Henry C. Barry

Survival After In-Hospital Cardiopulmonary Resuscitation: A Meta-Analysis

OBJECTIVE: To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes.MEASUREMENTS AND MAIN RESULTS: The MEDLARS database of the National Library of Medicine was searched. In addition, the authors’ extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio [OR] 31.3; 95% confidence interval [CI] 1.9, 515), metastatic cancer (OR 3.9; 95% CI 1.2, 12.6), dementia (OR 3.1; 95% CI 1.1, 8.8), African-American race (OR 2.8; 95% CI 1.4, 5.6), serum creatinine level at a cutpoint of 1.5 mg/dL (OR 2.2; 95% CI 1.2, 3.8), cancer (OR 1.9; 95% CI 1.2, 3.0), coronary artery disease (OR 0.55; 95% CI 0.4, 0.8), and location of resuscitation in the intensive care unit (OR 0.51; 95% CI 0.4, 0.8).CONCLUSIONS: When talking with patients, physicians can describe the overall likelihood of surviving discharge as 1 in 8 for patients who undergo cardiopulmonary resuscitation and 1 in 3 for patients who survive cardiopulmonary resuscitation.

Infrastructure Requirements for Practice-Based Research Networks

BACKGROUND The practice-based research network (PBRN) is the basic laboratory for primary care research. Although most PBRNs include some common elements, their infrastructures vary widely. We offer suggestions for developing and supporting infrastructures to enhance PBRN research success. METHODS Information was compiled based on published articles, the PBRN Resource Center survey of 2003, our PBRN experiences, and discussions with directors and coordinators from other PBRNs. RESULTS PBRN research ranges from observational studies, through intervention studies, clinical trials, and quality of care research, to large-scale practice change interventions. Basic infrastructure elements such as a membership roster, a board, a director, a coordinator, a news-sharing function, a means of addressing requirements of institutional review boards and the Health Insurance Portability and Accountability Act, and a network meeting must exist to support these initiatives. Desirable elements such as support staff, electronic medical records, multiuser databases, mentoring and development programs, mock study sections, and research training are costly and difficult to sustain through project grant funds. These infrastructure elements must be selected, configured, and sized according to the PBRN’s self-defined research mission. Annual infrastructure costs are estimated to range from

Exercise and aging. Issues for the practitioner.

69,700 for a basic network to

Overcoming exercise barriers in older adults

287,600 for a moderately complex network. CONCLUSIONS Well-designed and properly supported PBRN infrastructures can support a wide range of research of great direct value to patients and society. Increased and more consistent infrastructure support could generate an explosion of pragmatic, generalizable knowledge about currently understudied populations, settings, and health care problems.

Periodic Abstinence From Pap (PAP) Smear Study: Women’s Perceptions of Pap Smear Screening

The elderly present the health care system with a number of challenges, the most important of which centers on the declining functional capacity associated with aging. It remains to be clarified the degree to which these changes are related to the interactions among aging, disease, illness, injury, lifestyle, genetics, and other variables. While these issues are being clarified, however, it is clear that a well-designed exercise program that is of low to moderate intensity may be the single, most cost-effective means of maintaining function. The exercise program needs to be goal-oriented and goal congruent, yet it must be individualized to account for existing impairments. General guidelines, such as those in Table 7, may be useful in maintaining a perspective on the regimen. Regardless of the degree of functional limitations, all elderly can derive some benefit from engaging in an exercise program. The emphasis of any regimen should be on quality-of-life issues, such as improving flexibility, strength, and mobility. For the vast majority of elderly, a simple walking program is probably the safest, most effective form of activity.

TEST CHARACTERISTICS AND DECISION RULES

Barriers to exercise among older adults include personal factors such as discomfort, fear of injury, and social isolation, plus environmental difficulties such as lack of access and unfavorable weather. When selecting tactics to overcome the barriers, it is helpful to consider the patients position within the six stages of behavior change. Key measures include controlling pain, treating chronic conditions, explaining the benefits of exercise, dispelling misconceptions, identifying personal goals that exercise can help the patient attain, setting realistic exercise goals, and following up.

How Exercise Can Benefit Older Patients. A Practical Approach.

BACKGROUND The purpose of this study was to explore attitudes, beliefs, and perceived barriers to risk-based cervical cancer screening through focus group interviews of patients. METHODS We conducted 8 focus group interviews of women using semistructured interviews. The investigators independently reviewed the focus group transcripts and identified the overall themes and themes unique to each question using an immersion and crystallization approach. RESULTS Women are in agreement that cervical cancer screening is important and that women should get Pap smears regularly as an important way of protecting their health. They are not open to the idea of reducing the frequency of Papanicolaou (Pap) smears, however, because they perceive annual screening to be successful in reducing cervical cancer mortality. Additionally, they have concerns about test accuracy. Women are distrustful of the rationale for reducing the frequency of Pap smears. Women’s previous bad experiences have reinforced their need for self-advocacy. CONCLUSION Women are reluctant to engage in risk-based cervical cancer screening. In this environment, risk-based cervical cancer screening recommendations are likely to be met with resistance.

It’s NOT FAIR! Or is it? The promise and the tyranny of evidence-based performance assessment

We have demonstrated using several examples how different test characteristics can be used to assist clinicians in making better decisions for their patients. These probabilistic models may seem confusing and difficult to implement. Some general rules may help, such as SnNout and SpPin. Clinicians should know the test characteristics and decision rules for the acute problems they may face. For chronic conditions, advanced planning may be helpful. Electronic medical record systems may be able to incorporate these at the user interface. The improvements in hand-held computers may bring clinical decision-support systems directly to the point of service. We may also begin to see laboratories report test characteristics for important conditions as likelihood ratios (we already see estimates of the risk of heart disease corresponding to different lipid ratios). We also suspect that the medical literature will report likelihood ratios more frequently. As practice networks develop more sophisticated disease-tracking mechanisms, clinicians will be able to obtain estimates of disease prevalence more appropriate to their practice. Ultimately, for physicians to make better decisions, appropriate data are needed, including accurate estimates of test characteristics and of disease probability.

A family medicine clerkship curriculum in medication errors.

In brief Physical activity has both preventive and therapeutic benefits for the frail elderly, and the ultimate goal is improved quality of life. The greatest impact on functional capacity comes from physiologic changes that affect mobility. Walking programs and flexibility and strength training can prevent muscle weakness and impaired gait and balance, which are risk factors for falls in the elderly. In addition, changes in functional capacity can result in greater independence in daily living. Physical activity also provides therapeutic benefits for patients who have arthritis or dementia.

Integrating information management knowledge and skills in the pre-clinical curriculum

Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols.