Effect of a nurse case manager on postdischarge follow-up

OBJECTIVE: To examine whether use of a nurse case manager to coordinate postdischarge care would improve rates of follow-up, emergency department utilization, and unexpected readmission for general medicine patients. DESIGN: Prospective cohort trial. SETTING: Publicly supported, tertiary-care teaching hospital. PATIENTS: Four hundred seventy-eight patients admitted to the general medicine service. INTERVENTIONS: Use of a nurse case manager to provide discharge planning before hospital discharge and to arrange for postdischarge outpatient follow-up. Patients in the control group had discharge planning in the traditional (“usual care”) manner. MEASUREMENTS AND MAIN RESULTS: The proportion of patients with scheduled outpatient appointments in the medical clinic and the proportion making clinic visits, emergency department visits, or with readmission to the hospital within 30 days following discharge. A significantly greater proportion of patients assigned to the nurse case manager intervention had appointments scheduled at the time of hospital discharge (63% vs 46%,p<.001), and made scheduled visits in the outpatient clinic (32% vs 23%,p<.03). Intervention group patients were especially more likely than control group patients to have definite follow-up appointments if they were discharged on weekends. Intervention and control group patients did not differ, however, in the rates of emergency department utilization (p=.52) or unexpected readmissions within 30 days of discharge (p=.11). CONCLUSIONS: Use of a nurse case manager to coordinate outpatient follow-up prior to discharge improved the continuity of outpatient care for patients on a general medical service. The intervention had no effect on unexpected readmissions or emergency department utilization. Received from the Division of General Internal Medicine, Case Western Reserve University and the MetroHealth Medical Center, Cleveland, Ohio. Presented in part at the 17th annual meeting of the Society of General Internal Medicine, Washington, DC, April 27–29, 1994.     

When Should We Measure Functioning? A Comparison of Serial Measurement of the MOS SF-36 in an Australian Hospital Sample with Australian Norms

Objective: To compare the functional status at admission, discharge and three months post-discharge of a group of elderly hospitalised people with a range of general hospital medical and surgical conditions with Australian Bureau of Statistics (ABS) community data. Method: 400 randomly selected patients aged 65 and over completed the SF-36 survey within 48 hours of admission to Manly Hospital and within 24 hours of discharge. These patients were followed up three months post-discharge. Results: Functional status of the hospital sample differed from the ABS data. Approximately half of the 8 hospital SF-36 mean scores were significantly lower than the Australian norms for women and men on admission and discharge. However, by the three month follow-up, the majority of these differences disappeared, except for women aged 75 and over. Conclusions: This study describes differences in the SF-36 data at three points in time surrounding an acute hospital episode. The apparent differences in SF-36 scores at admission, discharge and 3 months post-discharge, with the lowest scores occurring at discharge has implications for planning post-hospital services for the elderly.     

Is this “My’ patient? Development and validation of a predictive model to link patients to primary care providers

BACKGROUND: Evaluating the quality of care provided by individual primary care physicians (PCPs) may be limited by failing to know which patients the PCP feels personally responsible for. OBJECTIVE: To develop and validate a model for linking patients to specific PCPs. DESIGN: Retrospective convenience sample. PARTICIPANTS: Eighteen PCPs from 10 practice sites within an academic adult primary care network. MEASUREMENTS: Each PCP reviewed the records for all outpatients seen over the preceding 3 years (16,435 patients reviewed) and designated each patient as “My Patient” or “Not My Patient.” Using this reference standard, we developed an algorithm with logistic regression modeling to predict “My Patient” using development and validation subsets drawn from the same patient set. Quality of care was then assessed by “My Patient” or “Not My Patient” designation by analyzing cancer screening test rates. RESULTS: Overall, PCPs designated 11,226 patients (68.3%, range per provider 15% to 93%) to be “My Patient.” The model accurately categorized patients in development and validation subsets (combined sensitivity 80.4%, specificity 93.7%, and positive predictive value 96.5%). To achieve positive predictive values of >90% for individual PCPs, the model excluded 19.6% of PCP “My Patients” (range 5.5% to 75.3%). Cancer screening rates were higher among model-predicted “My Patients.” CONCLUSIONS: Nearly one-third of patients seen were considered “Not My Patient” by the PCP, although this proportion varied widely. We developed and validated a simple model to link specific patients and PCPs. Such efforts may help effectively target interventions to improve primary care quality. Presented in part at the annual meeting of the Society of General Internal Medicine, New Orleans, LA in May, 2005. Supported by institutional funding through the Massachusetts General Hospital Primary Care Operations Improvement program.     

Difficult hospital discharges in internal medicine wards

Objective Investigate the prevalence of difficult hospital discharges (DHD), describe clinical and social patients’ characteristics as potential reasons for discharge delays in an internal medicine ward and implement tailored post-discharge care. Methods During the year 2005 we analysed, in a middle-sized country hospital, all the patients for which some delay for discharge, owing to their whole complexity, was presumable. Comprehensive multidimensional assessment, clinical-social risk score, specific needs of care, mean of stay and outcomes were evaluated. Results 68.5% of DHD patients were ≥80 years old, with 3.8 the mean number of diseases per patient; 57.5% presented a loss of autonomy (ADL) just before acute deterioration; 80% were functionally and/or cognitively impaired. Only 5% had suitable family support; 5.1% were living at a nursing home; 2% were living alone. The most frequent causes of admission were stroke, cognitive impairment-dementia, cardiovascular diseases, fractures and cancer. Mean length of stay was 12 days. Fifty-two percent of patients were discharged home, 30% were admitted to a long-term care facility, 1% to hospice and 17% died during their hospital stay. Conclusions The aim of “coordinated care” (i.e., targeting “at-risk” patients with assessment of medical, functional, social and emotional needs; provision of optimal medical treatment, self-care education, integrated services, monitoring of progress and early signs of problems) is to improve health outcomes and reduce costs. More than 80% of DHDs patients, with specific tailored programmes, may be discharged from hospital, with satisfactory solutions for them and their families.     

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care

Background: Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health‐care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients. Aim: To enhance assessment, communication, care and discharge planning by restructuring consistent, patient‐centred multidisciplinary teams in a general medicine service. Methods: Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral‐based multidisciplinary models with existing staffing levels. Results: Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6‐month readmissions. In‐hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients’ ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed‐day savings. Conclusion: This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.     

Effect of a nurse team coordinator on outcomes for hospitalized medicine patients

PURPOSE: Several randomized trials have found that discharge planning improves outcomes for hospitalized patients. We do not know if adding a clinical nurse specialist (CNS) to physician teams in hospitals that already have discharge planning services makes a difference. METHODS: In 2 teaching hospitals, patients were randomly assigned to regular hospital care or care with a clinical nurse specialist. The clinical nurse specialist facilitated hospital care by retrieving preadmission information, arranging in-hospital consultations and investigations, organizing postdischarge follow-up visits, and checking up on patients postdischarge with a telephone call. In-hospital outcomes included mortality and length of stay. Postdischarge outcomes included time to readmission or death, patient satisfaction, and the risk of adverse event. Adverse events were poor outcomes due to medical care rather than the natural history of disease. RESULTS: A total of 620 sequential patients were randomized (CNS n = 307, control n = 313), of which 361 were followed after discharge from hospital (CNS n = 175, control n = 186). The groups were similar for the probability of in-hospital death (CNS 9.3% vs control 9.7%) or being discharged to the community (58.0% vs 60.0%). The groups did not differ for postdischarge outcomes including readmission or death (21.6% vs 15.6%; P = 0.16) or risk of adverse event (23.6% vs 22.8%). Mean [SD] patient ratings of overall quality of care on a scale of 10 was higher in the clinical nurse specialist group (8.2 [2.2] vs 7.6 [2.4]; P = 0.052). CONCLUSION: The addition of a clinical nurse specialist to a medical team improved patient satisfaction but did not impact hospital efficiency or patient safety.     

Surgical wound infections diagnosed after discharge from hospital: epidemiologic differences with in-hospital infections

Bacground: The purpose of this study was to study postoperative infections detected in hospital and after discharge and to identify risk factors for such infections.Methods: A prospective cohort study was used, with a follow-up of 30 days after hospital discharge, on 1483 patients admitted to the general surgery service of a tertiary care hospital. The main outcome measure was surgical wound infection (SWI). Relative risks, crude and multiple risk factors adjusted for by logistic regression analysis, and their 95% confidence intervals (CIs) were estimated.Results: During follow-up 155 patients showed evidence of nosocomial infection, 134 in hospital and 21 at home, yielding a cumulative incidence of 10.5%. According to several variables (age, American Society of Anesthesiologists score, serum albumin, the SENIC and National Nosocomial Infections Surveillance indexes of intrinsic patient risk, length of hospital stay, etc.) there were no differences between patients with postdischarge SWI and uninfected patients; however, differences were detected between postdischarge SWI and in-hospital SWI, as well as between patients with in-hospital SWI and patients without infections. The analysis of risk factors showed that most predictors for in-hospital SWI did not behave in the same manner for postdischarge SWI. Stepwise logistic regression analysis identified cancer (odds ratio = 4.5, 95% CI = 1.7 to 12.2, p = 0.003) and surgeon performing the operation (for medium risk OR = 4.4, 95% CI = 0.9 to 21.3, p = 0.059; for high risk, OR = 3.0, 95% CI = 0.7–13.3, p = 0.144) as independent risk factors for postdischarge SWI.Conclusions: There were important epidemiologic differences between in-hospital SWI and postdischarge SWI; most risk factors for in-hospital SWI are not predictors for postdischarge SWI.     

Validation of a clinical prediction rule for the differential diagnosis of acute meningitis

Objective: To attempt to validate a previously reported clinical prediction rule derived to assist in distinguishing between acute bacterial meningitis and acute viral meningitis. Design: Retrospective chart review of patients treated at five hospitals between 1981 and 1990. The criterion standard for bacterial meningitis was a positive cerebrospinal fluid (CSF) or blood culture or a positive test for bacterial antigen in the CSF. For viral meningitis, the criterion standard was a positive viral culture from CSF, stool, or blood or a discharge diagnosis of viral meningitis with no other etiology evident. Setting: Two Department of Veterans Affairs (VA) hospitals, two county hospitals, and one private hospital, each affiliated with one of two medical schools. Patients: All persons aged more than 17 years who were hospitalized over a ten-year period at one of five academically affiliated hospitals for the management of acute meningitis. Measurements and main results: Sixty-two cases of bacterial meningitis and 98 cases of viral meningitis were confirmed. With all patients included, the discriminatory power of the model as measured by the area under the receiver operating characteristic curve (AUC) was 0.977 (95% CI, 0.957–0.997), compared with the AUC of 0.97 in the derivation set of the original publication. The AUCs (95% CIs) for data subsets were: Dallas cases 0.994 (0.986–1.0), Milwaukee cases 0.912 (0.834–0.990); ages 18–39 years 0.952 (0.892–1.0), ages 40–59 years 0.99 (0.951–1.0), and age >60 years 0955 (0.898–1.0). Conclusions. The authors conclude that the clinical prediction rule proved robust when applied to a geographically distinct population comprised exclusively of adults. There was sustained performance of the model when applied to cases from each city and from three age strata. Prospective validation of this prediction rule will be necessary to confirm its utility in clinical practice. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29, 1992. Supported by an Institutional Research Grant under the Regents Appropriations program at UT/Southwestern Medical School.     

Characteristics of patients in a ward of Academic Internal Medicine: implications for medical care,training programmes and research

To describe the characteristics of “delayed discharge patients” and the factors associated with “delayed discharges”, we performed a 12-month observational study on patients classified as “delayed discharge patients” admitted to an Academic Internal Medicine ward. We assessed the demographic variables, the number and severity of diseases using the Geriatric Index of Comorbidity (GIC), the cognitive, affective and functional status using, respectively, the Mini Mental Stare Examination, the Geriatric Depression Scale and the Barthel Index. We assessed the total length of stay (T-LHS), the total inappropriate length of stay (T-ILHS), the median length of stays (M-LHS), the median inappropriate length of stay (M-ILHS) and evaluated the factors associated with delayed discharge. “Delayed discharge patients” were 11.9% of all patients. The mean age was 81.9 years, 74.0% were in the IV class of GIC and 33.5% were at the some time totally dependent and affected by severe or non-assessable cognitive impairments. The patients had 2584 T-LHS, of which 1058 (40.9%) were T-ILHS. Their M-LHS was 15 days, and the M-ILHS was 5 days. In general, the greater the LHS, the greater is the ILHS (Spearman’s rho + 0.68, P < 0.001). Using a multivariate analysis, only the absence of formal aids before hospitalisation is independently associated with delayed discharge (F = 4.39, P = 0.038). The majority of the delays (69%) resulted from the difficulty in finding beds in long-term hospital wards, but the longest M-ILHS (9 days) was found in patients waiting for the Geriatric Evaluation Unit. The profile of patients and the pattern of hospital utilisation suggest a need to reorient the health care system, and to develop appropriate resources for the academic functions of education, research and patient care.     

The relation between health status changes and patient satisfaction in older hospitalized medical patients

OBJECTIVE: To examine the relation between two patient outcome measures that can be used to assess the quality of hospital care: changes in health status between admission and discharge, and patient satisfaction. DESIGN: Prospective cohort study. SETTING AND PATIENTS: Subjects were 445 older medical patients (aged ≥70 years) hospitalized on the medical service of a teaching hospital. MEASUREMENTS AND MAIN RESULTS: We interviewed patients at admission and discharge to obtain two measures of health status: global health and independence in five activities of daily living (ADLs). At discharge, we also administered a 5-item patient satisfaction questionnaire. We assessed the relation between changes in health status and patient satisfaction in two sets of analyses, that controlled for either admission or discharge health status. When controlling for admission health status, changes in health status between admission and discharge were positively associated with patient satisfaction (p values ranging from .01 to .08). However, when controlling for discharge health status, changes in health status were no longer associated with patient satisfaction. For example, among patients independent in ADLs at discharge, mean satisfaction scores were similar regardless of whether patients were dependent at admission (i.e., had improved) or independent at admission (i.e., remained stable) (79.6 vs 81.2, p=.46). Among patients dependent in ADLs at discharge, mean satisfaction scores were similar regardless of whether they were dependent at admission (i.e., remained stable) or independent at admission (i.e., had worsened) (74.0 vs 75.7, p=.63). These findings were similar using the measure of global health and in multivariate analyses. CONCLUSIONS: Patients with similar discharge health status have similar satisfaction regardless of whether that discharge health status represents stable health, improvement, or a decline in health status. The previously described positive association between patient satisfaction and health status more likely represents a tendency of healthier patients to report greater satisfaction with health care, rather than a tendency of patients who improve following an interaction with the health system to report greater satisfaction. This suggests that changes in health status and patient satisfaction are measuring different domains of hospital outcomes and quality. Comprehensive efforts to measure the outcomes and quality of hospital care will need to consider both patient satisfaction and changes in health status during hospitalization. Supported in part by grants from the National Institute on Aging (AG-10418-04) and the John A. Hartford Foundation (88277-3G). Dr. Covinsky was supported in part by a clinical investigator award from the National Institute on Aging (1K08AG00714). Dr. Chren was supported in part by a clinical investigator award from the National Institute of Arthritis, Musculoskeletal and Skin Diseases (K08AR01962). Dr. Landefeld is a Senior Research Associate and Dr. Rosenthal is a Research Associate, Health Service Research and Development Service, Department of Veterans Affairs.     

“Fast-track” rehabilitation after rectal cancer resection

Background and aims: After rectal cancer surgery, postoperative general complications occur in 25–35% of all patients and postoperative hospital stay is 14–21 days. “Fast-track” rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Because the feasibility of “fast-track” rehabilitation in patients undergoing rectal cancer surgery has not been demonstrated yet, we demonstrate our initial results of “fast-track” rectal cancer surgery.Patients and methods: Seventy consecutive unselected patients undergoing rectal cancer resection by one surgeon underwent a perioperative “fast-track” rehabilitation. Demographic and operative data, pulmonary function, pain and fatigue, local and general complications and mortality were assessed prospectively.Results and findings: Thirty-six female and 34 male patients aged 65 (34–77) years underwent open (n=31) or laparoscopic (n=39) anterior resection with partial mesorectal excision (PME 27), anterior resection with total mesorectal excision and protective loop ileostomy (TME 29) or abdominoperineal excision with colostomy (APR 14). Overall, pulmonary function returned to >80% of preoperative value on day 2 (1–4) and the first bowel movement occurred on day 1 (0–3) after surgery. The incidence of local and general complications was 27 and 18%, respectively. Postoperative hospital stay was 8 (3–50) days overall, but shorter after PME [5 (3–47)] than TME [10 (5–42)] or APR [9 (5–50)] (p<0.01).Interpretation and conclusion: “Fast-track” rehabilitation was feasible in patients undergoing rectal cancer resection. Local morbidity was not increased, while general morbidity and postoperative hospital stay compared favourably to other series with “traditional” perioperative care.     

Hospital discharge risk score system for the assessment of clinical outcomes in patients with acute myocardial infarction (Korea Acute Myocardial Infarction Registry [KAMIR] score)

Assessment of risk at time of discharge could be a useful tool for guiding postdischarge management. The aim of this study was to develop a novel and simple assessment tool for better hospital discharge risk stratification. The study included 3,997 hospital-discharged patients with acute myocardial infarction who were enrolled in the nationwide prospective Korea Acute Myocardial Infarction Registry-1 (KAMIR-1) from November 2005 through December 2006. The new risk score system was tested in 1,461 hospital-discharged patients who were admitted from January 2007 through January 2008 (KAMIR-2). The new risk score system was compared to the Global Registry of Acute Coronary Events (GRACE) postdischarge risk model during a 12-month clinical follow-up. During 1-year follow-up, all-cause death occurred in 228 patients (5.7%) and 81 patients (5.5%) in the development and validation cohorts, respectively. The new risk score (KAMIR score) was constructed using 6 independent variables related to the primary end point using a multivariable Cox regression analysis: age, Killip class, serum creatinine, no in-hospital percutaneous coronary intervention, left ventricular ejection fraction, and admission glucose based on multivariate-adjusted risk relation. The KAMIR score demonstrated significant differences in its predictive accuracy for 1-year mortality compared to the GRACE score for the developmental and validation cohorts. In conclusion, the KAMIR score for patients with acute myocardial infarction is a simpler and better risk scoring system than the GRACE hospital discharge risk model in prediction of 1-year mortality.     

How age,outcome severity,and scale influence general medicine clinic patients’ interpretations of verbal probability terms

Objective: To assess whether the type of scale used (scaling effects) and the severity of outcome (outcome severity) influence patients’ numerical interpretations of verbal probability expressions. Design: Cross-sectional survey of patients in a general medicine clinic. Setting: A university-based Department of Veterans Affairs Medical Center. Participants: 210 patients seen consecutively in a general medicine clinic. Measurements and results: The patients were randomized to scale and health outcome (complications of surgery). Two scales (a long form and a short form ) were used to expressly allow patients to choose probabilities less than 1%. The long form had a lower bound of “<1 out of 1,000,000”; the short form had a lower bound of “<1 out of 1,000.” Two complications were used: “death from anesthesia” and “severe pneumonia.” In the context of being told that their surgeon believed that the chance the complication would occur was “rare,” patients were asked to give the numerical estimate of that chance. The values elicited on both scales were significantly different for the two outcomes, with the “rare” risk of death from anesthesia being characterized as less likely than the “rare” risk of severe pneumonia (F=5.24, p=0.023). Linear regression and three-factor analysis of variance showed significant differences in the probabilities elicited for scale, outcome, and age, with older patients generally responding with higher probabilities than did younger patients. Conclusions: These findings suggest that the severity of the associated outcome and the scale used to elicit patients’ numerical estimates of verbal probability expressions influence patients’ quantitative interpretations of the verbal probability statement; and older patients respond with higher probabilities of negative outcomes than do younger patients. Future studies must continue to explore whether verbal probability expressions are adequate for communicating medical risk to patients or whether patients should be provided with numerical estimates of frequency. Supported in part by the National Science Foundation under contract SES-9020984 with Carnegie Mellon University.     

Survival in acute obstructing colorectal carcinoma

Acute intestinal obstruction was the presenting feature in 124 (19 per cent) of 646 patients with colorectal carcinoma seen over a six-year period. Forty-two per cent of tumors were incurable at presentation. Obstruction was complicated by perforation in 22 patients (18 per cent). Only 15 per cent of tumors occurred in the rectum. Although the postoperative mortality rate was higher in patients with coincidental perforation than in those without (52 vs. 26 per cent:P=0.03), five-year survival rates were the same: 18 per cent overall, rising to 29 to 34 per cent after “curative” resection. Five-year survival rates were best for right colon tumors and worst for rectal tumors (36 vs. 5 per cent:P=0.01). The overall hospital mortality rates for colostomy and delayed resection, resection with colostomy, and resection with anastomosis were equivalent (18 to 22 per cent), but following “curative” resection the hospital mortality rate was higher for resection with colostomy than with other treatments (29 vs. 15 per cent), since two patients died following early colosure of colostomy. Five-year survival was better following resection with anastomosis (48 per cent) than staged procedures (18 per cent:P=0.01), since two patients died following late closure of colostomy.     

Potential Unintended Consequences Due to Medicare’s “No Pay for Errors Rule”? A Randomized Controlled Trial of an Educational Intervention with Internal Medicine Residents

BACKGROUND  

Medicare has selected 10 hospital-acquired conditions for which it will not reimburse hospitals unless the condition was documented as “present on admission.” This “no pay for errors” rule may have a profound effect on the clinical practice of physicians.     

Health outcomes of patients undergoing cardiac surgery: repeated measures using Short Form-36 and 15 Dimensions of Quality of Life questionnaire

OBJECTIVE: The study assessed health-related quality of life (HRQOL) of patients before and after cardiac surgery. DESIGN: This was a prospective repeated-measures observational study. SETTING: The study took place in a 650-bed tertiary referral hospital in Sydney, Australia. METHODS: HRQOL was measured using the Medical Outcomes Study Short Form 36-item health survey (SF-36) and the 15 Dimensions of Quality of Life questionnaire before surgery, at hospital discharge, and 6 months postdischarge. RESULTS: Participants were representative of the cardiac surgery population. Scores for several concepts deteriorated at hospital discharge when compared with presurgery. There were significant improvements in health status at 6 months postdischarge when compared with previous measures for the majority of SF-36 and 15 Dimensions of Quality of Life questionnaire concepts, although mental health and social functioning demonstrated significant deterioration. SF-36 scores were substantially lower than population norms, but similar to previous studies of patients undergoing cardiac surgery except for mental health. CONCLUSION: Deterioration in health status at hospital discharge when compared with presurgery status reinforces the need for further patient care and support after discharge. All dimensions improved after 6 months, except mental health. This information can guide patient expectations regarding rehabilitation posthospitalization, and cardiac surgical services should implement and evaluate formal "outreach programs" for these patients.     

Outcomes of “Inadequate” antidepressant treatment

OBJECTIVE: To examine outcomes of primary care patients receiving low levels of antidepressant treatment. DESIGN: Cohort study comparing patients receiving antidepressant treatment within and below the recommended dosing range. SETTING: Primary care clinics of a staff-model health maintenance organization. PATIENTS: Primary care patients initiating antidepressant treatment for depression. MEASUREMENTS AND MAIN RESULTS: Of 88 patients beginning antidepressant treatment, 49 (56%) used “adequate” doses for 30 days or more. Likelihood of “adequate” pharmacotherapy was not related to patient age, gender, medical comorbidity, or baseline depression severity. All the patients showed substantial clinical improvement after four months. Compared with those using “adequate” pharmacotherapy, the patients receiving low-intensity treatment had lower likelihood of clinical response (64% vs 84%; chi-square=4.44; df=1; p=0.035). At four months, however, those receiving low-intensity and those receiving higher-intensity treatment did not differ significantly in either the score on the 20-item Symptom Checklist depression scale (18.91 and 15.72, respectively; F=1.45; df=1, 86; p=0.23) or the proportion with persistence of major depression (10% and 4%, respectively; chi-square=1.30; df=1; p=0.25). A replication sample of 157 patients (assessed only at baseline and four months) yielded similar results. CONCLUSIONS: While the patients receiving recommended levels of pharmacotherapy showed somewhat higher improvement rates, many of the patients receiving “inadequate” treatment experienced good short-term outcomes. Efforts to increase the intensity of depression treatment in primary care should focus on the subgroup of patients who fail to respond to initial treatment. Supported by NIMH grants #MH41739 and #51338.     

Functional recovery of elderly patients hospitalized in geriatric and general medicine units. The PROgetto DImissioni in GEriatria Study

OBJECTIVES: To investigate the characteristics of patients who regain function during hospitalization and the differences in terms of functional outcomes between patients admitted to geriatric and general medicine units. DESIGN: Multicenter, prospective cohort study. SETTING: Acute care geriatric and medical wards of five Italian hospitals. PARTICIPANTS: One thousand forty‐eight elderly patients hospitalized for acute medical diseases. MEASUREMENTS: Functional status 2 weeks before hospital admission (baseline), at admission, and at discharge, as measured using the Barthel Index (BI). RESULTS: Geriatric patients were older (P<.001) and had lower preadmission functional levels (P<.001) than medical patients. Between baseline and discharge, 43.2% of geriatric and 18.9% of medical patients declined in physical function. In the subpopulation of 464 patients who had declined before hospitalization (between baseline and admission), 59% improved during hospitalization (45% of geriatric and 75% of medical patients), whereas only approximately 1% declined further. High baseline function (odds ratio (OR)=1.03, 95% confidence interval (CI)=1.02–1.04, per point of BI) and greater functional decline before hospitalization (OR 0.95, 95% CI 0.94–0.97, per % point of BI decline) were significant predictors of in‐hospital functional improvement; type of hospital ward and age were not. CONCLUSION: Although geriatric patients have overall worse functional outcomes, in‐hospital functional recovery may be frequent even in geriatric units, particularly in patients with greater preadmission functional loss and high baseline level of function.     

Utilization of hospital resources by alcoholic and nonalcoholic patients

Objective:To measure any difference in the utilization of hospital resources between alcoholic patients and nonalcoholic patients (controls) in a department of internal medicine. Design:Prospective comparative study. Alcoholics were identified as patients with Michigan Alcoholism Screening Test (MAST) scores of ≥8. Controls were defined as patients with MAST scores of ≤4, and matched with alcoholics for sex, age, and time of admission. The length of stay, as well as several indicators of utilization of diagnostic and therapeutic procedures, was used for the comparison of resource utilization. Setting:General wards of internal medicine of a 1,000-bed city and teaching hospital in Lausanne, Switzerland. Participants:One bundred and three alcoholic patients and 103 controls aged 20–75 years, admitted from September 1, 1988, to March 18, 1989. Results:Alcoholics had the same lengths of stay (16 days), durations of intravenous infusions (six days), and durations of bladder catheterization (one day). Statistically nonsignificant differences were found between alcoholics and nonalcoholics regarding the charges for routine laboratory examinations [693 vs. 734 Swiss francs (Sfrs)], antibiotic therapies (218 vs. 145 Sfrs), and x-ray procedures (568 vs. 774 Sfrs; p=0.06). The average number of electrocardiograms (two vs. five; p<0.005) and the duration of intensive care unit (ICU) stay (one vs. two days; p<0.05) were significantly lower for alcoholics than for controls. A total hospital charges index was also lower for alcoholics than for controls (11,900 Sfrs vs. 12,800 Sfrs), but not significantly. Conclusion:The authors’ results suggest that alcoholics do not use more hospital resources per admission than do nonalcoholics. Moreover, alcoholics tend to use less frequently some procedures, such as the ICU, electrocardiography, and x-ray examinations. Several hypotheses are developed to explain these results in relation to those of previous studies, which showed more use of medical care by alcoholics than by nonalcoholics. Support by a grant from the Swiss National Research Foundation (no 3200-009282) and by a grant from the “Fondation du 450^eme Anniversaire de l’Université de Lausanne.”     

Effects of a postdischarge clinic on housestaff satisfaction and utilization of hospital services

This randomized, controlled clinical trial evaluated the effect of a postdischarge clinic on housestaff education and patient utilization of hospital services. Medicine housestaff were randomized either to attend a clinic once a week in which they saw all eligible patients they had recently discharged from the hospital, or to continue with usual discharge practices. We enrolled 751 patients, 312 on intervention teams and 439 on control teams. Intervention housestaff did not feel that the clinic took too much time and felt that they better knew how patients did after discharge. Fewer intervention patients had emergency room visits (28.0% to 20.8%,p=.03) in the 30 days after discharge. Length of stay, readmission rates, and mortality were similar for the two groups. We conclude that a postdischarge clinic can improve resident education and reduce postdischarge emergency room utilization.