Mindy Smith

Failure of Three Decision Rules to Predict the Outcome of In-hospital Cardiopulmonary Resuscitation

The objective of this study was to evaluate three decision-support tools (the Pre-Arrest Morbidity or PAM score, the Prognosis After Resuscitation or PAR score, and the Acute Physiology and Chronic Health Evaluation or APACHE III score) for their abilities to predict the outcomes of in-hospital cardiopulmonary resuscitation (CPR). The medical records of all 656 adult inpatients undergoing CPR during a two-to-three-year period in three large hospitals were retrospectively reviewed, and demographic and clinical variables were abstracted. Of 656 patients undergoing resuscitation, 248 (37.8%) survived the resuscitation attempt long enough to be stabilized (immediate survival), but only 35 (5.3%) survived to discharge. Only 11 patients had PAM scores higher than 8, none of whom survived to discharge; 131 patients had PAR scores above 8, of whom six survived to discharge. The PAR score and the APACHE III score had the greatest areas under the receiver operating characteristic curves (when predicting the outcome of survival to discharge), although no individual area for either outcome was greater than 0.6. None of the decision-support tools studied was able to effectively discriminate between survivors and non-survivors for the outcomes of immediate survival and survival to discharge following in-hospital CPR. This is consistent with previous work utilizing the APACHE II score, which did not identify a threshold above which patients did not benefit from CPR. The findings for the PAR score and the PAM score stand in contrast to previous studies that found them to be potentially useful decision rules. Further work is needed to develop a decision-support tool that better discriminates between survivors and non-survivors of in-hospital CPR. Key words: resuscitation; prognosis; cardiopulmonary resuscitation; decision support; decision making. (Med Decis Making 1997;17:171-177)

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

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.

Population-Level Quality Measures for Behavioral Screening and Intervention.

Delivered routinely in general health care settings, smoking, alcohol, depression, and obesity screening and intervention (behavioral screening and intervention [BSI]) could substantially improve population health and reduce health care costs. Yet BSI is seldom delivered in an evidence-based manner. This article assesses the adequacy of quality measures for BSI. Online searches of the National Quality Forum’s Quality Positioning System and the National Clearinghouse for Quality Measures databases were conducted using the keywords smoking, tobacco, alcohol, depression, and obesity. The types and focuses of each measure were classified, and differences between the metrics and evidence-based practice were identified. Most measures indicate whether BSI components are delivered, not how well. Clinicians can perform well on most metrics without delivering evidence-based services. More rigorous quality measures are needed. A new kind of measure is proposed, whereby separate terms representing the reach and effectiveness of key BSI components are multiplied to produce a single indicator of population-level impact for each behavioral topic.