Geriatric medicine: the anatomy of change.

We have studied workloads and patterns of care in geriatric medicine from 1982 to 1993 in the Ulster Hospital. There was a 137% rise in admissions, a 16% reduction in domiciliary visits and a 31% increase in ward assessments. The continuing care waiting list fell to zero in 1993. The number of new outpatients rose by a factor of 8.6 between 1987 and 1993. Between 1990 and 1993 there was an increased admission rate from nursing homes and of patients suffering from respiratory system diseases. Mortality rates fell from 27.8% in 1982 to 19.3% in 1990 and to 12.1% in 1993. Mean age and sex ratios remained unchanged over the years while the average length of stay halved from 43.3 to 22.6 days between 1990 and 1993. 81% of admissions in 1993 were emergencies. Care of the elderly in hospital and the interface with general medicine are changing.     

Acute medical bed usage by nursing home residents.

An increasing number of elderly patients in nursing home care appears to be presenting to hospital for acute medical admission. A survey of acute hospital care was undertaken to establish accurately the number and character of such admissions. A total of 1300 acute medical beds was surveyed in Northern Ireland in June 1996 and January 1997 on a single day using a standardised proforma. Demographic details, diagnosis and length of admission were recorded. A total of 84 patients over the age of 65 (mean 79.5 years) admitted from nursing home care was identified in June 1996 and a total of 125 (mean 83.3 years) in January 1997. A total of 88 (70%) of admissions in 1997 were accompanied by a general practitioner's letter. The assessing doctor judged that 12 (9.6%) of admissions in 1997 could have had investigations and or treatment reasonably instituted in a nursing home. The proportion of acute medical beds occupied by nursing home residents was 6% in June 1996 rising to 10% in January 1997. The study accurately identifies the significant contribution of nursing home patients to acute medical admissions and the low proportion in whom admission was unnecessary. Closure of long stay hospital facilities should be accompanied by investment in community medical services and also reinvestment in acute hospital care for elderly people.     

The epidemiology and natural history of pressure ulcers in elderly nursing home residents

We analyzed prospective data from 19,889 elderly residents of 51 nursing homes from 1984 to 1985 to determine the prevalence, incidence, and natural history of pressure ulcers. Among all residents admitted to nursing homes, 11.3% possessed a stage II through stage IV pressure ulcer. For those residents admitted to the nursing home without pressure ulcers during the study period, the 1-year incidence was 13.2%. This increased to 21.6% by 2 years of nursing home stay. People already residing in a nursing home at the start of the study had a 1-year incidence of 9.5%, which increased to 20.4% by 2 years. Pressure ulcers were associated with an increased rate of mortality, but not hospitalization. Longitudinal follow-up of residents with pressure ulcers demonstrated that a majority of their lesions were healed by 1 year. Most of the improvement occurred early in a person's nursing home stay. Although nursing home residents with pressure ulcers have a higher mortality, with good medical care pressure ulcers can be expected to heal.     

Mortality from bleeding peptic ulcer. Alfred Hospital, Melbourne, 1976-1980

Of 682 patients (755 admissions) who were admitted to hospital with bleeding peptic ulcers or erosive gastritis-duodenitis during a five-year period, 92 died (12% of admissions). In 70% of admissions to hospital, the patients were aged 50 years or older. The overall mortality rates were 13% in patients with bleeding gastric ulcers; 12% in those with duodenal ulcers; and 11% in those with gastritis-duodenitis. Fourteen per cent of patients with bleeding gastric ulcers, 21% of those with duodenal ulcers, and 4% of those with erosive gastritis-duodenitis had undergone surgery. Ten of 92 deaths (11%) occurred after the operation; of these, only one patient who died was aged less than 50 years. The postoperative mortality rates were 8% in patients with bleeding gastric ulcers, and 12% in those with duodenal ulcers; there were no deaths after operation for gastritis-duodenitis. Whereas the 13% overall mortality rate in patients with bleeding gastric ulcers closely resembled that found in other series, the 12% overall mortality rate in patients with bleeding duodenal ulcers was about twice that reported in recent British and Australian series.     

Outcomes for dialysis patients with end-stage renal failure admitted to an intensive care unit or high dependency unit

OBJECTIVE: To assess the outcomes for chronic dialysis patients requiring admission to an intensive care unit (ICU) or high dependency unit (HDU). DESIGN: Retrospective audit of prospectively collected data from local and national databases. SETTING: The ICU and HDU at a tertiary referral hospital. PARTICIPANTS: 70 chronic dialysis patients admitted between 2001 and 2006. MAIN OUTCOME MEASURES: Unit and hospital mortality, recurrent admission patterns and median survival after discharge from hospital. RESULTS: For patients' last admissions, mortality in the ICU or HDU was 17% and in hospital was 29%. The 12 deaths in the ICU or HDU occurred a median of 18 hours (range, 3-203 hours) after admission, reflecting the severity of their underlying illness. The independent predictors of death in hospital were age and the number of non-renal organ systems failing. Patients with pulmonary oedema had a lower risk of death than patients admitted for other reasons. Although 21 patients accounted for 55 of 104 admissions (53%), recurrent admissions to the ICU or HDU generally occurred during different hospital admissions. They were not associated with a higher risk of death in hospital. Patients discharged home had a median survival of 2.25 years, and a median survival of 3.5 years from starting dialysis. The median survival for patients on dialysis in Australia in general is 4.5 years (Australia and New Zealand Dialysis and Transplant Registry). CONCLUSION: Dialysis patients discharged home after an ICU or HDU admission have survival similar to that of Australian dialysis patients generally.     

Medical admission into the intensive care unit (ICU) of the Lagos University Teaching Hospital

The paper presents patterns of medical admissions into the intensive care unit of the Lagos University Teaching Hospital (LUTH) over an eight-year period from September 1990 to August 1998. Medical admission constituted 15% out of which 1% received surgery for medical complications. Patients with neurological diseases recorded the highest number of admission most of them being for tetanus. The commonest indication for admission was for respiratory insufficiency (33%). All the patients admitted for sub arachnoid haemorrhage, fulminant hepatitis, meningitis and motor neurone disease died. The least mortality was found amongst patients admitted for tetanus who constituted about 44% of the total number of medical admissions. The overall mortality rate was 69% and it was observed that the ages of the patients did not appear to affect the outcome except in patients who were admitted for myocardial infarction and cardiogenic shock. This study emphasizes the need to evolve a system of health evaluation of predicting the survival index of individual patients. There is an urgent need for proper training, motivation of staff and maintenance of equipment used in the ICU.     

Mortality in the elderly during respite hospital care.

This study examined the mortality in the elderly during 243 respite hospital admissions. Sixty-four dependent elderly patients entered a regular respite care scheme and were admitted to hospital for a period of 4 weeks out of every 12 weeks. The mortality rate in hospital was one death per 976 days, in comparison to one death per 1296 days at home. This small increase in mortality should not deprive patients and their carers from access to respite care.     

Comparing outcomes of care before and after implementation of the DRG-based prospective payment system

We compared patient outcomes before and after the introduction of the diagnosis related groups (DRG)-based prospective payment system (PPS) in a nationally representative sample of 14,012 Medicare patients hospitalized in 1981 through 1982 and 1985 through 1986 with one of five diseases. For the five diseases combined; length of stay dropped 24% and in-hospital mortality declined from 16.1% to 12.6% after the PPS was introduced (P less than .05). Thirty-day mortality adjusted for sickness at admission was 1.1% lower than before (16.5% pre-PPS, 15.4% post-PPS; P less than .05), and 180-day adjusted mortality was essentially unchanged at 29.6% pre-vs 29.0% post-PPS (P less than .05). For patients admitted to the hospital from home, 4% more patients were not discharged home post-PPS than pre-PPS (P less than .05), and an additional 1% of patients had prolonged nursing home stays (P less than .05). The introduction of the PPS was not associated with a worsening of outcome for hospitalized Medicare patients. However, because our post-PPS data are from 1985 and 1986, we recommend that clinical monitoring be maintained to ensure that changes in prospective payment do not negatively affect patient outcome.     

Estimating prognosis for nursing home residents with advanced dementia

Context  Survival varies for patients with advanced dementia, and accurate prognostic tools have not been developed. A small proportion of patients admitted to hospice have dementia, in part because of the difficulty in predicting survival. Objectives  To identify factors associated with 6-month mortality in newly admitted nursing home residents with advanced dementia and to create a practical risk score to predict 6-month mortality in this population. Design, Setting, and Participants  This was a retrospective cohort study of data from the Minimum Data Set (MDS). All Medicare or Medicaid licensed nursing homes in New York and Michigan were included. Participants had advanced dementia and were admitted to New York nursing homes between June 1, 1994, and December 30, 1998 (derivation cohort, n = 6799), and to Michigan nursing homes from October 1, 1998, through July 30, 2000 (validation cohort, n = 4631). Main Outcome Measures  MDS factors associated with 6-month mortality were determined in the derivation group, and the resulting mortality risk score was evaluated in the validation cohort. Risk score performance was compared with the cut point of 7c on the Functional Assessment Staging (FAST) scale. Results  Among residents with advanced dementia, 28.3% (n = 1922) died within 6 months of nursing home admission in the derivation cohort; 35.1% (n = 1626) died in the validation cohort. The 6-month mortality rate increased across risk scores (possible range, 0-19): 0 points, 8.9% mortality; 1 to 2, 10.8%; 3 to 5, 23.2%; 6 to 8, 40.4%; 9 to 11, 57.0%; and at least 12, 70.0% in the validation cohort. The area under the receiver operating characteristic (AUROC) curve for predicting 6-month mortality was 0.74 and 0.70 in the derivation and validation cohorts, respectively. Our risk score demonstrated better discrimination to predict 6-month mortality (AUROC, 0.64 for a cutoff of =" BORDER="0">6 points vs 0.51 for FAST stage 7c). Conclusion  A risk score based on 12 variables from the MDS estimates 6-month mortality for nursing home residents with advanced dementia with greater accuracy than existing prognostic guidelines.      

Physical and pharmacologic restraint of nursing home patients with dementia. Impact of specialized units

This case-control study of 31 specialized dementia units and 32 traditional units in five states investigated use of physical and pharmacologic restraints among 625 patients with the diagnosis of dementia. Physical restraints were observed in use on 18.1% of dementia unit patients and on 51.6% of comparison unit patients who were out of bed during the day (adjusted odds ratio, 0.283;95% confidence interval, 0.129 to 0.619). Pharmacologic restraints were routinely given to 45.3% of dementia unit patients and 43.4% of comparison unit patients (adjusted odds ratio, 0.950; 95% confidence interval, 0.611 to 1.477). We used multivariate logistic regression to identify residence in a nonspecialized nursing home unit, nonambulatory status, transfer dependency, mental status impairment, hip fracture history, and a high nursing staff-to-patient ratio, which we found to be independent predictors of physical restraint use. Physically abusive behavior, severe mental status impairment, and frequent family visitation were found to be significant predictors of pharmacologic restraint use, while advanced patient age, large nursing home size, and patient nonambulatory status were protective against such use. These results support the conclusion that physical and pharmacologic restraint constitute separate treatment modalities with different risk factors for use, and indicate that specialized dementia units are successful in reducing the use of physical but not pharmacologic restraints.     

Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes

CONTEXT: Infections caused by ceftazidime sodium-resistant gram-negative bacteria that harbor extended-spectrum beta-lactamases (ESBLs) are increasing in frequency in hospitals in the United States. OBJECTIVES: To report a citywide nursing home-centered outbreak of infections caused by ESBL-producing gram-negative bacilli and to describe the clinical and molecular epidemiology of the outbreak. DESIGN: Hospital-based case-control study and a nursing home point-prevalence survey. Molecular epidemiological techniques were applied to resistant strains. SETTINGS: A 400-bed tertiary care hospital and a community nursing home. PATIENTS: Patients who were infected and/or colonized with ceftazidime-resistant Escherichia coli, Klebsiella pneumoniae, or both and controls who were admitted from nursing homes between November 1990 and July 1992. MAIN OUTCOME MEASURES: Clinical and epidemiological factors associated with colonization or infection by ceftazidime-resistant E coli or K pneumoniae; molecular genetic characteristics of plasmid-mediated ceftazidime resistance. RESULTS: Between November 1990 and October 1992, 55 hospital patients infected or colonized with ceftazidime-resistant E coli, K pneumoniae, or both were identified. Of the 35 admitted from 8 nursing homes, 31 harbored the resistant strain on admission. All strains were resistant to ceftazidime, gentamicin, and tobramycin; 96% were resistant to trimethoprim-sulfamethoxazole and 41% to ciprofloxacin hydrochloride. In a case-control study, 24 nursing home patients colonized with resistant strains on hospital admission were compared with 16 nursing home patients who were not colonized on hospital admission; independent risk factors for colonization included poor functional level, presence of a gastrostomy tube or decubitus ulcers, and prior receipt of ciprofloxacin and/or trimethoprim-sulfamethoxazole. In a nursing home point-prevalence survey, 18 of 39 patients were colonized with ceftazidime-resistant E coli; prior receipt of ciprofloxacin or trimethoprim-sulfamethoxazole and presence of a gastrostomy tube were independent predictors of resistance. Plasmid studies on isolates from 20 hospital and nursing home patients revealed that 17 had a common 54-kilobase plasmid, which conferred ceftazidime resistance via the ESBL TEM-10, and mediated resistance to trimethoprim-sulfamethoxazole, gentamicin, and tobramycin; all 20 isolates harbored this ESBL. Molecular fingerprinting showed 7 different strain types of resistant K pneumoniae and E coli distributed among the nursing homes. CONCLUSIONS: Nursing home patients may be an important reservoir of ESBL-containing multiple antibiotic-resistant E coli and K pneumoniae. Widespread dissemination of a predominant antibiotic resistance plasmid has occurred. Use of broad-spectrum oral antibiotics and probably poor infection control practices may facilitate spread of this plasmid-mediated resistance. Nursing homes should monitor and control antibiotic use and regularly survey antibiotic resistance patterns among pathogens.     

Changing patterns of hip fracture care before and after implementation of the prospective payment system

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated.     

Patient outcomes and length of stay in a stroke unit offering both acute and rehabilitation services

OBJECTIVES: To compare hospital length of stay (LOS) and outcome after stroke between patients in a stroke unit offering combined acute and rehabilitation services and patients treated elsewhere in New South Wales. DESIGN: Retrospective audit of two hospital databases (Diagnosis-Related Groups [DRG] database and Australian National Subacute Non-Acute Patient Classification System [AN-SNAP] database), with comparison with DRG and AN-SNAP data for NSW. SETTING AND PARTICIPANTS: 242 episodes of acute stroke in patients admitted to the stroke unit of a metropolitan teaching hospital between July 1999 and November 2000, 113 of whom also underwent rehabilitation in the unit; 9777 episodes of acute stroke in the NSW DRG database, and 2350 in the NSW AN-SNAP database. MAIN OUTCOME MEASURES: Acute and rehabilitation LOS; mortality in acute care; FIM (Functional Independence Measure) score at discharge and change in FIM score; and discharge destination. RESULTS: Patients in the combined stroke unit had shorter LOS and better functional outcome in all DRG and AN-SNAP groups, with both higher discharge FIM scores and greater gain in FIM scores than NSW patients. Acute stroke mortality of 12% and nursing home admission rate of 15.5% in the combined stroke unit were not significantly different from rates for NSW (15.7% and 11.2%, respectively). CONCLUSIONS: Combining acute and rehabilitation services in a stroke unit may reduce LOS and improve functional outcome of patients with acute stroke.     

Surgical audit under scrutiny

Surgical audit must be shown to improve clinical practice and patient outcome if its widespread introduction is to be enthusiastically embraced by surgeons. Retrospective studies on hospital activity by their nature are often incomplete and unreliable. A 12-month prospective review (July 1990-June 1991) of the activity, morbidity and mortality that occurred within a district general surgical unit is analysed. During the study period, 3,927 patients were admitted to the unit, of whom 1,649 were elective and 2,278 (58%) were emergency cases. 48 patients (1.2%) were transferred to external specialist centres. 41 % of the admissions did not require surgery. There were 2,335 in-patient and 765 out-patient operations performed. Using the BUPA classification (n=3100), there were 388 major (12.5%), 802 intermediate (25.9%) and 1910 minor (61.6%) procedures. There were 15 perioperative and 38 nonoperative (27 metastatic carcinoma) deaths. 80% of the perioperative deaths were high risk, elderly patients with acute abdominal pathology. 369 complications (39 in non-operative cases) were recorded among both in-and out-patients: 212 systemic, 133 local/wound and 24 major/life threatening. The perioperative mortality rate was 0.6%. The operative morbidity rate was 9.0% and the procedure-related morbidity 4.7 %. The wound infection rate was 2%. In a non-specialist, general surgical unit with a broad case mix, it is possible to provide a standard of care and practice that produces very low mortality and an acceptable morbidity rate.     

Surgery in the elderly: is age a risk factor?

This prospective, observational one-year study analyzed 623 patients who were 60 years and older, out of a cohort of 2375 patients who were admitted consecutively to the general surgery wards of the University Hospital of the West Indies (UHWI). Even though only 9.7% of the Jamaican population are 60 years and older, this age group accounted for 26.2% of total admissions. Comparison of elderly and non-elderly patients showed no differences in gender, but less elderly patients were emergency admissions (52% vs 64%, p < 0.001), more underwent surgery (68% vs 60%, p < 0.001), their mean hospital stay was longer (11.5 vs 8.0 days, p < 0.001) and their mortality rate was higher (8.8% vs 1.9%, p < 0.001). Emergency admissions (52%) exceeded elective admissions in the elderly. Forty-four (80%) of the 55 deaths in the elderly group were admitted as emergencies compared to elective admissions (p < 0.001). There were 11 deaths among the 296 elective admissions (3.7%) but 44 deaths among the 327 emergency admissions (13.5%), a significant difference in mortality rates (p < 0.001). Overall, the death rate for males was higher. Cancer was the commonest admission diagnosis (21%) and that amongst mortalities. Steps to improve the opportunities for earlier admission and optimization of care of elderly surgical patients would not only benefit them but would be an important step towards a more efficient use of already scarce resources.     

预见性护理应用于院前急救有机磷农药中毒的探讨

目的:观察预见性护理在院前急救有机磷农药中毒患者的应用效果.方法:选择2009年2月至2011年7月我科接诊的重症有机磷农药中毒患者100例,按照随机数字表达法分为对照组和试验组各50例,对照组院前及入院后接受传统的急救护理,试验组院前及到院后采取预见性护理措施,比较两组患者的护理效果.结果:试验组患者的抢救成功率明显高于对照组(P＜0.05),试验组患者死亡率及并发症明显低于对照组(P＜0.05).结论:对院前重症有机磷农药中毒患者实施预见性护理有助于提高抢救成功率、降低死亡率及并发症,改善患者的预后.     

提供照料者支持对老年痴呆患者护理质量的影响

[目的]探讨提供照料者支持对老年痴呆病人护理质量的影响。[方法]以浙江省中医院干部科2008年1月至2010年12月收治的154例老年痴呆患者及其照料者为对象,其中2008年12月前未提供照料者支持的53例为对照组,2009年1月起提供照料者支持的101例为试验组,比较两组患者生理病理参数差异和住院期间意外事件发生率、患者家属满意度。[结果]两组患者生理病理参数差异无统计学意义(P0.05),试验组患者意外事件发生率低于对照组(P0.05),患者家属满意度高于对照组(P0.05)。[结论]提供照料者支持是提高老年痴呆患者护理质量的有效途径。     

Comparison of asthmatic patients admitted to hospital from health districts experiencing high and low asthma mortality rates.

Geographical variation in asthma mortality rates within the United Kingdom could be a reflection of variability in effectiveness of medical care services, or epidemiological variation. In order to ascertain whether differing hospital admission processes could contribute to this variation, asthmatic patients admitted from two districts, experiencing above and below average mortality rates were compared. The present study was part of a cohort study of 1,200 consecutive acute adult admissions in 1987/88. In the main study, social data and information on referral were collected by interview for all patients. The admitting doctors'' perception of the patient''s severity was assessed on the basis of the severity of symptoms, and likelihood of morbidity or mortality if the patient was not admitted. Further information on asthmatic patients (treatment and physiological measurements) was retrieved from the notes. Sixty-six asthmatic patients resident in Wandsworth (a district with high asthma mortality rates) were admitted to St George''s Hospital or St James'' Hospital (WW) and 31 patients resident in East Surrey (ES) (a district with low asthma mortality rates) were admitted to the East Surrey Hospital (ESH). Notes were obtained on 55 (83%) and 27 (87%) of patients in the two districts, respectively. WW received significantly more patients by self-referral: 68% of patients called an ambulance or came directly to casualty compared with 30% in ES (chi-squared = 13.7, d.f. = 2, P = < 0.001). There was a tendency for more admissions to ESH to be taking oral steroids (chi-squared = 3.2, d.f. = 1, P = 0.07). Patients admitted in WW tended to have more severe disease: 39 (85%) of patients admitted to WW had peak expiratory flow less than 200 1/minute on admission compared to 14 (58%) in ES (chi-squared = 6, d.f. = 1, P = 0.01). In WW the mean first recorded peak expiratory flow on admission was 154 1/minute compared to 172 1/minute in ES; their mean peak flow on discharge was 318 1/minute compared with 377 1/minute in ES. Twenty-one (38%) of admissions in WW were considered to be very urgent by the admitting hospital doctor compared to four (15%) in ESH (chi-squared = 4.67, d.f. = 1, P = 0.03). This opportunistic study found that, in an area experiencing high mortality rates, more patients with severe disease were admitted to hospital compared to a low mortality area. This does not appear to be due to differing hospital practices but rather to increased levels of morbidity in the community. As patients with more severe asthma are at a greater risk of dying, these finding reinforce the need to standardize asthma treatment in the community.     

痴呆患者激越行为的调查研究

目的 研究痴呆患者激越行为的发生情况。方法 用问卷法调查72例居家和65例老人院痴呆患者。结果 两组痴呆患者激越行为发生率分别为86．1％和90．8％，主要表现为反复问问题、骂人、不恰当地处理物品、藏东西、徘徊等；其中不恰当地处理物品、身体攻击及徘徊的发生率老人院痴呆患者与居家痴呆患者间差异有显著性意义，而居家痴呆患者藏东西的发生率与老人院痴呆患者问差异有显著性意义；某些激越行为在中重度痴呆患者更多见，还与日常生活能力受损明显相关。结论 激越行为在痴呆患者中普遍存在，表现多样，可结合不同场所、不同程度痴呆患者激越行为的特点进行相应的护理干预，从而有针对性地降低其发生率。     

Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes

CONTEXT: Hip fracture is a common clinical problem that leads to considerable mortality and disability. A need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fracture. OBJECTIVES: To identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care. DESIGN: Prospective study with data obtained from medical records and through structured interviews with patients and proxies. SETTING AND PARTICIPANTS: A total of 571 adults aged 50 years or older with hip fracture who were admitted to 4 New York, NY, metropolitan hospitals between August 1997 and August 1998. MAIN OUTCOME MEASURES: In-hospital and 6-month mortality; locomotion at 6 months; and adverse outcomes at 6 months, defined as death or needing assistance to ambulate, compared by hospital, adjusting for patient risk factors. RESULTS: The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P =.02 for both) but were not significantly associated with mortality. Adjustment for baseline characteristics either substantially augmented or diminished interhospital differences in outcomes. Two hospitals had 1 outcome (functional status or mortality) that was significantly worse than the overall mean while the other outcome was nonsignificantly better than average. CONCLUSIONS: Mortality and functional status ideally should be considered both together and individually to distinguish effects limited to one or the other outcome. Hospital performance for these 2 measures may differ substantially after adjustment, probably because different processes of care are important to each outcome.