Problems for clinical judgement: 4. Surviving in the report card era

HEALTH CARE REPORT CARDS INVOLVE COMPARISONS of health care systems, hospitals or clinicians on performance measures. They are going to be an important feature of medical care in Canada in the new millennium as patients demand more information about their medical care. Although many clinicians are aware of this growing trend, they may not be prepared for all of its implications. In this article, we provide some historical background on health care report cards and describe a number of strategies to help clinicians survive and thrive in the report card era. We offer a number of tips ranging from knowing your outcomes first to proactively getting involved in developing report cards.     

急性有机磷农药中毒120例的救治

0　引言　近年来 ,我科在救治急性有机磷农药 (organophos-phorus,OP)中毒方面 ,积累了一些经验 ,现报告如下 .1　对象和方法1 .1　对象　本组 1 2 0例符合《急诊急救学》中的诊断标准 [1 ](男 2 9例 ,女 91例 ) ,年龄 1 .5～ 70岁 ,平均 2 8.6岁 .经口中毒 99例 ,经皮肤中毒 2 1例 .轻度中毒 1 5例 ,中度中毒 42例 ,重度 (含极重度 )中毒 6 3例 . 1 996年 39例 ,1 997年 43例 ,1 998年 38例 . DDV 79例 ,乐果 2 0例 ,混合性中毒 1 0例 ,水胺磷 3例 ,氧化乐果、 391 1、 1 0 5 9、对硫磷各 2例 ,敌百虫 1例 ,药名不详 1 0例 .服毒量 >2 5 …     

Neuropsychological prediction of decline to dementia in nondemented elderly

This study examined whether baseline neuropsychological performance in elderly assessed at a research clinic could accurately predict subsequent decline to dementia. Logistic regression analyses were applied to (1) 213 nondemented elderly with a Global Deterioration Scale (GDS) score of 1, 2, or 3, of whom 74 (35%) subsequently declined to any diagnosis of dementia, and (2) a diagnostically more restricted subset of this sample (N = 179), of whom 56 (31%) declined to a diagnosis of probable Alzheimer's disease (AD). The mean follow-up intervals were 3.8 and 3.7 years, respectively. A small set of baseline neuropsychological measures (especially a Paragraph Delayed Recall Test) significantly differentiated decliners from nondecliners to dementia or AD, after accounting for the contribution of age, sex, education, follow-up interval, and the rating of global clinical status. When examined in combination with the other factors or alone, the cognitive tests produced reasonably high specificities (91%-97%) and sensitivities (73%-89%). Using the obtained regression model, a similar level of classification accuracy was replicated on an independent sample of 119 nondemented elderly. A subanalysis of the high-risk GDS 3 subgroup indicated that cut scores from the paragraph test distinguished nondecliners from decliners (overall accuracies 87%-91%), implying that this assessment may accurately predict future cognitive status in elderly with mild cognitive impairment.     

Age and sex differences in the management of ischaemic heart disease

Objective

To investigate age and sex differences in the utilisation of hospital services for ischaemic heart disease.

Design

Analysis of routine mortality data and hospital activity data.

Setting

South West Thames Regional Health Authority.

Subjects

Residents of the South West Thames Regional Health Authority who in 1991 either died from ischaemic heart disease or were admitted to an NHS hospital in England and Wales with a main diagnosis of ischaemic heart disease.

Main outcome measures

Ratio of consultant episodes to deaths from ischaemic heart disease (as a proxymeasure of the utilisation of hospital care), and the percentages of consultant episodes in which further investigation (angiography or catheterisation) or revascularisation treatment (coronary artery bypass grafting or angioplasty) were carried out.

Results

The ratio of episodes to deaths was similar in men and women (odds ratio for men vs. women 0.96, 95% confidence intervals 0.90 to 1.03). The percentage of episodes in which further investigation was carried out was higher in men than women (odds ratio for men vs. women 1.46, 95% confidence intervals 1.25 to 1.70) as was the percentage of episodes in which revascularisation treatment was carried out (odds ratio for men vs. women 1.46, 95% confidence intervals 1.20 to 1.77). The ratio of episodes to deaths, the percentage of episodes in which further investigation was carried out, and the percentage of episodes in which revascularisation treatment was carried out all declined with age (all p values <0.001).

Conclusions

Women with ischaemic heart disease are as likely as men to be admitted to hospital, but afteradmission are less likely to undergo further investigation and revascularisation treatment. Elderly patients with ischaemic heart disease are less likely than younger patients to be admitted to hospital; after admission, they are also less likely to undergo further investigation and revascularisation treatment. Further research is needed to determine whether these age and sex differences in the use of hospital services are clinically justified.     

Congenital pulmonary atresia with ventricular septal defect: angiographic and surgical correlates

Of 181 patients with severe congenital pulmonary atresia and ventricular septal defect or "type IV truncus" (an obsolete term), all but 11% had true central pulmonary arteries. These arteries were demonstrable by large serial biplane angiograms using multiple selective injections into collateral vessels, frequent photographic subtraction, and occasional pulmonary vein-wedge angiograms. These techniques are extremely important for accurate diagnosis and in planning corrective or palliative surgery, which was done in 77% of patients with pulmonary arteries.     

A phase II study of carboplatin and paclitaxel in esophageal cancer.

BACKGROUND: This study was conducted to evaluate the efficacy and toxicity of combination carboplatin and paclitaxel in patients with esophageal cancer. MATERIALS AND METHODS: Thirty-five patients were enrolled. Patients were treated with paclitaxel 200 mg/m(2) intravenously (i.v.) over 3 h and carboplatin i.v. at an AUC of 5 mg/h/ml. Thirty-three patients were assessable for toxicity and objective response. RESULTS: A total of 166 treatment courses were administered with a median of five courses per patient. The objective response rate was 43% [90% confidence interval (CI) 0.3-0.58] by the intention-to-treat analysis. The median response duration was 2.8 months (90% CI 2.1-5.4). The median survival time was 9 months (90% CI 7-13.8) and the 1-year survival rate was 43% (90% CI 0.29-0.57). The major grade 3-4 toxicity observed was neutropenia, occurring in 17 patients (52%). There were no treatment-related deaths. CONCLUSIONS: The combination of carboplatin and paclitaxel is an moderately active and tolerable regimen in advanced esophageal cancer.     

Biobehavioral factors are associated with obesity in Puerto Rican children

The purpose of this case-control study was to identify predictors of obesity among Puerto Rican children from Hartford, CT. The study included 53 prepubertal children, 31 girls and 22 boys, between 7 and 10 y of age. Children were classified as obese [n = 29, body mass index (BMI) >/= 85th percentile] or controls (n = 24, BMI < 85th percentile). Multivariate logistic regression analyses indicated that frequency of fruit juice consumption [odds ratio (OR), 95% confidence interval (CI); 4.02, 1.48-10.95], hours of daily TV viewing (1.86, 1.02-3.42), maternal BMI (1.39, 1.10-1.77) and lower dairy product intake (0.41, 0.19-0.93) were associated with obesity. Television viewing was correlated (P < 0.05) with lower physical activity in girls, and with higher snacking frequency and sweets consumption in boys. Obese children were more likely than controls to have higher systolic and diastolic blood pressures and to have experienced more ear infections and diarrhea during the previous year. Results provide evidence of the multifactorial nature of childhood obesity in this community.     

The patient-physician relationship. Ensuring competency in end-of-life care: communication and relational skills

Physician competence in end-of-life care requires skill in communication, decision making, and building relationships, yet these skills were not taught to the majority of physicians during their training. This article presents a 7-step approach for physicians for structuring communication regarding care at the end of life. Physicians should prepare for discussions by confirming medical facts and establishing an appropriate environment; establish what the patient (and family) knows by using open-ended questions; determine how information is to be handled at the beginning of the patient-physician relationship; deliver the information in a sensitive but straightforward manner; respond to emotions of the patients, parents, and families; establish goals for care and treatment priorities when possible; and establish an overall plan. These 7 steps can be used in situations such as breaking bad news, setting treatment goals, advance care planning, withholding or withdrawing therapy, making decisions in sudden life-threatening illness, resolving conflict around medical futility, responding to a request for physician-assisted suicide, and guiding patients and families through the last hours of living and early stages after death. Effective application as part of core end-of-life care competencies is likely to improve patients' and families' experiences of care. It may also enhance physicians' professional fulfillment from satisfactory relationships with their patients and patients' families.      

New‐Concept Part‐Time Employment as a Work‐Family Adaptive Strategy for Women Professionals with Small Children*

This study investigates how the option for new‐concept part‐time (NPT) employment influences the ability of mothers of preschool children working in professional occupations to successfully integrate work and family responsibilities. Female NPT professionals (n = 279) and female full‐time (FT) professionals (n = 250) were compared. The NPT group reported 20 fewer weekly work hours and about $18,000 less estimated annual household income than the FT group. They allocated this additional time primarily to caring for and nurturing their dependent children. They also reported less job‐related travel, unnecessary work, and work‐to‐family conflict, as well as greater work‐family success, childcare satisfaction, and family success. However, NPT mothers reported a more traditional division of labor in household responsibilities and less career opportunity and work success. Implications are presented and discussed.