Stephen H. Gehlbach

The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients.

A 14-item, self-administered, multidimensional, functional social support questionnaire was designed and evaluated on 401 patients attending a family medicine clinic. Patients were selected from randomized time-frame sampling blocks during regular office hours. The population was predominantly white, female, married, and under age 45. Eleven items remained after test-retest reliability was assessed over a 1- to 4-week follow-up period. Factor analysis and item remainder analysis reduced the remaining 11 items to a brief and easy-to-complete two-scale, eight-item functional social support instrument. Construct validity, concurrent validity, and discriminant validity are demonstrated for the two scales (confidant support—five items and affective support —three items). Factor analysis and correlations with other measures of social support suggest that the three remaining items (visits, instrumental support, and praise) are distinct entities that may need further study.

Recognition of vertebral fracture in a clinical setting

Abstract: Osteoporosis-related vertebral fractures have important health consequences for older individuals, including disability and increased mortality. Because these fractures can be prevented with appropriate medications, recognition and treatment of high-risk patients is warranted. A cross-sectional survey was carried out in a large, regional hospital in New England to examine the frequency with which vertebral fractures are identified and treated by clinicians in a population of hospitalized older women who have radiographic evidence of fractures. The study population consisted of 934 women aged 60 years and older who were hospitalized between October 1, 1995 and March 31, 1997, and who had a chest radiograph obtained. Vertebral fractures in the thoracic region were identified by two radiologists. Discharge diagnoses, medical record notes and radiology reports were compared with the results of the radiologists’ readings to determine the frequency with which fractures were identified and appropriate, osteoporosis-preventing medications prescribed. Moderate or severe vertebral fractures were identified for 132 (14.1%) study subjects, but only 17 (1.8%) of the 934 participants had a discharge diagnosis of vertebral fracture. Of these 132, only 17% had fracture noted in the medical record or discharge summary; 50% of contemporaneous radiology reports identified a fracture as present; and 23% of the time it was found in the radiologist’s summary impression. Only 18% of medical records indicated that fracture patients had been prescribed calcium, vitamin D, estrogen replacement or an antiresorptive agent. Relatively few hospitalized older women with radiographically demonstrated vertebral fractures were thus identified or treated by clinicians, suggesting a need for improved recognition.

Obesity is not protective against fracture in postmenopausal women: GLOW

OBJECTIVE To investigate the prevalence and incidence of clinical fractures in obese, postmenopausal women enrolled in the Global Longitudinal study of Osteoporosis in Women (GLOW). METHODS This was a multinational, prospective, observational, population-based study carried out by 723 physician practices at 17 sites in 10 countries. A total of 60,393 women aged ≥ 55 years were included. Data were collected using self-administered questionnaires that covered domains that included patient characteristics, fracture history, risk factors for fracture, and anti-osteoporosis medications. RESULTS Body mass index (BMI) and fracture history were available at baseline and at 1 and 2 years in 44,534 women, 23.4% of whom were obese (BMI ≥ 30 kg/m(2)). Fracture prevalence in obese women at baseline was 222 per 1000 and incidence at 2 years was 61.7 per 1000, similar to rates in nonobese women (227 and 66.0 per 1000, respectively). Fractures in obese women accounted for 23% and 22% of all previous and incident fractures, respectively. The risk of incident ankle and upper leg fractures was significantly higher in obese than in nonobese women, while the risk of wrist fracture was significantly lower. Obese women with fracture were more likely to have experienced early menopause and to report 2 or more falls in the past year. Self-reported asthma, emphysema, and type 1 diabetes were all significantly more common in obese than nonobese women with incident fracture. At 2 years, 27% of obese women with incident fracture were receiving bone protective therapy, compared with 41% of nonobese and 57% of underweight women. CONCLUSIONS Our results demonstrate that obesity is not protective against fracture in postmenopausal women and is associated with increased risk of ankle and upper leg fractures.

A method for assessing the clinical performance and cost-effectiveness of intensive care units : a multicenter inception cohort study

ObjectivesTo present an approach for assessing intensive care unit (ICU) performance which takes into account both economic and clinical performance while adjusting for severity of illness. To present a graphic display which permits comparisons among a group of hospitals. DesignA multicenter, inception cohort study. SettingTwenty-five ICUs in U.S. hospitals that participated in the European and North American Study of Severity Systems for ICU Patients. PatientsConsecutive patients (n = 3,397) admitted to ICUs in participating hospitals between September 30, 1991 and December 27, 1991. Excluded were coronary care patients, burn patients, cardiac surgery patients and patients aged <18 yrs. Measurements and Main ResultsThe clinical performance index is the difference between observed hospital survival rate and survival rate predicted by the Mortality Probability Model measuring severity of illness at ICU admission. The economic performance (resource use) measure is a length of stay index, Weighted Hospital Days, which weights ICU days more heavily than non-ICU days. The economic performance index is the difference between actual mean resource use and the resource use predicted by a regression including severity of illness and percent of surgical patients. Both the clinical and economic performance indices are standardized to show how far a particular hospital is from the overall mean and are graphed together. Most of the 25 hospitals lie within 1 SD of the mean on both clinical and economic performance scales. The graph makes it easy to identify those hospitals that are outside this range. There is no evidence of a tradeoff between high clinical performance and high economic performance; i.e., it is possible to achieve both. ConclusionsCross-indexing of clinical and economic ICU performance is easy to calculate. It has potential as a research and evaluation tool used by physicians, hospital administrators, payers, and others. (Crit Care Med 1994; 22:1385–1391

Errors in a busy emergency department.

STUDY OBJECTIVE We describe errors occurring in a busy ED. METHODS This is a prospective, observational study of reported errors at an academic emergency department (ED) with 100000 annual visits. Trained personnel interviewed all ED staff with direct patient contact, during and at the end of every shift, by using standardized data sheets. RESULTS One thousand nine hundred thirty-five ED patients registered during the 7-day study period in the summer of 2001. Four hundred error reports were generated, identifying 346 nonduplicative errors (18 per 100 registered patients; 95% confidence interval [CI] 15.9 to 20.0). Forty percent of errors were reported by nurses, 25% by providers, 19% by clerical staff, 13% by technicians and orderlies, and 3% multiple reporters. Errors reported for every 100 hours worked were similar for all groups (5.5; 95% CI 5.2 to 5.9). Errors were categorized as 22% diagnostic studies, 16% administrative procedures, 16% pharmacotherapy, 13% documentation, 12% communication, 11% environmental, and 9% other. Patients involved in errors were more likely to be older (P <.0001) and more likely to have higher visit level intensity (P <.0001) than registered ED patients. Ninety-eight percent of errors did not have a significant adverse outcome. Seven errors (0.36 per 100 registered patients; 95% CI 0.14 to 0.72) were associated with an adverse outcome. CONCLUSION Reported errors occurred in almost every aspect of emergency care. Ninety-eight percent of errors in the ED do not result in adverse outcomes. System changes need to be implemented to reduce ED errors.

Mortality probability models for patients in the intensive care unit for 48 or 72 hours: A prospective, multicenter study

ObjectiveTo develop models in the Mortality Probability Model (MPM II) system to estimate the probability of hospital mortality at 48 and 72 hrs in the intensive care unit (ICU), and to test whether the 24-hr Mortality Probability Model (MPM24), developed for use at 24 hrs in the ICU, can be used on a daily basis beyond 24 hrs. DesignA prospective, multicenter study to develop and validate models, using a cohort of consecutive admissions. SettingSix adult medical and surgical ICUs in Massachusetts and New York adjusted to reflect 137 ICUs in 12 countries. PatientsConsecutive admissions (n = 6,290) to the Massachusetts/New York ICUs were studied. Of these patients, 3,023 and 2,233 patients remained in the ICU and had complete data at 48 and 72 hrs, respectively. Patients <18 yrs of age, burn patients, coronary care patients, and cardiac surgical patients were excluded. Outcome MeasureVital status at the time of hospital discharge. ResultsThe models consist of five variables measured at the time of ICU admission and eight variables ascertained at 24-hr intervals. The 24-hr model demonstrated poor calibration and discrimination at 48 and 72 hrs. The newly developed 48− and 72-hr models—MPM48 and MPM72—contain the same 13 variables and coefficients as the MPM24. The models differ only in their constant terms, which increase in a manner that reflects the increasing probability of mortality with increasing length of stay in the ICU. These constant terms were adjusted by a factor determined from the relationship between the data from the six Massachusetts and New York ICUs and a more extensive data set, from which the ICU admission Mortality Probability Model (MPM0) and MPM24 were developed. This latter data set was assembled from ICUs in 12 countries. The MPM48 and MPM72 calibrated and discriminated well, based on goodness-of-fit tests and area under the receiver operating characteristic curve. ConclusionsModels developed for use among ICU patients at one time period are not transferable without modification to other time periods. The MPM48 and MPM72 calibrated well to their respective time periods, and they are intended for use at specific points in time. The increasing constant terms and associated increase in the probability of hospital mortality exemplify a common clinical adage that if a patients clinical profile stays the same, he or she is actually getting worse. (Crit Care Med 1994; 22:1351–1358)

Functional versus Structural Social Support and Health Care Utilization in a Family Medicine Outpatient Practice

Three hundred forty-three family-practice patients were surveyed by questionnaire and medical record audit to evaluate the relationships between social support and medical care utilization. Social support was not associated with laboratory test ordering. The mean number of office visits per year was higher for patients with low versus high confidant support (4.71 vs. 3.81, P < 0.10) and affective support (5.21 vs. 3.60, P < 0.05). Mean total charges in 1 year were higher for patients with low versus high confidant support (

Impact of Prevalent Fractures on Quality of Life: Baseline Results From the Global Longitudinal Study of Osteoporosis in Women

232 vs.

Relationship of Weight, Height, and Body Mass Index with Fracture Risk at Different Sites in Postmenopausal Women: The Global Longitudinal study of Osteoporosis in Women (GLOW)

148, P<0.05) and affective support (

Improving drug prescribing in a primary care practice.

244 vs.