A new concept for DRG-based reimbursement of services in German intensive care units: results of a pilot study

Objective To evaluate LOS in developing a concept of borderline ICU LOS for a realistic reimbursement of intensive care.Design Retrospective analysis of LOS and cost data extracted from patients electronic records.Setting Surgical ICU of the University Hospital Göttingen, Germany.Patients and participants All adult ICU admissions with LOS >24 h over a 24-month period (1 January 2000 to 31 December 2001; n=1631.)Interventions None.Measurements and results Cluster analysis partitioned the ICU population into three homogenous groups based on ICU LOS and total direct costs: cluster 1 (n=1405; mean LOS=2.8; mean cost=€2399); cluster 2 (n=190; mean LOS=13.4; mean cost=€12,754); cluster 3 (n=36; mean LOS=34.9; mean cost=€34,173). Cost distribution between cluster 1 and clusters 2 and 3 combined was 48 vs 52%. Upper 95 percentile LOS of 6.7 allowed cluster 1 to be replaced by an LOS profile population of 7 days population (n=1355; 96% population and 91% total ICU cost overlap with cluster 1) representing 83% of total ICU population and 44% of total ICU costs. Stratification of >7 day population into LOS less than or >20 days (n=220; n=56) were further differentiated by mortality (11 vs 23%) and sepsis incidence (33 vs 79%).Conclusions It may be feasible to formulate a LOS-based reimbursement scheme for ICU services in Germany based on the selection of (appropriate) patients ICU LOS profiles.     

A narrative review of interventions to support family carers who provide physical care to family members with cancer

Objectives

Most reports of cancer caregivers’ needs focus on information and psychosocial needs. Less is known about practical knowledge and support carers need to provide physical care in the home. This review aimed to identity and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical/practical care to a family member with cancer.

Design

Narrative review.

Data sources

Studies which included adult carers who provided care to a family member with cancer (any stage). Search sources included Psych Info., Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid Medline, CINAHL, other databases, systematic and other reviews.

Review methods

All types of study designs were included. Initially, multiple and broadly defined search strategies and terms were used to capture the range of potential studies; later more refined procedures were applied.

Results

In total, 19 studies were included in the review. Interventions focused on skills development (n = 1), managing symptoms (n = 9), problem solving (n = 5) and learning (n = 4). Few studies were identified with well-defined and evaluated interventions to assist carers to provide physical care for their family member with cancer.

Conclusions

Future research is needed to develop well-defined interventions on practical skills and evaluate the outcomes for patients and caregivers.     

Intraobserver reproducibility and interobserver agreement of ultrasonic flowmetry using the velocity profile color doppler method in the common carotid artery

Application of the velocity profile method is recommended for reliable measurement of flow volume in larger vessels, and ultrasonic flowmetry is a useful clinical tool for this purpose. We used the velocity profile in conjunction with a minor modification in the conventional velocity profile method and examined the reproducibility of flowmetry from color Doppler data. Data of three examiners were allowed to analyze intraobserver reproducibility and interobserver agreement in the common carotid artery, and we measured flow volume in the peripheral vessels of healthy individuals. Estimated flow volumes in five healthy examinees were 350 to 550 ml/min and did not vary significantly between examiners. Interobserver correlation was good (r ₁=0.63), but intraobserver correlations in two sonographers were excellent (r ₁=0.85) in by one who was experienced in this method and poor (r ₁=0.32) in the other. Good interobserver agreement and intraobserver reproducibility of experienced examiners suggests that this method is reliable. Values obtained with normal controls averaged 438±78 (mean±SD) ml/min and 449±64 ml/min, respectively, in the right and left carotid arteries (n=12) and 120±31 ml/min and 83±23 ml/min, respectively, in the right and left vertebral arteries (n=10). Normal values were 542±71 ml/min (n=11) in the right renal artery, 1210±211 ml/min in the abdominal artery (n=10), and 799±182 ml/min in the main portal vein (n=17). Arterial blood flow volume can measure reliably by the velocity profile color Doppler method.     

Validity,reliability and ease of use of the disabilities of arm,shoulder and hand questionnaire in adults following stroke

Purpose: The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire is a patient reported outcome measure for evaluating upper limb function in people with musculoskeletal conditions. While the DASH has good psychometric properties when used with people with musculoskeletal conditions, it has not been tested with adults after stroke.

Methods: Data for n?=?61 adults following stroke (aged 32–93 years, 44% male) were analyzed to test validity and reliability of the DASH for use with a stroke population. Data included demographic and clinical attributes, DASH scores (baseline and four weeks later) and Patient Rated Wrist Evaluation (PRWE) measures.

Results: Internal consistency was good (Cronbach alpha 0.92, SEM 6.65). Factor analysis and Rasch modeling suggested that the questionnaire comprised three subscales: pain, impact and function. Concurrent validity between the DASH and PRWE (Spearman’s Rho r_s?=_?0.41) was moderate. The scale was perceived by clinicians to be useful, quick and simple to administer. The DASH had low four-week test-retest reliability (ICC 0.56 [95% Cl 0.05–0.79]).

Conclusions: The DASH is considered to have acceptable validity when used with adults following stroke. Test–retest reliability was low but further research is needed to establish whether this is a result of condition-related change or the stability of the measure.

• Implications for Rehabilitation

• The DASH questionnaire examines upper limb function in task performance and appears to be a useful tool, which is simple to administer in the clinical setting with adults following stroke.

• Upper limb function post stroke can be meaningfully assessed using the DASH as it has good internal consistency and moderate concurrent validity.

• Rasch analysis and factor analysis suggests that the tool appears to consist of three subscales: pain, impact and function. The total score of the DASH may be less meaningful than the totals of these subscales.

• The test–retest reliability of the DASH requires further research; over a four-week period DASH stability was poor in a group of people with moderate to severe upper limb impairment.

     

Analysis of terminal events in 109 successive deaths in a Belgian intensive care unit

Objective To determine the incidence of end-of-life decisions in intensive care unit (ICU) patients.Design and setting Prospective data collection and questionnaire in a 31-bed medicosurgical ICU in a university hospital.Patients and participants All 109 ICU patients who died during a 3-month period (April–June 2001). Members of the ICU team were also invited to complete a questionnaire regarding the circumstances of each patients death. Cardiopulmonary resuscitation was performed in 21 of the patients; other mechanisms leading to death were brain death (n=19), refractory shock (n=17), and refractory hypoxemia (n=2). The decision was taken in the remaining 50 patients to withdraw (n=43) or withhold (n=7) therapy. Questionnaires were completed for 68 patients, by physician and nurse in 40 cases, physician only in 20 cases, and nurse only in 8 cases. Questionnaires were obtained for 34 of 50 patients for whom a decision was made to limit therapy.Results Respondents generally felt that the decision was timely (n=28, 82%), 5 (15%) felt the decision was too late, and one (3%) that the decision was made too soon, before the family could be informed.Conclusions Therapeutic limitations are frequent in patients dying in the ICU, with withdrawing more common than withholding life support. Generally members of the ICU staff were satisfied with the end-of-life decisions made.     

Family functioning and psychological distress among Japanese breast cancer patients and families

Goals of work The purpose of this study was to develop a typology of family functioning in the families of breast cancer patients.Patients and methods Seventy-four families (189 individuals: 74 patients, 54 spouses, 46 offspring, and 15 other relatives) completed self-report questionnaires. Perception of family functioning was assessed using the family relationship index (FRI) and its three dimensions (cohesiveness, expressiveness, and conflict) and was classified into groups by a cluster analytic approach. Psychological distress was assessed using the Zung self-rating depression scale (SDS) and the Zung self-rating anxiety scale (SAS).Main results Cluster analysis yielded three groups of patients and their family members: one cluster with high cohesiveness, high expressiveness, and low conflict (supportive type: n=64); a second group with low cohesiveness, low expressiveness, and high conflict (conflictive type: n=65); and a third group with limited cohesiveness, limited expressiveness, and low conflict (intermediate type: n=60). Analysis of variance revealed that conflictive families manifested the highest level of depression and anxiety among these clusters.Conclusions Typology of family functioning can identify psychologically at-risk families. A family-focused approach can help to reduce psychological distress, especially in conflictive families.     

Development and testing of a patient‐centred care competency scale for hospital nurses

This study aimed to develop and test the psychometric soundness of a patient‐centred care competency (PCC) scale for hospital nurses. A cross‐sectional questionnaire survey was conducted among 594 nurses in two teaching hospitals (response rate 99.5%). Reliability and validity analyses were performed. The PCC scale consisted of 17 items divided into four subscales: respecting patients' perspectives (6 items), promoting patient involvement in care processes (5 items), providing for patient comfort (3 items) and advocating for patients (3 items). The Cronbach's alpha coefficient of the entire scale was 0.92, and those for the subscales were 0.85, 0.81, 0.84 and 0.80, respectively. Multitrait scaling analysis indicated that the four subscales had satisfactory convergent and discriminant validity. Significant correlations were found between total PCC scores and overall self‐ratings of patient‐centred care performance (r = 0.60, P < 0.001). The PCC scale was therefore determined to be a highly valid and reliable tool.     

Development and Assessment of a Measure of Parent and Child Needs in Pediatric Palliative Care

Context

Pediatric palliative care has no evidence-based needs assessment measure. The Parent and Child Needs Survey (PCNeeds) is a new instrument designed to assess the needs of children in palliative care, including children receiving end-of-life care, and their families.

Estimation of left ventricular systolic function by single transpulmonary thermodilution

Objective The single-indicator transpulmonary thermodilution technique (PiCCO system) provides two derived indices of cardiac systolic function: the cardiac function index and the global ejection fraction. We used transesophageal echocardiography to compare theses indices with left ventricular fractional area of change only for patients with no isolated right ventricular dysfunction. (The global cardiac systolic function may be decreased despite preserved left ventricular function in this situation.)Design Prospective, open, clinical study.Setting Intensive care unit (ICU) in a university hospital.Patients Thirty-three mechanically ventilated patients.Intervention Left ventricular fractional area of change (LVFAC) was measured using transesophageal echocardiography. The cardiac function index (CFI) and the global ejection fraction (GEF) were determined from transpulmonary thermodilution-derived cardiac output and thoracic volumes.Measurements and main results Transesophageal echocardiography identified 3 patients with isolated right ventricular failure (PiCCO underestimated LVFAC in this situation). Significant correlations were established between LVFAC and CFI (r=0.87, n=30, p<0.0001) or GEF (r=0.82, n=30, p<0.0001). The mean differences between measured LVFAC and LVFAC estimated with CFI or GEF were 0.8±8.5% (range: –17 to 14%) and 0.8±9.0% (range: –21 to 19%), respectively. Area under the receiver operating characteristics curves for the estimation of LVFAC 40% using CFI or GEF was 0.92. CFI >4 and GEF >18% estimated LVFAC 40% with respective sensitivities of 86 and 88% and specificities of 88 and 79%. Significant correlations were established between changes of LVFAC and CFI/GEF over time.Conclusions In mechanically ventilated ICU patients, PiCCO-derived cardiac function index and global ejection fraction provide reliable estimations of LV systolic function but may underestimate it in the cases of isolated right ventricular failure.     

Validity and reliability of the French translation of the VISA-A questionnaire for Achilles tendinopathy

Purpose: The Victorian Institute of Sport Assessment – Achilles tendinopathy questionnaire (VISA-A) evaluates the clinical severity of Achilles tendinopathy. The aim of this study was to translate the VISA-A into French and to study the reliability and validity of this French version, the VISA-AF.

Method: The VISA-A was translated into French to produce the VISA-AF using a validated methodology in six steps. Thereafter, several psychometric properties of this French version such as test–retest reliability, internal consistency, construct validity and floor and ceiling effects were evaluated. Therefore, we recruited 116 subjects, distributed into 3 groups: pathological patients (n?=?31), at-risk athletes (n?=?63) and healthy people (n?=?22).

Results: The final version of the VISA-AF was approved by an expert committee. On a scale ranging from 0 to 100, the average scores of the VISA-AF obtained were 59 (±?18) for the pathological group, 99 (±?1) for the healthy group and 94 (±?7) for the at-risk group. The VISA-AF shows excellent reliability, low correlations with the discriminant subscales of the SF-36 and moderate correlations with the convergent subscales of the SF-36.

Conclusions: The French version of the VISA-A is equivalent to its original version and is a reliable and valid questionnaire for French-speaking patients with Achilles tendinopathy.

• Implication for Rehabilitation

• The VISA-AF questionnaire is a reliable translation of the original VISA-A, from English into French, which is one of the most widespread languages in the world.

• The VISA-AF questionnaire is now a valid instrument that can be used by clinicians and researchers to assess the severity of pain and disability of French-speaking subjects with Achilles tendinopathy.

• The VISA-AF is a questionnaire to assess the severity of Achilles tendinopathy symptoms but is not a diagnostic tool.

     

Validation transculturelle de l’Oswestry disability index en français

Aim

The aim of this study was to interpret and validate a French version of the Oswestry disability index (ODI), using a cross-cultural validation method. The validity and reliability of the questionnaire was assessed in order to ensure the psychometric characteristics.

Method

The cross-cultural validation was carried out according to Beaton's methodology. The study was conducted with 41 patients suffering from low back pain. The correlation between the ODI and the Roland-Morris disability questionnaire (RMDQ), the medical outcome survey short form-36 (MOS SF-36) and a pain visual analogical scale (VAS) was assessed.

Results

The validity of the Oswestry questionnaire was studied using the Cronbach Alpha coefficient calculation: 0.87 (n = 36). The significant correlation between the ODI and RMDQ was 0.8 (P < 0.001, n = 41) and 0.71 (P < 0.001, n = 36) for the pain VAS. The correlation between the ODI and certain subscales (physical functioning 0.7 (P < 0.001, n = 41), physical role 0.49 et bodily pain 0.73 (P < 0.001, n = 41)) of the MOS SF-36 were equally significant. The reproducibility of the ODI was calculated using the Wilcoxon matched pairs test: there was no significant difference for eight out of ten sections or for the final score.

Conclusion

This French translation of the ODI should be considered as valid and reliable. It should be used for any future clinical studies carried out using French language patients. Complimentary studies must be completed in order to assess its sensitivity to change in the event of any modifications in the patients functional capacity.     

A review of instruments to measure interprofessional team-based primary care

Interprofessional team-based care is increasingly regarded as an important feature of delivery systems redesigned to provide more efficient and higher quality care, including primary care. Measurement of the functioning of such teams might enable improvement of team effectiveness and could facilitate research on team-based primary care. Our aims were to develop a conceptual framework of high-functioning primary care teams to identify and review instruments that measure the constructs identified in the framework, and to create a searchable, web-based atlas of such instruments (available at: http://primarycaremeasures.ahrq.gov/team-based-care/). Our conceptual framework was developed from existing frameworks, the teamwork literature, and expert input. The framework is based on an Input-Mediator-Output model and includes 12 constructs to which we mapped both instruments as a whole, and individual instrument items. Instruments were also reviewed for relevance to measuring team-based care, and characterized. Instruments were identified from peer-reviewed and grey literature, measure databases, and expert input. From nearly 200 instruments initially identified, we found 48 to be relevant to measuring team-based primary care. The majority of instruments were surveys (n = 44), and the remainder (n = 4) were observational checklists. Most instruments had been developed/tested in healthcare settings (n = 30) and addressed multiple constructs, most commonly communication (n = 42), heedful interrelating (n = 42), respectful interactions (n = 40), and shared explicit goals (n = 37). The majority of instruments had some reliability testing (n = 39) and over half included validity testing (n = 29). Currently available instruments offer promise to researchers and practitioners to assess teams’ performance, but additional work is needed to adapt these instruments for primary care settings.     

Factors affecting the compliance of Israeli women with screening for intimate partner violence

Violence against women has become a frequent occurrence. In Israel, some 200 000 women are subjected to various types of violence by their intimate partners annually. Routine screening for intimate partner violence is endorsed by the Ministry of Health in Israel; however, screening rates in health‐care settings remain problematic. This study aimed to examine whether the model based on the Theory of Reasoned Action (TRA) succeeds in predicting women's intention to comply with screening for intimate partner violence. A questionnaire based on the literature review and research model was administered to a convenience sample of 200 married women. Although only 4.5% (n = 9) of respondents were screened for violence at various health‐care institutions over the past year, 75% (n = 150) of women declared that they intend to cooperate with screening. A positive correlation was found between women's marriage duration, beliefs concerning violence, attitudes towards screening, family member support for compliance with screening—and women's intention to comply with screening. The TRA succeeds in partially predicting women's intention to comply with screening.     

Late Referrals to Palliative Care Units in Japan: Nationwide Follow-Up Survey and Effects of Palliative Care Team Involvement After the Cancer Control Act

Referral to palliative care units tends to be delayed. In Japan, the Cancer Control Act was established in 2006 to improve the quality of life of cancer patients by facilitating greater access to specialized palliative care services. The primary aims of this study were to clarify the family-perceived appropriateness of the timing of referral to palliative care units after the Cancer Control Act, and to determine the effects of the involvement of the palliative care team on the family-perceived referral timing. An additional aim of this study was to clarify the family-perceived usefulness of the palliative care team. A multicenter questionnaire survey was conducted on a sample of 661 bereaved family members of cancer patents who were admitted to palliative care units in Japan. A total of 451 responses were analyzed (response rate: 68%). Half of the bereaved family members regarded the timing of referrals to palliative care units as late or too late: too late (25%, n = 114), late (22%, n = 97), appropriate (47%, n = 212), early (2.4%, n = 11), and very early (1.8%, n = 8). Among 228 families who reported that patients had commented on the timing of referrals, about half reported that the patients said the timing of referral was late or too late: too late (23%, n = 52), late (21%, n = 49), appropriate (48%, n = 110), early (4.4%, n = 10), and very early (3.1%, n = 7). The families of patients with a palliative care team (n = 191) tended to report less frequently that they believed the referral timing to be late or too late (43% vs. 51%, P = 0.073); they also reported significantly less frequently that the patients said that the referral timing was late or too late (36% vs. 52%, P = 0.037). The percentages of families who evaluated the palliative care team as useful or very useful were: 93% (symptom control), 90% (emotional support), 92% (family support), and 87% (care coordination). Half of the Japanese bereaved families of patients admitted to palliative care units regarded the timing of referrals as late or too late, and the rates identified in the survey were similar to those recorded before the Cancer Control Act. Involvement of the palliative care team, however, significantly correlated with lower family- and patient-perceived late referrals, and palliative care team activity was generally perceived as useful by the bereaved family members. Further dissemination of palliative care teams could contribute to better access to palliative care units and quality palliative care throughout the country.     

The prosthesis evaluation questionnaire: reliability and cross-validation of the Turkish version

[Purpose] Currently, there are a limited number of amputee-specific instruments for measuring prosthesis-related quality of life with good psychometric properties in Turkey. This study translated the Prosthetic Evaluation Questionnaire to Turkish and analyzed as well as discussed its construct validity and internal consistency. [Subjects and Methods] The Prosthetic Evaluation Questionnaire was adapted for use in Turkish by forward/backward translation. The final Turkish version of this questionnaire was administered to 90 unilateral amputee patients. Second evaluation was possible in 83 participants within a median 28 day time period. [Results] Point estimates for the intraclass correlation coefficient ranged from 0.69 to 0.89 for all 9 Prosthetic Evaluation Questionnaire scales, indicating good correlation. Overall Cronbach’s alpha coefficients ranged from 0.64 to 0.92, except for the perceived response subscale of 0.39. The ambulation subscale was correlated with the physical functioning subscales of Short Form-36 (SF-36) (r=0.48). The social burden subscale score of the Prosthetic Evaluation Questionnaire was correlated with social functioning subscales of SF-36 (r= 0.63). [Conclusion] The Turkish version of the Prosthetic Evaluation Questionnaire is a valid and reliable tool for implementation in the Turkish unilateral amputee population.Key words: Prosthetic Evaluation Questionnaire, Turkish, Validity     

Development of a family-based pulmonary rehabilitation programme: an exploratory study

Abstract

Purpose: This study explored the expectations of patients with chronic obstructive pulmonary disease (COPD) and family members about a family-based pulmonary rehabilitation (PR) programme; developed and implemented a family-based PR programme and explored the impacts of the intervention on patients and family members. Method: Patients with COPD and family members were interviewed. A family-based PR programme was designed. Patients' breathlessness, muscle strength, exercise tolerance, functional balance and health-related quality of life were collected pre/post-programme. Family coping and adjustment to illness were measured in patients and family members. Focus groups were conducted after the programme. Results: Patients (n?=?35; 69?±?10 years; FEV₁ 62?±?15% predicted) and family members (n?=?35; 57?±?12 years) had similar expectations/needs about a PR programme. Nine dyads participated. Patients' quadriceps strength, exercise tolerance and functional balance improved significantly (all p values?<?0.023). Patients and family members seem to use more positive coping behaviours (p?=?0.026; p?=?0.011). Patients (n?=?7; 78%) and family members (n?=?8; 89%) considered having more knowledge about COPD and its management. Patients felt more functional (n?=?9; 100%) and reported their family members to be more active (n?=?3; 38%). In family members' perspective, their relationship with the care receiver was enhanced (n?=?2; 22%). Conclusions: PR programmes, if inclusive of family members, may enhance the skills of the whole family to manage COPD.

• Implications for Rehabilitation

• Patients with chronic obstructive pulmonary disease (COPD) and their family members have similar expectations and needs about a family-based pulmonary rehabilitation (PR) programme.

• A family-based PR programme is feasible to implement within primary care.

• PR programmes, if inclusive of family members, may enhance the skills of the whole family to manage COPD.

     

A Patient Self-Disclosure Instrument

Four studies in which a patient self-disclosure questionnaire was developed and tested are reported. The instrument was designed to include only content judged by both patients and clinicians as important. Three areas of patient difficulty in disclosing to a health care provider were measured: personal problems and feelings, responses to health care, and life style. Patient difficulty in disclosure was assessed by 21 7-point rating scales, 7 for each disclosure area; ratings were summed to obtain scores. A correlation matrix of the ratings of 216 patients was subjected to a three-factor principal components analysis with varimax rotation; the solution accounted for 59% of the total variance. High internal consistency and test re-test reliability for the total scale and subscales were obtained; Cronbach's alpha .82–.83, n = 214; r = .81–.87, n = 66. In separate tests of construct validity patient self-disclosure was shown to be influenced by locus of control and perception of clinician empathy, and to covary with heart rate changes.     

Cost-effectiveness of pharmaceutical care on patients undergoing maintenance hemodialysis – a multicenter randomized controlled study

Objectives: The aim of the study is to assess the cost-effectiveness of pharmaceutical care versus usual care on the treatment costs in patients undergoing maintenance hemodialysis (HD) in the outpatient HD centers of academic, government, and corporate hospitals.

Methods: An open-labeled randomized controlled study was registered under clinical trial registry of India (Ref. no. CTRI/2014/004900). The study was conducted for a period of 12-month follow-up in patients undergoing maintenance HD. The patients were randomized into Usual Care (UC) group and Pharmaceutical Care (PC) group by the block design method. The UC group received the usual care provided by the hospital staff like physicians, nurses, and technicians whereas, the PC group received the usual care along with the pharmaceutical care delivered by a qualified registered pharmacist. The patient perspective ‘out-of-pocket expenditures’ was considered for calculating the annual cost incurred for the treatment of HD patients.

Results: Out of 153 patients, academic hospital (n = 83), government hospital (n = 18), and corporate hospital (n = 52). The incremental cost-effectiveness ratio for academic, government, and corporate hospitals HD patients of PC group compared with UC group were 86,230 Indian Rupee (INR)/Quality-adjusted life year (QALY), 231,016.66 INR/QALY, and 87,430 INR/QALY, respectively. Our study results revealed that PC group was costlier and more effective compared to the UC group.

Conclusions: It depends upon the policymakers and regulators to take the decision, if they believe that the extra cost is worth the extra QALY.     

The abbreviated injury scale as a predictor of outcome of severe head injury

Objective This study examined the correlation between the worst abbreviated injury scale 1990 (AIS) intracranial severity score and outcome following severe head injury.Design The initial CT scans of 109 severly head injury patients were examined by a neuroradiologist and classified according to the worst applicable intracranial severity code from the AIS. This score was then correlated with the glasgow outcome scale (GOS) at 6 months. For comparison, the GOS was also correlated with the diffuse injury scale (DIS) described by L.F. Marshall et al. [5], the worst post-resuscitation Glasgow coma score (GCS) in the first 24 h, and the head injury outcome prediction tree described by Choi et al. [1].Results Our results show Spearman rank correlation coefficients of 0.58 (p<0.001), 0.47 (p<0.001), 0.45 (p<0.001), and 0.31 (p<0.01) for the correlation between the AIS, prediction tree, DIS, and GCS respectively and the GOS. Independent outcome (i.e. GOS good or moderate) was strongly predicted by an AIS of 3 or less (positive predictive value 95%, specificity 98%, sensitivity 40%, likelihood ratio 251). Death or vegetative survival was less strongly predicted in patients with an AIS of 5 (positive predictive value 71%, specificity 75%, sensitivity 67%, likelihood ratio 2.71).Conclusion The AIS, based on initial CT scan, provides useful prognostic information in patients with severe head injury.