Relationship between hospital length of stay and quality of care in patients with congestive heart failure

Objective: To determine the relationship between hospital length of stay (LOS) and quality of care in patients admitted for congestive heart failure (CHF).

Methods: This observational study was conducted in the medical wards of the Geneva University Hospitals, Geneva, Switzerland. A random sample of 371 patients was drawn from the 1084 patients discharged alive with a principal diagnosis of CHF between January 1997 and December 1998. Explicit criteria grouped into three scores were used to assess the quality of processes of care: admission work-up (admission score); evaluation and treatment during the stay (treatment score); and readiness for discharge (discharge score). The association between LOS and quality of care was analysed using linear regression with adjustment for clinical characteristics.

Results: The mean proportion of criteria met were 80% for the admission score, 66% for the treatment score, and 76% for the discharge score. Mean (SD) LOS was 13.2 (8.8) days. The admission score was not associated with LOS, but the treatment score increased by 0.5% (95% CI 0.3 to 0.7; p<0.001) with each additional day in hospital and the discharge score increased by 2.5% (95% CI 1.6 to 3.3; p<0.001) per day from admission to day 10 but remained unchanged thereafter. Adjustment for potential confounders did not substantially modify these relationships.

Conclusions: In patients with CHF there is a significant association between LOS and the quality of the treatment provided, as well as with readiness for discharge. Appropriate reorganisation of processes of care should accompany attempts at reducing LOS to avoid detrimental effects on quality of care.

     

A comparison of cigarette smokers recruited through the Internet or by mail.

OBJECTIVES: To compare smokers recruited by mail or through the Internet. METHODS: A questionnaire was mailed to 19,352 inhabitants of Switzerland in 1998, in an effort to enroll them in a smoking cessation trial. The same questionnaire was also available on the Internet. Furthermore, we mailed a survey to a representative sample (n = 1000) of the population of Geneva, Switzerland, in 1996. In this study, we compare three groups: 1027 smokers recruited through the Internet, 2961 volunteer trial participants recruited by mail (response rate 16%), and 211 smokers in the representative sample also recruited by mail (response rate 75%). RESULTS: Smokers self-recruited through the Internet were younger, more educated, more motivated to quit smoking and smoked more cigarettes per day than smokers in the other samples. Compared to trial participants, Internet participants had more negative attitudes towards smoking, higher self-efficacy scores, and were more addicted to tobacco. The strength of associations between smoking-related variables was similar in Internet and trial participants. CONCLUSION: As expected, the three groups of smokers differed on several characteristics. However, bias in distributions of variables did not imply bias in associations between variables. Thus, Internet recruitment is a potentially useful method for analytical studies that focus on associations between variables.     

Guidelines in establishing telerehabilitation services for people with vision impairment

Telerehabilitation is a viable option to provide continuum of rehabilitation intervention in situations like the ongoing pandemic. Presently, there is no policy guidelines to the minimum standard of telerehabilitation. This paper describes procedures for telerehabilitation for people with blindness and low vision from the evidence-based practices from a premier eye institute in South India. The suggested guidelines can help develop and replicate similar models of telerehabilitation to reach people in need in difficult situations like COVID 19 pandemic.     

Quality of life on chronic dialysis: comparison between haemodialysis and peritoneal dialysis.

BACKGROUND: Quality of life (QOL) assessment in patients on chronic haemodialysis (HD) or peritoneal dialysis (PD) has only rarely been carried out with the generic Euroqol-5D questionnaire. METHODS: All chronic HD and PD patients in the 19 centres of western Switzerland were requested to fill in the validated Euroqol-5D generic QOL questionnaire, assessing health status in five dimensions and on a visual analogue scale, allowing computation of a predicted QOL value, to be compared with the value measured on the visual analogue scale. RESULTS: Of the 558 questionnaires distributed to chronic HD patients, 455 were returned (response rate 82%). Fifty of 64 PD patients (78%) returned the questionnaire. The two groups were similar in age, gender and duration of dialysis treatment. Mean QOL was rated at 60+/-18% for HD and 61+/-19% for PD, for a mean predicted QOL value of 62+/-30 and 58+/-32% respectively. Results of the five dimensions were similar in both groups, except for a greater restriction in usual activities for PD patients (P = 0.007). The highest scores were recorded for self-care, with 71% HD and 74% PD patients reporting no limitation, and the lowest scores for usual activities, with 14% HD and 23% PD patients reporting severe limitation. Experiencing pain/discomfort (for HD and PD) or anxiety/depression (for PD) had the highest impact on QOL. CONCLUSIONS: QOL was equally diminished in HD and PD patients. The questionnaire was well accepted and performed well. Improvement could be achievable in both groups if pain/discomfort and anxiety/depression could be more effectively treated.     

Gender differences in the psychological determinants of cigarette smoking

Aims To compare the distributions of smoking‐related variables and the size of associations between these variables in men and women. Design and participants Mail survey in 2934 daily smokers (1533 women and 1401 men) who volunteered for a smoking cessation trial. Follow‐up after 7 months in 2456 people (84%). Setting Community setting (French‐speaking part of Switzerland, 1998). Findings Women smoked less than men (18 versus 22 cigarettes per day, p < 0.001), had lower confidence in their ability to refrain from smoking, used more frequently the strategy defined as ‘coping with the temptation to smoke’ and reported more drawbacks of smoking (gender differences ranged between 0.1 and 0.3 standard deviation units on these scales). There was no gender difference in the distribution of smokers by stage of change. At follow‐up, smoking cessation rates were similar in men and women (6% versus 5%, p = 0.3). Intention to quit, quit attempts in the previous year and a more frequent use of self‐change strategies predicted smoking cessation and were associated with tobacco dependence in both sexes. A more frequent use by women of coping strategies suggests that some women are ‘self‐restrained’ smokers who control their smoking permanently. This could explain lower smoking rates in women. The size of associations between smoking‐related variables was similar in men and women. Conclusions Even though there were gender differences in the distributions of some smoking‐related variables, associations between these variables were similar in men and women. This suggests that smoking behaviour is regulated by similar psychological mechanisms in men and women.     

Self-reported management of pain in hospitalized patients: link between process and outcome

PURPOSE: Hospitalized patients commonly experience pain. We investigated the association between patients' reported use of recommended pain management practices and overall pain relief. METHODS: All adult patients discharged during a 1-month period from a Swiss teaching hospital were invited to complete a mailed survey that included the Picker patient experience questionnaire, questions on pain relief during hospitalization, and questions on various procedures that are recommended as standards of pain management. RESULTS: Of 2156 eligible patients, 1518 (70%) participated. Sixty-nine percent (n = 1050) had experienced pain during their hospital stay, of whom 71% (n = 697/978) reported complete pain relief. After adjustment for sex, age, general health, and hospital department, pain relief was associated independently with availability of physicians (odds ratio [OR] = 11; 95% confidence interval [CI]: 3.3 to 36 for excellent vs. poor availability), having received information about pain and its management (OR = 2.8; 95% CI: 1.8 to 4.2), regular pain assessment (OR = 1.8; 95% CI: 1.2 to 2.8), modification of pain treatment when ineffective (OR = 3.0; 95% CI: 1.6 to 5.6), and waiting less than 10 minutes for pain medications (OR = 3.5; 95% CI: 1.9 to 6.6). CONCLUSION: Patient reports that recommended pain management procedures had been used were associated with better self-reported pain relief among hospitalized patients.     

Effectiveness of a computer-tailored smoking cessation program: a randomized trial.

BACKGROUND: From a public health perspective, prevention of cancer and cardiovascular diseases requires effective smoking cessation programs that can be used on a large scale. OBJECTIVE: To test the effectiveness of a new computer-tailored smoking cessation program vs no intervention. METHODS: Randomized controlled trial, in the French-speaking part of Switzerland, September 20, 1998, to December 31, 1999. Potential participants were randomly selected from a general population register and recruited by mail. Daily cigarette smokers who wished to participate (N = 2934) were randomized to either the program or no intervention. A mean of 1.5 times per 6 months, participants in the active arm received by mail a computer-tailored counseling letter based on their answers to a questionnaire and stage-matched booklets. The counseling letters were tailored to the participants' stage of change (categorized as precontemplation [no intention of quitting smoking in the next 6 months], contemplation [seriously considers quitting in the next 6 months], or preparation [has decided to quit in the next 30 days]), level of tobacco dependence, self-efficacy, and personal characteristics. The outcome measure was self-reported abstinence (no puff of tobacco smoke in the past 4 weeks) 7 months after entry into the program. RESULTS: Abstinence was 2.6 times greater in the intervention group than in the control group (5.8% vs 2.2%, P<.001). The program was effective in "precontemplators" who were not motivated to quit smoking at baseline (intervention vs control, 3.8% vs 0.8%; P =.001) and was effective regardless of perceived difficulty in quitting smoking at baseline. CONCLUSIONS: The program was effective in increasing smoking cessation rates. Because it can reach a large number of smokers, this program can substantially contribute to disease prevention at a population level.     

The treatment of malignant histiocytosis

Twenty-four consecutive cases of malignant histiocytosis (MH) treated at Stanford Medical Center between 1973 and 1983 have been reviewed. Most patients presented with systemic symptoms (91%) and advanced disease (stage IV, 80%). Multiple organ involvement was common. In six cases, pathologic tissue was further characterized by frozen section immune histochemistry, using a panel of monoclonal antibodies known to react with monocytes and macrophages, as well as a variety of hematopoietic cells. One case expressed a mature monocyte/macrophage phenotype; three cases were considered null cell or primitive lesions; and two cases were identified as probable T cell lymphomas. Seven patients underwent splenectomy. Two patients died prior to any treatment. Twenty-two patients were treated with CHOP (cyclophosphamide, Adriamycin, vincristine, prednisone) +/- bleomycin (B), +/- midcycle high-dose methotrexate (HD-MTX) with leucovorin rescue. Seven patients received prophylactic intrathecal MTX. Of 22 evaluable patients, there was a 68% complete response rate (CR), a 23% partial response rate (PR), and a 9% no response rate (NR). Median duration of CR was 30+ months; median duration of PR was 2.4 months. Median survival for patients attaining a CR has not been reached v 3 months for the PR and NR groups. For all 24 patients, median survival was 2 years, with a 5-year actuarial survival of 40%. Multivariate analysis revealed that a platelet count less than 150,000 (P Cox = .005) and the dose of drug delivered (P Cox = .057) were the most important prognostic factors. Prophylactic intrathecal MTX therapy and splenectomy did not influence survival. Although MH is an aggressive disease with a poor prognosis, it is potentially curable. Systematic and aggressive treatment should further improve the outcome.