Susan Jaglal

Multicenter Validation of a Risk Index for Mortality, Intensive Care Unit Stay, and Overall Hospital Length of Stay After Cardiac Surgery

BACKGROUND A multicenter population-based study was conducted to develop and validate a risk index for mortality, intensive care unit (ICU) length of stay, and postoperative length of stay after cardiac surgery. METHODS AND RESULTS Data were collected from 13,098 patients undergoing cardiac surgery between April 1, 1991, and March 31, 1993, at all nine adult cardiac surgery institutions in Ontario, Canada. A six-variable risk index (age, sex, left ventricular function, type of surgery, urgency of surgery, and repeat operation) was developed using logistic regression analysis to predict in-hospital mortality, ICU stay in days, and postoperative stay in days after cardiac surgery in a derivation set of 6213 patients who had cardiac surgery during fiscal year 1991 (April 1, 1991, to March 31, 1992). The index predicted mortality, prolonged ICU stay (> or = 6 days), and prolonged postoperative length of stay (> or = 17 days) after cardiac surgery with areas under the receiver-operating characteristic (ROC) curve of 0.75, 0.66, and 0.69, respectively, in an independent validation set of 6885 patients who had cardiac surgery during fiscal year 1992 (April 1, 1992, to March 31, 1993). Increasing risk scores were associated with greater mortality rates and longer ICU and postoperative stays at all nine institutions. CONCLUSIONS Mortality, ICU length of stay, and postoperative length of stay after cardiac surgery can be predicted using a simple six-variable risk index. The index has potential application as a risk stratification tool for comparing patient outcomes and resource use among different hospitals and surgeons.

Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong?

A worldwide epidemic of hip fractures has been predicted. Time trends in BMD testing, bone‐sparing medications and hip and wrist fractures in the province of Ontario, Canada, were examined. From 1996 to 2001, BMD testing and use of bone‐sparing medications increased each year, whereas despite the aging of the population, wrist and hip fracture rates decreased.

Practitioner and Organizational Barriers to Evidence-based Practice of Physical Therapists for People With Stroke

Background and Purpose: The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists’ implementation of evidence-based practice (EBP) for people with stroke. Subjects: The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada. Methods: A cross-sectional mail survey was conducted. Results: Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature. Discussion and Conclusion: Lack of education, negative perceptions about research and physical therapists’ role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.

The effect of hospital type and surgical delay on mortality after surgery for hip fracture

Death during the first year after hip fracture may be influenced by the type of hospital in which patients are treated as well as the time spent awaiting surgery. We studied 57,315 hip fracture patients who were admitted to hospital in Ontario, Canada. Patients treated in teaching hospitals had a decreased risk of in-hospital mortality (odds ratio (OR) 0.89; 95% confidence interval (CI) 0.83 to 0.97) compared with those treated in urban community institutions. There was a trend toward increased mortality in rural rather than urban community hospitals. In-hospital mortality increased as the surgical delay increased (OR 1.13; 95% CI 1.10 to 1.16) for a one-day delay and higher (OR 1.60; 95% CI 1.42 to 1.80) for delays of more than two days. This relationship was strongest for patients younger than 70 years of age and with no comorbidities but was independent of hospital status. Similar relationships were seen at three months and one year after surgery. This suggests that any delay to surgery for non-medical reasons is detrimental to a patients outcome.

Should Calcaneal Fractures Be Treated Surgically?: A Metaanalysis

A MEDLINE search from 1980 through 1996 revealed 1845 articles dealing with calcaneal fractures. Six of these articles that compared operative versus nonoperative treatment for displaced calcaneal fractures met the minimum criteria for inclusion in a metaanalysis. A statistical summary of information across the six articles revealed a trend for surgically treated patients to be more likely to return to the same type of work as compared with nonoperatively treated individuals. There also was a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients. Unfortunately, none of the other outcomes could be summarized formally across studies using statistical techniques because of variability in reporting across studies. Although the tendency was always for operatively treated patients to have better outcomes (reaching statistical significance in some of the articles), the strength of evidence to recommend operative treatment for displaced intraarticular calcaneal fractures remains weak. A large prospective randomized controlled trial should be able to answer this question.

The validity of decision rules for selecting women with primary osteoporosis for bone mineral density testing

The purpose of this study was to determine the validity of the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST) chart and equation, and a criterion based on body weight for identifying women with asymptomatic primary osteoporosis. Prospective recruitment and chart abstractions from family practices of three University affiliated hospitals were completed for women aged 45 years or more with baseline bone mineral density (BMD) testing results by dual energy X-ray absorptiometry. Those taking bone active medication other than hormone therapy, with prior fragility fracture or with risk factors for secondary osteoporosis were excluded. Women were categorized as being normal, osteopenic or osteoporotic by lowest BMD T-score at either the femoral neck or lumbar spine (L1–L4). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve to identify those with osteoporosis were determined for each decision rule. The positive predictive value (PPV) for detecting osteoporosis after using a second cut point to convert each decision rule into a risk index (low, moderate or high risk) was also determined. The sensitivity of the decision rules to identify women with osteoporosis ranged from 92% to 95% and specificity from 35% to 46%. The area under the ROC curves were significantly better for the ORAI (0.80), OST chart (0.82) and OST equation (0.82) compared with the body weight criterion (0.73). PPV for detecting osteoporosis ranged from 30% to 58% among women deemed at high risk. These data confirm the validity of the ORAI, the OST chart and the OST equation as screening tools for BMD testing. Further evidence is required to confirm the validity of the body weight criterion.

Risk Factors for Harm in Cognitively Impaired Seniors Who Live Alone: A Prospective Study

Objectives: To identify risk factors for harm due to self‐neglect or behaviors related to disorientation in cognitively impaired seniors who live alone that can be used in primary care.

A PROSPECTIVE COMPARISON OF CARDIAC REHABILITATION ENROLLMENT FOLLOWING AUTOMATIC VS USUAL REFERRAL

OBJECTIVE Cardiac rehabilitation remains grossly under-utilized despite its proven benefits. This study prospectively compared verified cardiac rehabilitation enrollment following automatic vs usual referral, postulating that automatic referral would result in significantly greater enrollment for cardiac rehabilitation. DESIGN Prospective controlled multi-center study. PATIENTS AND METHODS A consecutive sample of 661 patients with acute coronary syndrome treated at 2 acute care centers (75% response rate) were recruited, one site with automatic referral via a computerized prompt and the other with a usual referral strategy at the physicians discretion. Cardiac rehabilitation referral was discerned in a mailed survey 9 months later (n = 506; 84% retention), and verified with 24 cardiac rehabilitation sites to which participants were referred. RESULTS A total of 124 (52%) participants enrolled in cardiac rehabilitation following automatic referral, vs 84 (32%) following usual referral (p < 0.001). Automatically referred participants were more likely to be referred from an in- patient unit (p < 0.01), and to be referred in a shorter time period (p < 0.001). Logistic regression analyses revealed that, after controlling for sociodemographic characteristics and case-mix, automatically referred participants were significantly more likely to enroll in cardiac rehabilitation (odds ratio = 2.1; 95% confidence interval 1.4-3.3) than controls. CONCLUSION Automatic referral resulted in over 50% verified cardiac rehabilitation enrollment; 2 times more than usual referral. It also significantly reduced utilization delays to less than one month.

Validation of the simple calculated osteoporosis risk estimation (SCORE) for patient selection for bone densitometry.

Abstract: Bone densitometry using dual energy X-ray absorptiometry (DXA) is the ‘gold standard’ for osteoporosis diagnosis. However, mass screening for osteoporosis has not been recommended, and no consensus has been reached regarding specific targeted screening programs. Recently, the Simple Calculated Osteoporosis Risk Estimation (SCORE) was developed to identify postmenopausal women likely to have low BMD (≤−2.0 SD of the young adult normal), who may be selected for DXA testing. This instrument uses a case-selective approach to screen for osteoporosis by summing a score based on: age, race, rheumatoid arthritis, history of nontraumatic fracture over 45 years of age, estrogen use, and weight. In our study, SCORE was validated using 398 postmenopausal women at least 45 years of age residing within 50 km of Toronto, Ontario, Canada (one of 9 centers of the Canadian Multicentre Osteoporosis Study, a national population-based study). At the recommended threshold of 6, SCORE had a sensitivity of 90%, specificity of 32% and a positive predictive value of 64%. From receiver operating characteristic (ROC) analysis, no threshold identified SCORE as a useful instrument in our population; area under the ROC curve was 0.71. Specificity of the SCORE is poor; at the recommended threshold of 6, 68% of those with normal bone mineral density (BMD) would be selected for bone densitometry. Development and validation of SCORE by Lydick and colleagues may have been confounded by the nature of the study sample; sampling from specialty clinics; and by the choice of outcome, combining data from different DXA machines, and using only data from the femoral neck to identify low BMD. A simple and effective approach to select patients for bone densitometry has yet to be established.

Does the Apolipoprotein e4 Allele Predispose Varsity Athletes to Concussion? A Prospective Cohort Study

Objective:To determine the association between the apolipoprotein ϵ4 allele and concussion. We hypothesized that apolipoprotein ϵ4 carriers may be more likely to sustain a concussion. Design:Prospective cohort study. Setting:University of Toronto varsity athletics. Participants:Included 318 of 822 collegiate student athletes who participated in University of Toronto varsity sports from September 2002 to April 2006. Assessment of Risk Factors:The presence of apolipoprotein ϵ4 was described dichotomously after genotyping blood samples collected from participants. Main Outcome Measurements:Concussions were identified by sport-medicine professionals present on the sidelines using on-field assessment forms. All concussion diagnoses were verified by a sports medicine physician. Survival analysis was used to determine the association between apolipoprotein ϵ4 and first concussion. Results:The unadjusted hazard ratio for concussion in the apolipoprotein ϵ4 carriers was 1.18 (95% CI: 0.52, 2.69) compared to noncarriers. Adjustment for sex, weight, height, and team type resulted in a hazard ratio of 1.06 (95% CI: 0.41, 2.72), indicating little effect from confounding factors. Conclusions:There is no important association between carrying the apolipoprotein ϵ4 allele and sustaining a concussion. At this time, we do not recommend preseason genetic testing for varsity athletes as a mechanism for targeting prevention strategies.