Tom J. Wachtel

Quality of life in persons with human immunodeficiency virus infection : measurement by the medical outcomes study instrument

OBJECTIVE To assess the reliability and validity of the Medical Outcomes Study (MOS) Short Form Health Survey as an indicator for quality of life in patients infected with the human immunodeficiency virus (HIV). DESIGN Patient interview survey. SETTING The AIDS Health Services Program in seven sites: Newark and Jersey City, New Jersey; Nassau County, New York; Atlanta, Georgia; Dallas, Texas; Fort Lauderdale and Miami, Florida; New Orleans, Louisiana; and Seattle, Washington. PATIENTS Patients (520) with HIV infection receiving health services at one of the above sites. MEASUREMENTS All components of the MOS Short Form Health Survey were included in the interview. Minor modifications were made to adapt the survey to the particular circumstances of the study. Measured sociodemographic characteristics included age, sex, race, intravenous drug use, and education. Symptoms were assessed by closed-ended questions concerning memory, seizure, weakness or numbness, fever, chills, diaphoreses, dyspnea, diarrhea, and weight loss. Information on the frequency of symptoms was also collected. History of Pneumocystis carinii pneumonia and Kaposi sarcoma was noted. MAIN RESULTS The sociodemographic characteristics resemble those of patients with the acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control (CDC): mean age, 36; men, 89%; nonwhite, 31%; intravenous drug use, 34%. Neurologic symptoms (memory trouble, seizures, weakness or numbness) occurred in 71% of patients; constitutional symptoms (fever, chills, night sweats, weight loss) in 69%; dyspnea in 50%; and diarrhea in 47%. Although older age, female sex, nonwhite race, and intravenous drug use were associated with lower MOS scores in several areas, the strongest single or adjusted indicator of lower MOS scores was the presence of symptoms. Finally, patients with HIV infection had significantly lower scores than did previously reported patients with other chronic medical conditions (P less than 0.001). CONCLUSIONS The MOS survey is a reliable measure of quality of life for patients with HIV infection. These patients tend to have low scores, suggesting validity of the survey. The MOS survey is extremely sensitive to the effect of symptoms, which suggests that it might be useful as a quality-of-life indicator for AIDS clinical drug trials.

Differences in access to zidovudine (AZT) among symptomatic HIV-infected persons

Object:To evaluate socioeconomic factors that determine whether symptomatic HIV-infected persons are offered zidovudine (AZT).Design:Cross-sectional survey conducted as part of the Robert Wood Johnson Foundation’s AIDS Health Services Program.Setting:Public hospital clinics and community-based AIDS organizations in nine American cities.Patients:880 HIV-seropositive outpatients interviewed between October 1988 and May 1989.Main results:Males were more likely to have been offered AZT than were females (adjusted odds ratio 2.99; 95% confidence interval 1.67 to 5.36), those with insurance were more likely to have been offered AZT than were those without (adjusted odds ratio 2.00; 95% confidence interval 1.25 to 3.21), and whites more likely to have been offered AZT than were non-whites (adjusted odds ratio 1.73; 95% confidence interval 1.11 to 2.69). Intravenous drug users were less likely to have been offered AZT than were non-drug users (adjusted odds ratio 0.44; 95% confidence interval 0.28 to 0.69). Persons who had had an episode of Pneumocystis cariniipneumonia were more likely to have been offered AZT than were persons who had AIDS and had not had Pneumocystis cariniipneumonia (adjusted odds ratio 2.95; 95% confidence interval 1.71 to 5.11).Conclusion:The authors conclude that traditionally dis-advantaged groups have less access to AZT, the only antiretroviral agent demonstrated to increase survival of patients who have symptomatic HIV infection.

Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island

Objectives:Diabetic acidosis (DA) and the diabetic hyperosmolar state (DHS) are generally considered to be two distinct clinical entities. However, clinical experience and the literature suggest that there may be some overlap. The purposes of this study were 1) to establish the proportion of overlap cases, 2) to identify any occurrence of DHS in diabetic patients under the age of 30 years (likely type I) and any occurrence of DA in diabetic patients over the age of 60 years (likely type II), 3) to describe clinical factors associated with the development of DA and DHS, and 4) to identify factors that influence the prognosis of DHS.Patients and methods:613 cases were identified by retrospective chart review, using discharge information from all 15 Rhode Island community hospitals during 1986, 1987, and part of 1988. DA alone [serum glucose (glu)>300 mg/dL, bicarbonate (HCO3)<15mEq/L,calculated total serum osmolarity (osm)≤320 mOsm/L] was the diagnosis for 134 subjects (22%), DHS alone (glu>600 mg/dL, HCO3≥15 mEq/L, osm>320 mOsm/L), for 278 subjects (45%), and a mixed case (glu>600 mg/dL, HCO3<15mEq/L, osm>320 mOsm/L), for 200 subjects (33%). Information about serum or urinary ketones was available for 109 subjects who had DA alone [103 bad diabetic ketoacidosis (DKA)] and 144 subjects who had mixed DA and DHS (131 had mixed DKA and DHS). All the data were also analyzed using the effective osmolarity and a cutoff of 310 mOsm/L for this alternative case definition.Results:Patients with DA alone were younger (mean age 33 years) and patients with DHS alone were older (mean age 63 years). However, 28 (10%) of the 278 cases of DHS alone and 72 (36%) of the 200 cases of mixed DA and DHS occurred in patients under the age of 30. Eighteen cases (13%) of DA alone and 62 cases (31%) of mixed DA and DHS occurred in patients over the age of 60. The results were not substantially changed when effective osmolarity >310 mOsm/L was used to define hyperosmolarity and when only cases with documented DKA were included. An infection was the most common precipitating factor of DA (30%), DHS (27%), and mixed cases (32%). Other common associated factors included noncompliance with treatment (20% for DA, 12% for DHS, and 22% for mixed cases) and previously undiagnosed diabetes (24% for DA, 18% for DHS, and 10% for mixed cases). Nursing home residents accounted for 0.7% of DA cases, 18% of DHS cases, and 4.5% of mixed cases. Mortality was 4% for DA, 12% for DHS, and 9% for mixed cases. The mortality for DHS is the lowest reported in the literature, continuing a downward trend that began in the 1970s. Nonsurvival was associated with older age, higher osmolarity, and nursing home residence. Survival was associated with the presence of an infection.Conclusions:1) many patients experience mixed DA (DKA) and DHS rather than either condition alone, 2) both DA (DKA) and DHS occur in young and old diabetic persons, 3) infection is the most common predisposing factor for either condition, and 4) higher osmolarity, older age, and nursing home residence are associated with nonsurvival in DHS.

Practice guidelines to reduce testing in the hospital.

Objective:To reduce testing among bospitalized patients using practice guidelines for any of 14 medical problems.Design:Comparison of test use before and after implementation of guidelines. The guidelines were developed by consensus panels of self-selected participating physicians. Non-participating physicians were monitored during the same periods. In addition, the two groups of physicians were evaluated similarly for their management of three medical problems for which guidelines were not developed.Setting:Acute care hospital.Patients/participants:1,638 hospitalized patients and their 79 physicians.Intervention:Implementation of practice guidelines for the care of hospitalized patients.Measurement and main results:Geometric mean charges expressed in inflation-adjusted dollars were used as measures of test use. For the intervention group, laboratory tests decreased by 20.6%, x-rays by 42.3%, and EKGs by 34.2%. All the decreases were significant (p=0.001). The non-participating physicians who were higher test users during both years of the study also achieved significant (p<0.05) but smaller reductions during the intervention year: 13.9% for laboratory tests, 30.3% for x-rays, and 21.8% for EKGs, perhaps because the same residents were involved in the care of both groups of patients. For the non-guideline diagnoses, the participating physicians achieved reductions of 11.1% for laboratory tests and 19.2% for x-rays, and a 3.5% increase in EKGs. Two-way analyses of variance that took into account the reductions in testing achieved by non-participants, or by participants with non-guideline diagnoses, revealed no significant reduction in testing attributable directly to the guidelines except for EKGs. Follow up of the participating physicians during the six months after the end of the intervention revealed that testing remained at the lower level achieved while the guidelines were in use. Outcome of care, as measured by deaths in the hospital, deaths within 90 days of discharge, and readmissions within 90 days of discharge, was not affected by the use of the guidelines.Conclusions:1) A large group of physicians could be recruited in a hospital to establish practice guidelines by group consensus. 2) These self-selected physicians were willing to use the guidelines (or allow the bousestaff to use them) while caring for their patients. 3) Participating physicians were able to achieve substantial and significant reductions in testing without any demonstrable adverse effect on quality of care as measured by deaths and readmissions, and without any demonstrable shifting of resources from the inpatient to the outpatient setting of care. 4) The reductions in testing, whether caused by the guidelines or not, persisted for at least six months beyond the end of the period of implementation.

The end stage cancer patient: terminal common pathway.

ABSTRACTMeasures of symptom prevalence, awareness, physical function and quality of life associated with terminal cancer were collected during the National Hospice Study. Symptoms were common in te...

Prognostic Factors in the Diabetic Hyperosmolar State

To evaluate the current outcome of patients hospitalized with diabetic hyperosmolar state (DHS), we retrospectively studied 135 patients admitted to two general hospitals over an 11‐year period. Mortality was 17%. Patients who died had a mean age of 77 years, compared to 68 years for the survivors (P = 0.008). They were also more likely to be nursing home residents (48 versus 23%, P = 0.01). Additionally, mean serum osmolality was significantly higher among those who died (383 versus 358 mosm/L, P < 0.0001) as was blood urea nitrogen (81.3 versus 62.3 mg/dl, P = 0.006) and sodium (148 versus 137.4 mEq/L, P < 0.001). However, mean glucose level and anion gap were similar among patients who died and patients who survived (1068 versus 1092 mg%; 23 versus 24 mEq/L, respectively). The presence of a chronic disease or an acute comorbid illness was not associated with mortality. Diminished physiologic reserve, attendant comorbidity, or functional disability may explain the effect of age and nursing home residence. High osmolality may indicate a greater water deficit and a more advanced stage of DHS at the time of diagnosis.

A comprehensive support system for reducing house staff distress

The stresses of postgraduate medical training may lead to depression, impaired patient care, and a poor professional attitude. The goal of the Rhode Island Hospital House Staff Support System is to reduce stress among residents by providing them with a forum for their views and by offering counseling to those who need it. The authors report that the program has been well received during its first three years, and they offer guidelines for implementing similar support programs at other institutions.

Physicians’ utilization of health care

OBJECTIVE: To describe how physicians attend to their own health care needs.SETTING: Rhode Island.PARTICIPANTS: A random sample of Blue Cross/Blue Shield providers. The 306 respondents (67% of 458) primarily (92%) had MD or DO degrees. The nonphysician providers were chiropractors, dentists, optometrists, and podiatrists.DESIGN: A mailed survey provided data describing the respondents’ medical conditions and utilization of formal and informal care during a three-year period. Questions asked about provider visits, physical examinations, preventive and diagnostic tests, and medication use. The respondents indicated whether services had been initiated by themselves or by another physician.MAIN RESULTS: The physicians’ overall use of formal health services was low; their number of office visits was a fourth of the national average. Two-thirds of the respondents reported having a primary care physician, and one-third had sought informal care. The respondents’ use of preventive services was high. During the three-year period, 82% of the women physicians had received a Pap test, and 81% of the women physicians over the age of 40 years had received mammography. Cholesterol levels were checked for more than two-thirds of all the respondents. Medical examinations and laboratory tests tended to be ordered by another physician, although self-prescribing was not uncommon. Furthermore, 61% of the respondents had self-prescribed at least one medication.CONCLUSIONS: Physicians’ care-seeking behavior covers a broad spectrum, ranging from self-care, to informal consultation, to formal treatment by another physician. Physicians appear to be low users of formal services overall, but high users of preventive care.

The Impact of Age on the Quality of Life in Persons with HIV Infection

The authors administered the Medical Outcomes Study (MOS 20) Short Form Health Survey to 369 persons with HIV disease. The MOS survey measures six domains of health: physical function, role function, social function, mental health, health perception, and pain. Additional data included sociodemographics, HIV risk group, time since HIV diagnosis, symptoms (dyspnea, diarrhea, fever, chills, sweats, weight loss, weakness, numbness, memory trouble, seizures), and CD4 lymphocyte count within 3 months of the MOS survey. Bivariate analyses revealed worse MOS scores associated with older age in five health domains: physical function (p < .01), health perception (p < .10), role function (n.s.), social function (n.s.), and mental health (n.s.). Older subjects reported less pain. When controlling for CD4 count and for sociodemographic and clinical variables, older age was significantly (p <.05) associated with worse MOS scores in physical function, social function, and health perception, nonsignificantly associated with worse MOS scores in role function and mental health, and nonsignificantly associated with less reporting of pain.

Patient characteristics associated with the use of mechanical restraints.

Study objective:To compare the characteristics of restrained patients with those of unrestrained patients by assessing a number of medical, behavioral, and cognitive variables including a disruptive-behavior inventory.Design:Case-control study.Setting:A 719-bed university-affiliated teaching hospital.Patients:The 80 cases were patients identified by the nursing staff as having had a restraint applied within the last 24 hours prior to entry in the study. The 80 unrestrained controls were selected from the rooms adjacent to the cases’ in order to match for proximity to the nursing station and nurse staffing.Measurements and main results:Demographic data, data on diagnoses and treatments, results of the Folstein Mini-Mental State (MMS) test and an eight-item disruptive-behavior inventory, and outcome information were obtained for each patient using a standardized procedure. Three important patient characteristics were significantly associated with restraint use in a multiple logistic regression model: disruptive behaviors, nursing assessment of risk of falling, and cognitive impairment. Cases were older than controls, but age was not an independent characteristic associated with restraint use when controlling for cognitive impairment, risk of falling, and disruptive behaviors.Conclusions:Restraint use was more likely in patients with disruptive behaviors, at risk of falling, and with cognitive impairment. Attention to these factors and alternative strategies for dealing with them may reduce the use of physical restraints.