Bernard S. Linn

CUMULATIVE ILLNESS RATING SCALE

Abstract: A Cumulative Illness Rating Scale, designed to meet the need for a brief, comprehensive and reliable instrument for assessing physical impairment, has been developed and tested. The scale format provides for 13 relatively independent areas grouped under body systems. Ratings are made on a 5‐point “degree of severity” scale, ranging from “none” to “extremely severe.” Findings, in terms of reliability and validity, reflect statistical significance at the P < .01 level. As a rapid assessment technique which is objective and easily quantified, the scale is well suited to a variety of research uses.

Effects of counseling for late stage cancer patients

Much has been written about working with the dying. Few, if any, controlled studies have examined the application of principles set forth. The authors evaluate the effectiveness of working with dying cancer patients by assessing changes in quality of life, physical functioning, and survival. One‐hundred twenty men with end‐stage cancer were randomly assigned to experimental or control groups; the 62 experimental group patients were seen regularly by a counselor. Patients were assessed before random assignment and at one, three, six, nine, and 12 months on quality of life and functional status. Experimental group patients improved significantly more than the control group on quality of life within three months. Functional status and survival did not differ between groups. A subsample of lung cancer patients provided cross‐validation of findings. Although survival was not expected to differ, it was predicted that functioning would be enhanced if quality of life improved. One interpretation is that little can be done to alter physical function and survival when intervention occurs late in the progression of a fatal disease. This in no way reduces the value of improving overall quality of life, since enhancing the quality of survival for end‐stage cancer patients is a high priority medical goal.

The rapid disability rating scale-2.

A revised version of the Rapid Disability Rating Scale (RDRS‐2) is presented. Item definitions have been sharpened and directions expanded to indicate that ratings are based upon the patients performance in regard to behavior, and that prostheses normally used by the patient should be included in the assessment. Three items have been added to increase the breadth of the scale. Response items have been changed from three‐point to four‐point ratings in order to increase group discrimination and make the scale more sensitive to changes in treatment. The new appraisals of reliability, factor structure, and validity are reported, along with the potential uses of the scale.

Objective and self-assessed health in the old and very old.

Abstract There is increasing support for the concept that persons who live into extreme old age are biologically elite. In this study, self-health assessments and eight objective health indices were studied in 286 elderly living in the community. Self-health was measured on a 5-point scale ranging from very poor to excellent. Objective health measures included impairment and disability rating; number of physician visits, days in bed, and days hospitalized for the prior six months; diagnoses; medications; and operations. The sample was divided by good (70%) and poor (30%) self-health assessments and by old (age 65–74, 66%) and very old (75 and over, 34%). The objective health measures were compared between these groups in a multivariate analysis of variance. Number of medications was less and surgical operations more for the very old than old. All but two of the eight objective measures of health (surgery and days in bed) differentiated significantly between self-assessed health groups. It therefore seems that age, by itself, is a poor indicator of health among the elderly; however, how the elderly view their own health may be an extremely useful clinical guide as to their overall health status.

Satisfaction with ambulatory care and compliance in older patients.

Predictors of satisfaction with ambulatory care and compliance in 267 older and 581 younger patients were determined. Each patient rated a 45-item satisfaction-with-care-scale. Race, SES, marital status, distance from clinic, severity of illness (as measured by physician ratings, self-health assessment, number of medications, number of diagnoses, and number of clinic visits and hospitalizations in the prior year), and physician expectations of improvement were entered as predictors into stepwise multiple regression analyses for the elderly and the young. Predictors of better satisfaction in the young were less severe conditions, being nearer to the clinic and having fewer prior clinic visits over the year. In the elderly, having fewer visits to the clinic, more expectation of improvement by the physician and less severe conditions were associated with better satisfaction. Severity and clinic visits were predictors in each age group. The young, however, were also influenced by distance from the clinic. The elderly were influenced separately by the physicians prognosis. Thus, when the more impaired elderly are seen frequently without expecting a benefit, their satisfaction with care is poor. Further, satisfaction with care was correlated significantly with compliance in the elderly but not in the young. Findings suggest that improving satisfaction with care might also improve rates of compliance with the medical regimen in older patients.

Evaluation of results of surgical procedures in the elderly.

Authorities are not in full agreement in regard to risk of surgery in the elderly. One hundred eight studies of surgery in the elderly over the past 40 years were reviewed. The purpose was not merely to tabulate results, but to identify differences existing between reports with regard to data reported that could affect results independent of the surgical management itself. Sources of variance that need to be taken into account in comparing mortality rates between studies, such as whether mortality was computed by number of patients or operations, differing lengths of follow-up for recording mortality, proportions of emergency versus elective operations, and types of surgical procedures, were documented. A nine-item confidence in results scale was used to classify studies into high and low confidence groups. Surgical specialties scored substantially higher than general surgical studies. More recent studies received higher scores than earlier studies. Although mortality rates varied widely depending on methods of their calculation, there appeared to be a trend toward increases in elective, but not emergency, mortality rates in general surgery since 1941 that should be examined more closely. One thing that cannot be answered clearly from these studies is the relative risk of surgery with age. Some control of variations between studies and standardization of reporting surgical deaths are required before risk of surgery in the elderly can be assessed more accurately.

Effects of psychophysical stress on surgical outcome.

&NA; The aim was to determine the effects of stress on immune status and surgical outcome in 24 healthy men undergoing hernia repair. Stressful life events over the prior 6 mo and social support was assessed at time of admission. Physiological response to a cold pressor test was measured the day before surgery. Lymphocyte blastogenesis and neutrophil chemotaxis were measured before and 3 and 30 days after surgery in patients and controls. Surgical outcomes were assessed by length of stay, narcotics used, and complications. Data were analyzed in 2 x 2 factorial designs for multivariate analysis of covariance where one factor was life stress and the other was response to the cold pressor. Age and social support were covaried in comparing immune responses before surgery. High responders to life stress had significantly less response to PHA, and high responders to cold pressor stress had lower PWM responses. With preoperative immune status covaried, high responders to cold pressor stress had significantly lower PWM response after surgery, indicating some T‐B cell interaction defect and more narcotics and complications. Data suggest that high psychological and physiological stress responses before surgery (that is itself an additional psychophysiologic stressor) lead to poorer outcomes even in otherwise healthy men undergoing relatively simple elective surgical procedures.

Performance rating scale for peer and self assessment1

A performance rating scale was developed and tested on a class of junior medical students who rated themselves and four to ten of their peers. When 928 ratings were factor analysed, two strong factors, knowledge and relationship, emerged. Test-retest reliabilities were good. Validity was measured by correlation of ratings with grades, and though both sources of ratings correlated significantly with grades given by faculty, peer ratings were more highly related to grades than were self ratings. Students tended to rate themselves lower than they were rated by their peers. Grades are probably not the best estimate of performance, but are currently one of the most reliable. Use of the scale to judge performance of physicians in practice has not been tested. The question of how such evaluation of peer and self would relate to other measures of quality of care is raised.

Stressful Events, Dysphoric Mood, and Immune Responsiveness

This study measured depressive symptoms in 98 men of whom 49 had and 49 had not had a recent experience of family death or serious family illness. The relationships of depression and occurrence of the stressful event to immune function was explored. Persons with higher scores on depression in both groups showed less responsiveness of their lymphocytes to phytohemagglutinin and to allogeneic cells. Data indicate that not all persons react the same way to stressful events and that those with high and low depressive features can be differentiated by their immune responses.

Does surgery attract students who are more resistant to stress

This article examines perceptions of stress and career choice. One hundred sixty-nine junior students specified what they thought were the two most and two least stressful careers, as well as their own career preferences before and after a 12-week surgical clerkship. The class was divided for analysis into three groups: those who selected careers that they said were A) most stressful (42%), B) least stressful (10%), and C) neither most nor least stressful (48%). Surgery was cited as one of the two most stressful choices by 99% of the class before and 93% after the clerkship. The next most stressful career was internal medicine, cited by 43% before and 35% after the clerkship. The two least stressful careers were dermatology and radiology, cited by approximately 50% of the class before and after the clerkship. Those who chose careers that they said were most stressful had significantly higher self-esteem (p less than 0.05), experienced less unfavorable stress themselves as measured by a 31-item stress scale before and after the clerkship (p less than 0.01), and experienced more favorable (in their view) stress (p less than 0.05) than did the other two groups. Reanalysis of data comparing those who selected surgery with those who did not confirmed findings similar to that of the matched high-stress career group. The study suggests that some students may be able to tolerate stress better and in fact, tend to thrive in an environment that they perceive as stressful, and that such students are more likely to go into a surgical career, which they foresee as one of the most stressful that they can enter.