Gregory F. Petroski

Causes of higher in-hospital mortality in women than in men after acute myocardial infarction

Clinical, laboratory and cardiac catheterization parameters were reviewed in 355 men and 155 women hospitalized at a tertiary care referral center between February 1987 and December 1991 to analyze why women have a higher in-hospital mortality rate than do men after acute myocardial infarction. Hospital mortality was 21.4% in women and 12.1% in men (p = 0.007). In comparison with men, women were older (63.3 +/- 11.9 vs 60.5 +/- 12.6 years; p = 0.023), had more systemic hypertension (46.5 vs 34.4%; p = 0.001) and higher serum total cholesterol levels (211 +/- 51 vs 197 +/- 49 mg/dl; p = 0.0015), sought medical care later (8.9 vs 5.3 hours; p = 0.026), were referred later (47.7 vs 43.7 hours; p = 0.063) and had more shock (34.8 vs 24.2%; p = 0.013). Logistic regression analysis revealed 5 variables predictive of hospital mortality; age > 65 years, diabetes, shock, non-Q-wave infarction, and not undergoing cardiac catheterization. Gender was of borderline significance in predicting hospital mortality. Cardiac catheterization, performed in 88% of women and 87% of men, showed similar rates of 1-, 2- and 3-vessel disease, and similar characteristics of the infarction-related artery. The differences in hospital mortality between men and women are due to a combination of pre- and in-hospitalization factors in women. The excess mortality is not due to differences in disease severity as evaluated by cardiac catheterization information.

Laparoscopic Appendectomy—Is it Worth the Cost? Trend Analysis in the US from 2000 to 2005

BACKGROUND Although laparoscopic appendectomy is widely used for treatment of appendicitis, it is still unclear if it is superior to the open approach. STUDY DESIGN From the Nationwide Inpatient Sample 2000 to 2005, hospitalizations with the primary ICD-9 procedure code of laparoscopic (LA) and open appendectomy (OA) were included in this study. Outcomes of length of stay, costs, and complications were assessed by stratified analysis for uncomplicated and complicated appendicitis (perforation or abscess). Regression methods were used to adjust for covariates and to detect trends. Costs were rescaled using the hospital and related services portion of the Medical Consumer Price Index. RESULTS Between 2000 and 2005, 132,663 (56.3%) patients underwent OA and 102,810 (43.7%) had LA. Frequency of LA increased from 32.2% to 58.0% (p < 0.001); conversion rates decreased from 9.9% to 6.9% (p < 0.001). Covariate adjusted length of stay for LA was approximately 15% shorter than for OA in both uncomplicated and complicated cases (p < 0.001). Adjusted costs for LA were 22% higher in uncomplicated appendicitis and 9% higher in patients with complicated appendicitis (p < 0.001). Costs and length of stay decreased over time in OA and LA. The risk for a complication was higher in the LA group (p < 0.05, odds ratio=1.07, 95% CI 1.00 to 1.14) with uncomplicated appendicitis. CONCLUSIONS LA results in higher costs and increased morbidity for patients with uncomplicated appendicitis. Nevertheless, LA is increasingly used. Patients undergoing LA benefit from a slightly shorter hospital stay. In general, open appendectomy may be the preferred approach for patients with acute appendicitis, with indication for LA in selected subgroups of patients.

Implementing smoking bans in American hospitals: results of a national survey

OBJECTIVES To determine how well hospitals complied with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) tobacco control standards, which required banning smoking in hospital buildings; to explore issues involved in developing and implementing smoking bans; and to ascertain the perceived success of the policies. DESIGN Postal survey conducted January through June 1994. PARTICIPANTS Stratified random sample of American hospitals surveyed by JCAHO (n = 1055). MAIN OUTCOME MEASURES Enacting smoking policies more restrictive than the JCAHO standard; the respondent’s judgment of the relative success of the hospital’s smoking policy. RESULTS More than 96% of hospitals complied with the smoking ban standard; 41.4% enacted policies that were more restrictive than required by JCAHO. Several characteristics were associated with exceeding JCAHO requirements: location in a “non-tobacco state”; having fewer than 100 beds; location in a metropolitan statistical area; having unionised employees; and having no psychiatric or substance abuse unit, favour having the same tobacco policy in psychiatry and substance abuse units as the rest of the hospital. More than 95% of respondents viewed their hospital’s policy as successful. The JCAHO requirements and concern for employees’ health were the major forces influencing hospitals to go smoke-free. Negative employee morale and lack of acceptance by visitors and patients were the most commonly cited barriers to overcome when implementing smoke-free policies. CONCLUSIONS Smoking bans were successfully implemented in American hospitals, with many restricting smoking beyond the JCAHO standard. Other industries wishing to follow hospitals’ lead would be most likely to succeed in the context of a social norm favouring a smoking ban and regulation by an outside agency.

Nursing Home Quality and Pressure Ulcer Prevention and Management Practices

Objectives: To measure pressure ulcer quality indicator (QI) scores and to describe the self‐reported skin integrity assessment, pressure ulcer risk assessment, and pressure ulcer prevention and treatment practices in long‐term care facilities (LTCFs).

Contraction force generated by tarsal joint flexion and extension in dogs with golden retriever muscular dystrophy

Force generated due to torque caused by tarsal joint flexion and extension was measured noninvasively at 3, 4.5, 6, and 12 months of age in dogs with the Duchenne homologue, golden retriever muscular dystrophy (GRMD). Absolute and body-weight-corrected GRMD twitch and tetanic force values were lower than normal at all ages (P<0.01 for most). Tarsal flexion and extension were differentially affected. Flexion values were especially low at 3 months, whereas extension was affected more at later ages. Several other GRMD findings differed from normal. The twitch/tetany ratio was generally lower; post-tetanic potentiation for flexion values was less marked; and extension relaxation and contraction times were longer. The consistency of GRMD values was studied to determine which measurements will be most useful in evaluating treatment outcome. Standard deviation was proportionally greater for GRMD versus normal recordings. More consistent values were seen for tetany versus twitch and for flexion versus extension. Left and right limb tetanic flexion values did not differ in GRMD; extension values were more variable. These results suggest that measurement of tarsal tetanic force should be most useful to document therapeutic benefit in GRMD dogs.

The MDS Mortality Risk Index: The evolution of a method for predicting 6-month mortality in nursing home residents

BackgroundAccurate prognosis is vital to the initiation of advance care planning particularly in a vulnerable, at risk population such as care home residents. The aim of this paper is to report on the revision and simplification of the MDS Mortality Rating Index (MMRI) for use in clinical practice to predict the probability of death in six months for care home residents.MethodsThe design was a secondary analysis of a US Minimum Data Set (MDS) for long term care residents using regression analysis to identify predictors of mortality within six months.ResultsUsing twelve easy to collect items, the probability of mortality within six months was accurately predicted within the MDS database. The items are: admission to the care home within three months; lost weight unintentionally in past three months; renal failure; chronic heart failure; poor appetite; male; dehydrated; short of breath; active cancer diagnosis; age; deteriorated cognitive skills in past three months; activities of daily living score.ConclusionA lack of recognition of the proximity of death is often blamed for inappropriate admission to hospital at the end of an older persons life. An accurate prognosis for older adults living in a residential or nursing home can facilitate end of life decision making and planning for preferred place of care at the end of life. The original MMRI was derived and validated from a large database of long term care residents in the USA. However, this simplification of the revised index (MMRI-R) may provide a means for facilitating prognostication and end of life discussions for application outside the USA where the MDS is not in use. Prospective testing is needed to further test the accuracy of the MMRI-R and its application in the UK and other non-MDS settings.

A biopsychosocial model of disability in rheumatoid arthritis

OBJECTIVE To test and cross-validate a model using disease activity, pain, and helplessness to predict future psychological and physical disability in persons with rheumatoid arthritis (RA) across time. METHODS Measures of disease activity, pain, helplessness, psychological function, and physical function were collected from 63 males with RA at baseline, 3 months, and 6 months. Path analytic methods were used to examine longitudinal relationships among these variables. RESULTS Path analysis revealed that pain and helplessness were significant mediators of the relationship between disease activity and future disability in RA; the predictive model withstood two cross-validations. CONCLUSION The findings suggest that pain and helplessness are key biopsychosocial variables that affect the development of disability in RA.

Stress Management in Rheumatoid Arthritis: What Is the Underlying Mechanism?

OBJECTIVE To test whether change in cognitive-behavioral variables (such as self-efficacy, coping strategies, and helplessness) is a mediator in the relation between cognitive behavior therapy and reduced pain and depression in persons with rheumatoid arthritis (RA). METHODS A sample of patients with RA who completed a stress management training program (n = 47) was compared to a standard care control group (n = 45). A path analysis testing a model including direct effects of comprehensive stress management training on pain and depression and indirect effects via change in cognitive-behavioral variables was conducted. RESULTS The path coefficients for the indirect effects of stress management training on pain and depression via change in cognitive-behavioral variables were statistically significant, whereas the path coefficients for the direct effects were found not to be statistically significant. CONCLUSION Decreases in pain and depression following stress management training are due to beneficial changes in the arenas of self-efficacy (the belief that one can perform a specific behavior or task in the future), coping strategies (an individuals confidence in his or her ability to manage pain), and helplessness (perceptions of control regarding arthritis). There is little evidence of additional direct effects of stress management training on pain and depression.

Nationwide Impact of Laparoscopic Lysis of Adhesions in the Management of Intestinal Obstruction in the US

BACKGROUND Treatment of adhesion-related complications is cost intensive and presents a considerable burden to the health care system. The objective of this study was to compare open (OLA) and laparoscopic lysis of adhesions (LLA) in the treatment of intestinal obstruction, based on a nationwide representative sample. STUDY DESIGN Patients with intestinal obstruction undergoing OLA, LLA, and conversion were identified from the 2002 National Inpatient Sample. After propensity methods were used to adjust for covariates including patient demographics, hospital characteristics, and comorbidities, the impact of OLA and LLA was analyzed concerning in-hospital mortality, postoperative complications, length of stay (LOS), and in-hospital costs. RESULTS Of 6,165 patients, 88.6% underwent OLA and 11.4% had LLA. Conversion was required in 17.2% of LLA patients. Unadjusted mortality was equal between LLA and conversion (1.7%) and half the rate compared with OLA (3.4%) (p = 0.014). After adjusting with propensity methods, the odds of complications in the LLA group (intention to treat) were 25% less than in the OLA (p = 0.008). The LLA group had a 27% shorter LOS (p = 0.0001) and was 9% less expensive than the OLA group (p = 0.0003). There was no statistical significant difference for LOS, complications, and costs between the conversion and OLA groups. CONCLUSIONS Results from this study suggest that when LLA is applied to selected patients with intestinal obstruction, there are reductions in postoperative complications, LOS, and costs. Prospective studies are needed to confirm these data and better identify the subgroup of patients who have improved outcomes with LLA.

Relationship between management philosophy and clinical outcomes

BACKGROUND Medical research continues to focus overwhelmingly on biomedical interventions, such as drugs, devices, and procedures. The dysfunctional health care cultures and systems need more attention for quality of care to improve further. PURPOSE The existing health services management research has not used a systematic theoretical framework to predict the effects of organizational variables on clinical outcomes. This study tests the theoretical model proposed by N. Khatri, A. Baveja, S. Boren, and A. Mammo (2006). METHODOLOGY This study surveyed employees from hospitals in Missouri. The sample consisted of 77 respondents from 16 hospitals. FINDINGS The control-based management approach (Management Control and Silos) was found to be positively associated with Culture of Blame and negatively with Learning From Mistakes. In contrast, the commitment-based approach (Fair Management Practices and Employee Participation) was negatively associated with Culture of Blame and positively with Learning From Mistakes, Camaraderie, and Motivation. Mediating variables of Learning From Mistakes and Camaraderie showed a significant negative relationship with Medical Errors. Learning From Mistakes, Camaraderie, and Motivation all showed a significant positive relationship with Quality of Patient Care. The mediating variables had much stronger relationships with Medical Errors and Quality of Patient Care than did the independent variables, lending support to the proposed mediation. IMPLICATIONS FOR PRACTICE Health care organizations can improve the quality of care and reduce medical errors significantly by enhancing learning from mistakes and boosting camaraderie and morale of their employees. They can do so by breaking down silos in their structures, implementing just and fair management practices, and involving employees in decision making.