months. Patients filled out questionnaires for subjective appraisal of HRQL (physical well-being, mood, physical performance, perceived health, social support and coping/adjustment). RESULTS: The greatest improvement in weight and HRQL was seen within 6 months of surgery. Twenty-four months after VBG weight reduction (P<0.05), perceived health (P<0.05), physical well-being (P<0.05), physical performance (P<0.05), mood (P<0.05), coping/adjustment (P<0.05) continued to be better than before surgery. Preoperative binge eating was the most important predictor of HRQL. CONCLUSION: Two years after VBG weight loss and a significant improvement of HRQL can be found. HRQL and weight loss are not associated in terms of outcome, indicating that weight loss alone may not be enough to improve HRQL.     

Long-term symptom recovery and health-related quality of life in patients with mild-to-moderate-severe community-acquired pneumonia

STUDY OBJECTIVES: The long-term outcomes of patients with community-acquired pneumonia (CAP) in terms of symptom resolution and health-related quality of life (HRQL) is unknown. Our objective was to determine the rate of symptom resolution using validated patient-based outcome measures, and to assess HRQL 18 months after the episode. PARTICIPANTS: Patients were recruited from a group enrolled in a randomized trial comparing two durations of treatment for CAP. Between 2000 and 2003, we included 102 adults with a mild-to-moderate-severe CAP (pneumonia severity index, < or = 110). INTERVENTIONS: CAP-related symptoms were assessed until month 18 using the CAP score. The CAP score was divided into respiratory and well-being sections to assess the recovery of respiratory and well-being symptoms separately. The HRQL was assessed at 18 months using the Medical Outcomes Study 36-item short form (SF-36) questionnaire and compared to a Dutch reference group. RESULTS: Respiratory symptoms resolved within 14 days, while the well-being symptoms resolved more slowly. Taking the prepneumonia status into account, patients recovered fully from pneumonia after 6 months. Patients with comorbid conditions had significantly more symptoms prepneumonia and during follow-up than patients without comorbidities, but at all time points the proportion of patients that reached > or = 80% of the prepneumonia health level did not depend on comorbidity, age, or etiology. SF-36 scores at 18 months were significantly impaired in four of the eight dimensions for patients with comorbid illness, but did not differ from the reference population for patients without comorbid illness. CONCLUSION: Patients with mild-to-moderate-severe CAP recover fully from pneumonia after 6 months. The presence of symptoms beyond 28 days and any impairment in HRQL were found to reflect age and comorbidity rather than the persistent effects of the pneumonia itself.     

Health-related quality of life in patients with chronic respiratory failure after long-term mechanical ventilation

STUDY OBJECTIVES: This study was aimed at assessing health-related quality of life (HRQL) in patients with chronic respiratory failure (CRF) and long-term survival following prolonged intensive care mechanical ventilation. DESIGN: Observational cohort study. SETTING: Patients with CRF who had been transferred to our specialized weaning centre due to prolonged mechanical ventilation (>14 days) and weaning failure. PATIENTS AND PARTICIPANTS: Out of 87 long-term survivors (>6 months), 73 patients (mean age: 60.3+/-13.6 years, chronic obstructive pulmonary disease (COPD, 43%), thoraco-restrictive (21%) or neuromuscular disorders (15%), various chronic diseases (22%)) returned the MOS 36-Item Short-Form Health Status Survey (SF-36) and the St. George's respiratory questionnaire (SGRQ). MEASUREMENTS AND RESULTS: The total ventilation time was 38.7+/-45.9 days. The time between discharge from ICU and HRQL assessment was 31.0+/-22.2 months. Physical health was markedly reduced compared to general population norm, but mental health was mildly impaired. HRQL was comparable to patients with stable CRF receiving non-invasive ventilation who did not need prolonged invasive MV. In addition, general HRQL was better in patients with restrictive respiratory disease compared to patients with neuromuscular diseases (P<0.05). Physiological parameters such as blood gases or lung function parameters were not correlated to any HRQL measurements. CONCLUSIONS: In patients with CRF surviving prolonged ventilation on ICU, the presence of CRF itself is the major determinant of HRQL. Here, the underlying cause of CRF is the major factor which determines the degree of HRQL impairment with patients suffering from restrictive ventilatory disorders reporting the best HRQL when compared to patients with COPD or neuromuscular diseases. Despite severe physical handicaps due to CRF mental health is only mildly compromised.     

Does functional recovery in elderly hip fracture patients differ between patients admitted from long-term care and the community?

BACKGROUND: It is largely unknown whether functional recovery following hip fracture differs between long-term care (LTC) and community-dwelling residents. Our primary purpose was to compare recovery between these patients 6 months following hip fracture, controlling for known prognostic factors. Secondarily, we examined the contribution of residential status, in addition to patient characteristics, to functional recovery. METHODS: We studied a population-based inception cohort of 451 hip fracture patients >/= 65 years old admitted to one Canadian health region hospital between July 1999 and September 2000. Participants completed the Modified Barthel Functional Index (MBI) in hospital and again via telephone interviews 6 months postoperatively. Data were also collected on surgery and rehabilitation timing, length of hospital stay (LOS). and discharge destination. Relative change from prefracture function adjusting for known prognostic factors, and the proportion of participants returning to prefracture function were compared between the LTC and community-dwelling residents. RESULTS: LTC residents (n = 115) were older, with lower function prefracture, more comorbidities, and increased dementia than community-dwelling residents (n = 336). Six months postfracture, 17 (22%) LTC and 180 (71%) community-dwelling residents had regained prefracture function (p <.001). LTC residents had 33% lower (-40.6, -27.2) and community-dwelling residents 11.6% lower (-14.8, -8.4) 6-month MBI scores relative to prefracture scores after risk adjustment. Residential status was significantly associated with risk-adjusted functional recovery (p <.001). Median LOS was 4 days less for LTC than for community-dwelling residents (p <.001). Twelve (10%) LTC and 266 (79%) community-dwelling residents were discharged to inpatient rehabilitation (p <.001). CONCLUSION: Following hip fracture, most LTC residents do not regain prefracture function irrespective of known prognostic factors. Further investigation is needed as to the extent to which personal and environmental characteristics contribute to outcome after hip fracture.     

Does acute organ dysfunction predict patient-centered outcomes?

BACKGROUND: Long-term patient-centered outcomes after acute illness may be associated with baseline health status, the development of acute organ dysfunction (AOD), or both. STUDY OBJECTIVE: To determine whether AOD (occurring in the first 30 days) was independently associated with 90-day survival, functional status, and health-related quality of life (HRQL) after controlling for baseline health status in patients who were hospitalized with community-acquired pneumonia (CAP) and survived to day 30. DESIGN: Prospective observational study. SETTING: Four hospitals in Pennsylvania, Massachusetts, and Nova Scotia, Canada, between October 1991 and March 1994. PATIENTS: One thousand three hundred thirty-nine patients who were hospitalized with CAP. INTERVENTIONS: Baseline and 90-day quality-of-life and functional status questionnaires. MEASUREMENTS AND RESULTS: We determined the 90-day survival rate in all patients (n = 1,339) and the functional status and HRQL in subsets of 261 and 219 patients, respectively. AOD occurred in one or more organ system in 639 patients (47.7%) and in two or more organ systems in 255 patients (19.1%). In univariate analyses, greater AOD was associated with a higher mortality rate (p < 0.0001), a lower HRQL (p = 0.006), and lower functional status (p = 0.009) at 90 days. However, after adjusting for baseline HRQL, AOD was not associated with mortality (p = 0.47) or HRQL (p = 0.14) at 90 days and was only weakly associated with 90-day functional status (p = 0.02). CONCLUSIONS: Although patients who develop AOD are at risk for late adverse outcomes, their risk is due predominantly to poor baseline status prior to illness and not to the organ dysfunction per se. Therefore, AOD does not appear to have significant long-term ramifications for patient-centered outcomes.     

Effects of a hospitalist model on elderly patients with hip fracture

BACKGROUND: Hospitalists' increased role in perioperative medicine allows for examination of their effects on surgical patients. This study examined the effects of a hospitalist service created to medically manage elderly patients with hip fracture. METHODS: During a 2-year historical cohort study of 466 patients 65 years or older admitted for surgical repair of hip fracture, we examined outcomes 1 year prior to and subsequent to the change from the standard to the hospitalist model. RESULTS: The mean (SD) time to surgery (38 [47] vs 25 [53] hours; P<.001), time from surgery to dismissal (9 [8] vs 7 [5] days; P = .04), and length of stay (10.6 [9] vs 8.4 [6] days; P<.001) were shorter in the hospitalist group. Predictors of shorter time to surgery were care by the hospitalist group (P = .002), older age (P = .01), and fall as the mechanism of fracture (P<.001), while American Society of Anesthesia scores of 3 and 4 were associated with increased time to surgery (P<.001). Receiving care by the hospitalist group (P<.001) and diagnosis of delirium (P<.001) were associated with increased chance of earlier dismissal, while admission to the intensive care unit decreased this chance (P<.001). Diagnosis of delirium was more frequent in the hospitalist group (74 [32.2%] of 230 vs 42 [17.8%] of 236; P<.001). There were no differences in inpatient deaths or 30-day readmission rates. CONCLUSION: In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal, and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.     

Low frequency of treatment of osteoporosis among postmenopausal women following a fracture

BACKGROUND: Osteoporosis is a major cause of morbidity. Treatment of osteoporosis reduces the risk of fracture, particularly for postmenopausal women with a history of fracture. METHODS: A retrospective study was conducted using the automated databases of 7 health maintenance organizations to evaluate the use of drugs recommended for secondary prevention of osteoporotic fracture. Women 60 years and older with an inpatient or outpatient diagnostic code for a fracture of the hip, vertebra, or wrist between October 1, 1994, and September 30, 1996, and at least 1 year of continuous enrollment with a drug benefit plan following the date of fracture, were identified. The frequency of use of medications for the treatment of osteoporosis (estrogen replacement therapy, bisphosphonates, and calcitonin) during the 1-year period following the date of the initial fracture was estimated overall and according to patient age, fracture site, and year of fracture. RESULTS: During the study period, 3492 women 60 years and older were diagnosed with a fracture of the hip, vertebra, or wrist, and met the inclusion criteria. Of these patients, 822 (24%) received a drug for osteoporosis treatment during the year following the fracture. The proportion of women receiving treatment for osteoporosis was approximately 2-fold higher among those with a fracture of the vertebra (44%) than among those with a fracture of the hip (21%) or wrist (23%) (P<.001). Of the 2605 women who had not been treated for osteoporosis in the 90 days before a fracture, 14% received treatment for osteoporosis in the year following a fracture. Increasing age was associated with a reduced likelihood of receiving osteoporosis treatment (P<.001). CONCLUSIONS: Most of the older women who had experienced a fracture of the hip, vertebra, or wrist did not receive drug treatment for osteoporosis within 1 year following the fracture. Interventions to improve the detection and treatment of osteoporosis in high-risk patients need to be developed.     

Health-related quality of life assessment in adult haemophilia patients: a systematic review and evaluation of instruments

The objective of this study was to review and evaluate the performance of health-related quality of life (HRQL) and other health status measures used in studies of adult haemophilia and provide recommendations for future research. A systematic literature review was performed to identify HRQL and health status measures used in haemophilia. Literature was identified using medical databases, Internet and manual searches. The search was restricted to articles published in English since 1986. Ninety-six abstracts were located; 19 relevant articles were selected for detailed review. Three main types of HRQL measures were identified: generic psychometric-based HRQL (SF-36 and SF-12), utility-based HRQL [EQ-5D and Health Utilities Index (HUI)], and musculoskeletal-specific HRQL (Arthritis Impact Measurement Scale 2, AIMS 2) instruments. No patient-rated haemophilia-specific HRQL instrument was found. The SF-36, the EQ-5D, and the HUI were able to discriminate haemophilia patient subgroups with respect to disease severity and HIV comorbidity status. Sixteen additional scales were identified that were used to measure the different aspects of physical, psychological, and social functioning of patients. There were no clinical studies of haemophilia carried out that employed HRQL instruments, thus responsiveness of these instruments could not be evaluated. The variety of instruments used in haemophilia studies highlights the need for a tool that can capture the full impact of haemophilia and its treatment on patients' HRQL. Developing such a tool poses the unique challenge of accounting for common comorbidities, such as HIV and chronic hepatitis that may have a greater HRQL impact than the underlying disease.