Showing papers by "Regenstrief Institute published in 1994"

Patient Outcomes Following Tricompartmental Total Knee Replacement: A Meta-analysis

Abstract: Objective. —To provide estimates of patient outcomes following tricompartmental knee replacement and to examine variation in outcomes due to patient and prosthesis characteristics. Data Sources. —English-language articles identified through a computerized literature search and bibliography review. Study Selection. —Studies were included if they enrolled 10 or more patients at the time of initial knee replacement and measured patient outcomes using a global knee-rating scale. Data Extraction. —Each study was subjected to a blinded qualitative assessment and unblinded abstraction of patient characteristics, surgical techniques, and outcomes. Data Synthesis. —A total of 130 studies reporting patient outcomes on 154 cohorts satisfied inclusion criteria. The total number of enrolled patients was 9879 with a mean enrollment of 64.1 patients. The mean follow-up was 4.1 years. The mean patient age was 65.0 years, 71.7% of patients were women, 62.6% had osteoarthritis, and 26.6% underwent bilateral knee replacement. Global rating scale scores improved by 100% for the typical enrolled patient, and 89.3% of patients reported good or excellent outcomes. Anatomic classification of the prosthesis, percentage of enrolled patients with osteoarthritis, publication year, and number of enrolled patients explained 27% of the variation in reported mean postoperative global rating scale scores. The weighted mean complication rate was 18.1%, and the mean mortality rate per year of follow-up was 1.5%. The overall rate of revision during 4.1 years was 3.8%. Conclusions. —Tricompartmental knee replacement was a safe and effective procedure for the patients reported in these studies. The knee pathology and the type of prosthesis were significant predictors of outcomes. Limitations in the reporting style of these articles severely constrain the ability to explore variation in outcomes due to study, patient, or prosthesis characteristics and restrict their generalizability. (JAMA. 1994;271:1349-1357)

Improving treatment of late life depression in primary care: a randomized clinical trial.

Abstract: The purpose of this study is to facilitate primary health care physicians' compliance with recommended standards of care for late life depression by reducing barriers to recognition and treatment.

Longitudinal Study of Depression and Health Services Use Among Elderly Primary Care Patients

Abstract: The objective of this study was to describe the prevalence and 9-month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use.

Hospital resource consumption among older adults: a prospective analysis of episodes, length of stay, and charges over a seven-year period.

Abstract: After linking their administrative records and interview data, the consumption of Medicare-reimbursed hospital resources during 1984 through 1990 by the 7,527 LSOA respondents was prospectively assessed using a two-part design. First, logistic regression was used to model whether a hospital episode occurred. Second, among those having had hospital episodes, OLS regression was used to model the number of episodes, as well as the natural logarithms of the total length of stay and the total charges. The risk of hospitalization was mostly associated with being male, prior hospital and physician utilization, and lower body limitations. Among those hospitalized: (a) greater numbers of episodes were mostly associated with prior hospital and physician utilization, and poorer perceived health; (b) longer lengths of stay were mostly associated with prior hospital and physician utilization, and poorer perceived health; and, (c) higher charges were mostly associated with population density, poorer perceived health, and prior physician and hospital utilization. Decedents consistently consumed substantially more hospital resources than survivors.

A Case Manager Intervention to Reduce Readmissions

Abstract: Background: Acute hospitalizations represent substantial financial liability to closed health care systems. Among hospitalized patients, those with repeated admissions are high-cost users. Most managed care plans employ case management to control hospital use. This technique attempts to detect and fulfill unmet medical and social needs, intensify postdischarge care, identify and mobilize effective community services, and enhance primary care access. Despite the popularity of case management to control hospital use, few trials have examined its efficacy. Methods: We conducted a randomized controlled trial of an intervention of case managers at a university-affiliated Veterans Affairs medical center. Six hundred sixty-eight patients aged 45 years or older who were discharged from the general medicine inpatient service, who had access to a telephone, and who received primary care at the hospital's clinics were randomized to the intervention (N=333) and control (N=335) groups. Within 24 hours of discharge, case managers mailed educational materials and access information to intervention patients, and within 5 days they called to review and resolve unmet needs, early warning signs, barriers to keeping appointments, and any readmissions. Case managers contacted intervention patients if they made no visits for 30 days. This resulted in a total of 6260 patient—case manager contacts. Control and intervention patients were followed up for 12 months. Results: Intervention patients had more frequent visits per patient per month to the general medicine clinic (0.30±0.23 vs 0.26±0.22, P =.008), but we detected no significant differences between groups in nonelective readmissions, readmission days, or total readmissions. Conclusions: Frequent contacts for education, care, and accessibility by case managers using protocols were ineffective in reducing nonelective readmissions. (Arch Intern Med. 1994;154:1721-1729)

The risk of hip fracture among noninstitutionalized older adults.

Abstract: The risk of hip fracture among the 7,527 respondents to the Longitudinal Study on Aging (LSOA) is prospectively modeled using logistic regression techniques. Based on existing studies, a seven-stage hierarchical model serially introduces ecological, demographic, and social factors as well as general health status before considering symptoms and diseases conductive to hip fracture, falling history and body mass, and previous hip fracture. Interaction terms involving age and White women are then introduced to explore novel hypothesis. Of the LSOA respondents, 368 (4.9%) experienced hip fracture between 1984 and 1991. Significant risks of hip fracture were associated with age, female gender, White race, being hospitalized (for any cause) in the year prior to baseline, having fallen at least once in the year prior to baseline, and leaner body mass. The risk associated with increasing age diminishes over the life course. Similarly, the protective effect of body mass diminishes over the life course. Finally, previous ecological findings are clarified by identifying an elevated risk for White women living in the rural South. Language: en

Global rating systems used in assessing knee arthroplasty outcomes.

Abstract: Global, aggregated knee rating systems are commonly used to assess patient outcomes following knee arthroplasty. In this study, the authors performed a systematic literature search and found that 17% of the English-language studies addressing primary knee arthroplasty reported on patient outcomes following the procedure using a standardized global rating system. The authors describe, in detail, the rating systems' development and format. This study found 34 different rating systems represented in the literature from 1972 to 1992. Great variability was found in the rating systems' design and utilization. Additionally, these condition-specific, physician-based rating systems did not have documented studies demonstrating their reliability or validity. Future research will need to address the issues of selecting and aggregating outcome measures and of deriving any necessary weighting schemes. The ability of researchers to compare patient outcomes across studies will be enhanced when there is consistency in reported outcome measures.

Tricompartmental knee replacement: A comparison of orthopaedic surgeons' self reported performance rates with surgical indications, contraindications, and expected outcomes

Abstract: The chance of a person with osteoarthritis of the knee receiving a knee replacement is highly variable. To understand better the reasons for this variation, all practicing orthopaedists in Indiana were surveyed about their management of severe knee osteoarthritis and their perception of tricompartmental knee replacement as a therapeutic option. Their perceptions of indications and outcomes of knee replacement were compared with the self reported annual number of patients for whom they performed (or referred to other surgeons for) tricompartmental knee replacements. A completed survey was returned by 220 (79%) of the 280 orthopaedists surveyed; analyses were limited to the 188 respondents who had cared for at least one patient with osteoarthritis of the knee in the prior 2 weeks (mean = 13). These surgeons reported performing (or referring patients for) a mean of 31 knee replacements in the prior year (SD 45, median 21, range 0–480 knee replacements). There was strong agreement (>95%) among respondents for seven (21%) of 33 surgical indications and contraindications, and more general agreement (>60%) for 21 (64%). In the live factors (15%) for which there was disagreement, there was no consistent relationship between opinions and self reported knee replacement performance rate. Surgeons reporting more knee replacements had significantly higher estimates of pain relief and functional improvement following surgery, and lower esti-

Depression in late life: the use of clinical characteristics to focus screening efforts.

Abstract: Background The objective of the study was to identify clinical characteristics associated with depressive symptoms in late life so that screening could focus on elderly patients most likely to benefit from further evaluation. Methods We used cross-sectional screening for significant symptoms of depression using the Center for Epidemiologic Studies Depression scale and identification of patients' clinical characteristics from patient interviews and a computerized medical record. The setting was an academic primary care group practice at an urban ambulatory care center. Participants were 1,633 consecutively consenting patients aged 60 and older who visited the center between January and August 1991. Mean age was 70 years; 72% were women, 32% were White, 47% had less than 8 years of education, and 7% had no health insurance. Results There were 251 (15%) patients with significant symptoms of depression. Antidepressants were prescribed to 1 in 7 patients with such symptoms, with amitriptyline being the most commonly prescribed. Bivariate analyses indicated that patients with significant symptoms of depression were more likely to be White, female, without health insurance, and were more likely to have probable alcoholism, mild cognitive loss, and to receive narcotics, histamine H2 antagonists, and/or benzodiazepines. Depressive symptoms were not significantly correlated with age, education, income, or chronic medical conditions. Conclusions Significant symptoms of depression were common and correlated with several readily available clinical variables. However, these variables lack sufficient discriminatory power to allow for the selective screening of elderly patients most likely to suffer from symptoms of depression. Thus, formal screening for depression among all elderly patients in primary care may be necessary to improve the recognition of this morbid illness.

Fertility in Adolescent Women Previously Treated for Genitourinary Chlamydial Infection

Abstract: Study Objective: To obtain follow-up pregnancy data on adolescent women in order to examine the effectiveness of anti-chlamydial therapy in the prevention of early infertility. Design: A longitudinal follow-up of adolescent women originally enrolled in a study of prevalence and recurrence of genital chlamydial infection. Setting: Public health adolescent clinics in Marion County (Indianapolis), Indiana. Participants: Sexually active female patients between 11 and 20 years old receiving gynecological care between October 1985 and February 1990. Interventions: None. Main Outcome Measures: Pregnancy during the follow-up period was ascertained using self-report during a telephone survey and/or the computerized record system of the county hospital. Rates were compared among the women separated into three groups: more than one documented chlamydial infection, a single infection, and no documented infection. Results: Using both data sources, the lowest proportion of women who became pregnant during the follow-up period was observed in the single infection group (34.9%, p = 0.029), but the other two groups were similar (multiple infections 54.2%, no documented infection 51.0%). Among women who were contacted by phone, the overall proportion was higher (68.3%) and did not differ by group even after adjustment for sexual activity and condom use. Conclusions: These data do not show an association between a history of treated genitourinary chlamydial infection and infertility. The frequent monitoring and treatment featured in the original study may have affected this.

Deciphering the physician note.

Abstract: Objective information about legibility of physician handwriting is scant. This retrospective chart review compared handwritten general medicine clinic chart notes from internal medicine faculty and housestaff with their typed counterparts. The written counterparts took 11 seconds (46%) longer to read and 5 seconds (11%) longer to answer comprehension questions. The authors' comprehension measure (developed specifically for ambulatory clinic notes) was only slightly higher for typed notes. The legibility of physician handwriting is not as dismal as assumed; physicians can effectively communicate on paper.