James M. Naessens

A Short Test of Mental Status: Description and Preliminary Results

A short test of mental status (encompassing about 5 minutes) was administered to 93 consecutive neurologic outpatients without dementia, 67 outpatients with Alzheimer-type dementia, and 20 outpatients with dementia of miscellaneous causes. The mean scores for patients with Alzheimer-type dementia were lower than those for the nondemented patients in the total scoring and on all subtests (P less than 0.001). When a total score of 29 or less (maximal attainable score, 38) was used as a screen for dementia, a sensitivity of 92% and a specificity of 91% were reached. For patients older than 60 years of age, a score of 29 or less resulted in a sensitivity of 95% and a specificity of 88%. Thus, in general, this easily administered test distinguishes demented from nondemented patients, but it should not be used as the sole means of diagnosing dementia.

Echocardiographic Findings in Systemic Amyloidosis: Spectrum of Cardiac Involvement and Relation to Survival

One hundred thirty-two patients with biopsy-proven systemic amyloidosis underwent echocardiographic examination to define the spectrum of cardiac involvement. Echocardiographic abnormalities were then correlated with clinical variables and survival at follow-up. Patients were subgrouped by left ventricular wall thickness: Group I, mean wall thickness 12 mm or less; Group II, mean wall thickness greater than 12 mm but less than 15 mm; Group III, mean wall thickness 15 mm or greater; or Group IV, atypical features such as wall motion abnormalities or left ventricular dilation. Patients with greater wall thickness had a higher frequency of associated echocardiographic abnormalities such as left atrial enlargement or granular sparkling appearance on two-dimensional examination and, more commonly, reduced systolic function. The occurrence of clinical congestive heart failure was strongly correlated with greater wall thickness and multiple other echocardiographic abnormalities. Survival was negatively influenced both by greater wall thickness and reduced systolic function. The median survival of the entire group was 1.1 years. Echocardiographic examination is an important tool for establishing the presence of cardiac amyloid involvement and may be useful in estimating prognosis in such patients.

Accuracy of hospital discharge abstracts for identifying stroke.

Much of the available data on stroke occurrence, service use, and cost of care originated with hospital discharge abstracts. This article uses the unique resources of the Rochester Epidemiology Project to estimate the sensitivity and positive predictive value of hospital discharge abstracts for incident stroke. Methods The Rochester Stroke Registry was used to identify all confirmed first strokes (hospitalized and nonhospitalized) among Rochester residents for 1970, 1980, 1984, and 1989 (n=364). The sensitivity of discharge abstracts was estimated by following these individuals for 12 months after stroke to determine the proportion assigned a discharge diagnosis of cerebrovascular disease (International Classification of Diseases [LCD] codes 430 through 438.9). The positive predictive value of discharge abstracts was assessed by identifying all hospitalizations of Rochester residents with an ICD code of 430-438.9 in 1970, 1980, and 1989 (n=377). Events were categorized as incident stroke, recurrent stroke, stroke sequelae, or nonstroke after review of the complete community-based medical record by a neurologist. Results Only 86% (n=313) of all first-stroke patients in 1970, 1980, 1984, and 1989 were hospitalized. Of hospitalized patients, only 76% were assigned a principal discharge diagnosis code of 430-438.9. Fatal strokes and those occurring during a hospitalization were less likely to be identified. Among all hospitalizations of Rochester residents in 1970, 1980, and 1989, there were 377 with a principal diagnosis code of 430-438.9. Less than half (n = 177) were determined by the neurologist to be incident stroke; only 60% (n=225) were either incident or recurrent stroke. Comparison of alternative approaches showed the validity of discharge abstracts was enhanced by increasing the number of diagnoses and excluding codes with poor positive predictive value. Conclusions This study provides previously unavailable estimates of the sensitivity of stroke-coded hospitalizations for a US community. A model for improving the sensitivity and positive predictive value of discharge abstracts is presented.

A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits

BACKGROUND Efficiently caring for frail older adults will become an increasingly important part of health care reform;telemonitoring within homes may be an answer to improve outcomes. This study sought to assess differences in hospitalizations and emergency department (ED) visits among older adults using telemonitoring vs usual care. METHODS A randomized controlled trial was performed among adults older than 60 years at high risk for rehospitalization. Participants were randomized to telemonitoring (with daily input) or to patient-driven usual care. Telemonitoring was accomplished by daily biometrics,symptom reporting, and videoconference. The primary outcome was a composite end point of hospitalizations and ED visits in the 12 months following enrollment. Secondary end points included hospitalizations,ED visits, and total hospital days. Intent-to-treat analysis was performed. RESULTS Two hundred five participants were enrolled,with a mean age of 80.3 years. The primary outcome of hospitalizations and ED visits did not differ between the telemonitoring group (63.7%) and the usual care group(57.3%) (P=.35). No differences were observed in secondary end points, including hospitalizations, ED visits,and total hospital days. No significant group differences in hospitalizations and ED visits were found between the pre-enrollment period vs the post-enrollment period. Mortality was higher in the telemonitoring group (14.7%)than in the usual care group (3.9%) (P=.008). CONCLUSIONS Among older patients, telemonitoring did not result in fewer hospitalizations or ED visits. Secondary outcomes demonstrated no significant differences between the telemonitoring group and the usual care group.The cause of greater mortality in the telemonitoring group is unknown.

How best to measure surgical quality? comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution

BACKGROUND Evaluating surgical outcomes is an important tool to compare providers and institutions and to drive process improvements. Differing methodologies, however, may provide conflicting measurements of similar clinical outcomes making comparisons difficult. ACS-NSQIP is a validated, risk-adjusted, clinically derived data methodology to compare observed to expected outcomes after a wide variety of operations. The AHRQ-PSI are a set of computer algorithms to identify potential adverse in-patient events using secondary ICD-9-CM diagnosis and procedure codes from hospital discharge abstracts. METHODS We compared the ACS-NSQIP and AHRQ-PSI methods for hospital general surgical (n = 6565) or vascular surgical inpatients procedures (n = 1041) at a tertiary-care academic institution from April 2006 to June 2009 on 7 adverse event types. RESULTS ACS-NSQIP inpatient adverse events were identified in 564 (7.4%) patients. AHRQ-PSIs were identified in 268 (3.5%) patients. Only 159 (2.1%) patients had inpatient events identified by both methods. Using ACS-NSQIP as the clinically based standard the sensitivity of the specific AHRQ-PSI ranged from 0.030 for infections to 0.535 for PE/DVT. Positive predictive values of AHRQ-PSI ranged from 18% for hemorrhage/hematoma to 89% for renal failure. Greater agreement at greater ASA class and wound classification was observed. CONCLUSION AHRQ-PSI algorithms identified less than a third of the ACS-NSQIP clinically important adverse events. Furthermore, the AHRQ-PSI identified a large number of events with no corresponding clinically important adverse outcomes. The sensitivity of the AHRQ-PSI for detecting clinically relevant adverse events identified by the ACS-NSQIP varied widely. The AHRQ-PSI as applied to postoperative patients is a poor measure of quality performance.

Evaluation of unfavorable histologic subtypes in endometrial adenocarcinoma

A retrospective review of 388 patients who presented to the Mayo Clinic for treatment of endometrial carcinoma between 1979 and 1983 was performed and the surgical and pathologic observations were documented. An uncommon histologic subtype was detected in 52 patients (13%): 20 adenosquamous, 14 serous papillary, 11 clear cell, 7 undifferentiated. In contrast to the survival of patients with endometrioid lesions (92%), the overall survival in these patients was only 33%. Each of the individual abnormal histologic subtypes exhibited a survival of less than 50%. At the time of surgical staging, 62% of patients with unfavorable histologic subtypes had extrauterine spread of disease. Despite liberal utilization of postoperative adjuvant therapy in 42 of the 52 patients (81%), only 10% of these patients survived 5 years. Fifty-five percent had a component of recurrence outside of the abdominal/pelvic cavity. Subsequent treatment considerations should incorporate regimens addressing systemic and local tissue control.

Myocardial Revascularization Before Abdominal Aortic Aneurysmorrhaphy: Effect of Coronary Angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) has assumed an increasing role in the preoperative preparation of patients with an abdominal aortic aneurysm (AAA). The influence of this modality on perioperative morbidity and long-term outcome has not been substantiated. To determine the effect of PTCA, we analyzed a cohort of 2,452 patients who underwent repair of an AAA between 1980 and 1990 at our institution. We compared the cardiac morbidity, mortality, and survival of patients who had preoperative coronary revascularization by PTCA or coronary artery bypass grafting (CABG). The overall perioperative mortality for the 2,452 patients was 2.9%. Preoperative coronary revascularization was necessary in 100 patients (4.1%)--86 had CABG and 14 had PTCA. Of these 100 patients, 95% had cardiac symptoms. Patients selected for PTCA, in comparison with CABG, had significantly less three-vessel disease but not significant differences in cardiac history or ejection fraction. During the study period, the use of PTCA increased significantly. The perioperative rate of myocardial infarction for patients with prior CABG was 5.8% in comparison with 0% for those with prior PTCA. No hospital deaths occurred in either group. The median interval between coronary revascularization and repair of an AAA was 10 days for PTCA and 68 days for CABG. The 3-year survival was not statistically different between CABG (82.8%) and PTCA (92.3%) groups. The rate of late cardiac events (at 3 years) was 56.5% in the PTCA group and 27.3% in the CABG group. We conclude that PTCA as part of a highly selective approach to coronary revascularization before repair of an AAA minimizes cardiac-related events and death.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of hospital adverse events identified by three widely used detection methods

OBJECTIVE Determine the degree of congruence between several measures of adverse events. DESIGN Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods. SETTING Mayo Clinic Rochester hospitals. PARTICIPANTS All inpatients discharged in 2005 (n = 60 599). INTERVENTIONS Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission. MAIN OUTCOME MEASURE Agreement of identification between methods. RESULTS About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI. CONCLUSIONS Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.

Age-related changes in aortic and mitral valve thickness: implications for two-dimensional echocardiography based on an autopsy study of 200 normal human hearts.

The thicknesses at 3 sites of each aortic cusp (nodule, closing edge and middle part) and 2 sites of both mitral leaflets (closing edge and clear zone) were measured in 200 autopsy specimens of normal hearts, evenly distributed by age and sex. There were no significant correlations between valvular thickness and height, weight, heart weight or body surface area. The mean thickness at each site was not different between men and women but increased significantly with age (p less than 0.001). For 3 age groups (less than 20, 20 to 59 and greater than or equal to 60 years), the corresponding mean thicknesses (mm) of the aortic nodule were 0.67, 0.87 and 1.42; those for the anterior mitral leaflet were 1.30, 1.60 and 3.20; and those for the posterior mitral leaflet were 0.91, 1.13 and 2.04. For the aortic valve, the nodule was nearly twice as thick as the closing edge (p less than 0.001), and the closing edge was at least 25% thicker than the middle part (p less than 0.001). Furthermore, the posterior aortic cusp was thicker than the right and left cusps (p less than 0.05). For both mitral leaflets, the closing edge was thicker than the clear zone (p less than 0.05). Moreover, along the closing edges, the anterior leaflet was thicker than the posterior leaflet (p less than 0.05). These observations may be useful in echocardiographic evaluations of aortic and mitral valve sclerosis in elderly patients.

Popliteal Artery Aneurysms: The Risk of Nonoperative Management

To evaluate the risk of nonoperative management of popliteal artery aneurysms (PAAs), a retrospective cohort study of 106 consecutive patients (103 males and 3 females) with PAAs seen between January 1, 1980, and December 31, 1985, was performed. The mean age was 70.5 years (range 50 to 90 years). The 106 patients with 161 PAAs were followed for a mean of 6.7 years (range 3 days to 12.1 years). Follow-up was complete in 91.5% (97/106) of the patients. PAA was confirmed by ultrasonography in 124 limbs (77%), arteriography only in 7 (4.3%), and physical examination only in 32 (19.9%). Fifteen limbs presented with acute symptoms, 52 with chronic symptoms, and 94 were asymptomatic. Five of the 15 limbs with acute symptoms (33%) underwent amputation (4 primary, 1 secondary). PAAs in 23 of the 52 limbs with chronic symptoms were repaired; 2 limbs required amputation (8.7%). Twenty-seven of the 94 asymptomatic limbs were repaired initially; 1 required amputation (3.7%). The remaining 67 asymptomatic limbs were initially managed nonoperatively. Amputation was required in 3 of 67 limbs (4.4%), 1 with acute symptoms and 2 with chronic symptoms, all of which had undergone attempted repair. Symptoms (3 acute, 9 chronic) eventually developed in 12 (17.9%). At least one of three risk factors (size >2 cm, thrombus, and poor runoff) was initially present in 11 of 12 limbs (91.7%) compared with 9 of 24 control limbs (37.5%) that remained asymptomatic (p<0.05). Amputation rates in symptomatic patients with PAAs continues to be high. In patients with asymptomatic PAAs, aneurysm size >2 cm, thrombus, or poor runoff predicted the development of symptoms. PAA patients with any of these factors should undergo elective repair, even asymptomatic patients who have a reasonable chance for long-term survival.