https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(04)17670-8.pdf

External validity of randomised controlled trials: “To whom do the results of this trial apply?”

OBJECTIVES: To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function.

DESIGN: Prospective observational study.

SETTING: The general medical service of two hospitals.

PARTICIPANTS: Two thousand two hundred ninety-three patients aged 70 and older (mean age 80, 64% women, 24% nonwhite).

MEASUREMENTS: At the time of hospital admission, patients or their surrogates were interviewed about their independence in five ADLs (bathing, dressing, eating, transferring, and toileting) 2 weeks before admission (baseline) and at admission. Subjects were interviewed about ADL function at discharge. Outcome measures included functional decline between baseline and discharge and functional changes between baseline and admission and between admission and discharge.

RESULTS: Thirty-five percent of patients declined in ADL function between baseline and discharge. This included the 23% of patients who declined between baseline and admission and failed to recover to baseline function between admission and discharge and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Twenty percent of patients declined between baseline and admission but recovered to baseline function between admission and discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23%, 28%, 38%, 50%, and 63% in patients aged 70–74, 75–79, 80–84, 85–89, and ≥90, respectively, P < .001). After adjustment for potential confounders, age was not associated with ADL decline before hospitalization (odds ratio (OR) for patients aged ≥90 compared with patients aged 70–74 = 1.26, 95% confidence interval (CI) = 0.88–1.82). In contrast, age was associated with the failure to recover ADL function during hospitalization in patients who declined before admission (OR for patients aged ≥90 compared with patients aged 70–74 = 2.09, 95% CI = 1.20–3.65) and with new losses of ADL function during hospitalization in patients who did not decline before admission (OR for patients aged ≥90 compared with patients aged 70–74 = 3.43, 95% CI = 1.92–6.12).

CONCLUSION: Many hospitalized older people are discharged with ADL function that is worse than their baseline function. The oldest patients are at particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization

Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age.

ContextBetter health care quality is a universal goal, yet measuring quality
has proven to be difficult and problematic. A central problem has been isolating
physician practices from other effects of the health care system.ObjectiveTo validate clinical vignettes as a method for measuring the competence
of physicians and the quality of their actual practice.DesignProspective trial conducted in 1997 comparing 3 methods for measuring
the quality of care for 4 common outpatient conditions: (1) structured reports
by standardized patients (SPs), trained actors who presented unannounced to
physicians' clinics (the gold standard); (2) abstraction of medical records
for those same visits; and (3) physicians' responses to clinical vignettes
that exactly corresponded to the SPs' presentations.SettingOutpatient primary care clinics at 2 Veterans Affairs medical centers.ParticipantsNinety-eight (97%) of 101 general internal medicine staff physicians,
faculty, and second- and third-year residents consented to be randomized for
the study. From this group, 10 physicians at each site were randomly selected
for inclusion.Main Outcome MeasuresA total of 160 quality scores (8 cases × 20 physicians) were generated
for each method using identical explicit criteria based on national guidelines
and local expert panels. Scores were defined as the percentage of process
criteria correctly met and were compared among the 3 methods.ResultsThe quality of care, as measured by all 3 methods, ranged from 76.2%
(SPs) to 71.0% (vignettes) to 65.6% (chart abstraction). Measuring quality
using vignettes consistently produced scores closer to the gold standard of
SP scores than using chart abstraction. This pattern was robust when the scores
were disaggregated by the 4 conditions (P<.001
to <.05), by case complexity (P<.001), by site
(P<.001), and by level of physician training (P values from <.001 to <.05). The pattern persisted,
although less dominantly, when we assessed the component domains of the clinical
encounter—history, physical examination, diagnosis, and treatment. Vignettes
were responsive to expected directions of variation in quality between sites
and levels of training. The vignette responses did not appear to be sensitive
to physicians' having seen an SP presenting with the same case.ConclusionsOur data indicate that quality of health care can be measured in an
outpatient setting by using clinical vignettes. Vignettes appear to be a valid
and comprehensive method that directly focuses on the process of care provided
in actual clinical practice. Vignettes show promise as an inexpensive case-mix
adjusted method for measuring the quality of care provided by a group of physicians.

https://jamanetwork.com/journals/jama/articlepdf/192552/joc91362.pdf

Comparison of vignettes, standardized patients, and chart abstraction: A Prospective validation study of 3 methods for measuring quality

http://www.hematology.fi/sites/default/files/hemorrhages-score.pdf

Clinical classification schemes for predicting hemorrhage: Results from the National Registry of Atrial Fibrillation (NRAF)

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)03425-9.pdf

Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome

OBJECTIVE: To determine the opinions of selected physicians in our community about use of warfarin for patients with nonrheumatic atrial fibrillation, and to determine the relation of the physicians’ opinions to their practices.

Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation?

OBJECTIVE: To determine how often warfarin was prescribed to patients with nonrheumatic atrial fibrillation in our community in 1992 when randomized trials had demonstrated that warfarin could prevent stroke with little increase in the rate of hemorrhage, and to determine whether warfarin was prescribed less frequently to older patients—the patients at highest risk of stroke but of most concern to physicians in terms of the safety of warfarin. DESIGN: Cross-sectional study. Appropriateness of warfarin was classified for each patient based on the independent judgments of three physicians applying relevant evidence and guidelines. SETTING: Two teaching hospitals and five community-based practices. PATIENTS: Consecutive patients with nonrheumatic atrial fibrillation (n=189). MEASUREMENTS AND MAIN RESULTS: Warfarin was prescribed to 44 (23%) of the 189 patients. Warfarin was judged appropriate in 98 patients (52%), of whom 36 (37%) were prescribed warfarin. Warfarin was prescribed to 11 (14%) of 76 patients aged 75 years or older with hypertension, diabetes mellitus, or past stroke, the group at highest risk of stroke. In a multivariable logistic regression model controlling for appropriateness of warfarin and other patient characteristics, patients aged 75 years or older were less likely than younger patients to be treated with warfarin (odds ratio 0.25; 95% confidence interval 0.10, 0.65). CONCLUSIONS: Warfarin was prescribed infrequently to these patients with nonrheumatic atrial fibrillation, especially the older patients and even the patients for whom warfarin was judged appropriate. These findings indicate a substantialopportunity to prevent stroke.

Meghal R. Antani

Papers

Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation?

Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation

An index of symptoms for infection with human immunodeficiency virus: reliability and validity.