Zara Cooper

Residual symptoms after partial remission : an important outcome in depression

This paper draws attention to an important adverse outcome in depression, the occurrence of residual symptoms after partial remission. Among patients with definite major depression followed every 3 months to remission and thereafter, residual symptoms reaching 8 or more on the Hamilton Depression Scale 17-item total were present in 32% (19) of the 60 who remitted below major depression by 15 months. The pattern was of mild but typical depressive symptoms. Residual symptoms were more common in subjects with more severe initial illness, but were not related to any other predictors, including longer prior illness, dysthymia, or lower dose of drug treatment during the illness episode. There were weak associations with personality that might have been consequences of symptom presence. Residual symptoms were very strong predictors of subsequent early relapse, which occurred in 76% (13/17) of those with residual symptoms and 25% (10/40) of those without.

Remission and relapse in major depression: a two-year prospective follow-up study.

This paper reports the course with respect to remission and relapse of a cohort of predominantly in-patient RDC major depressive subjects, who were followed at 3-monthly intervals to remission and for up to 15 months thereafter. Remission was comparatively rapid with 70% of subjects remitting within 6 months. Only 6% failed to do so by 15 months. However, 40% relapsed over the subsequent 15 months, with all the relapses occurring in the first 10 months. Greater severity of the depression and longer duration of the illness predicted a longer time to remission. Greater initial severity of depression also predicted relapse. Subjects with a worse outcome had not received less adequate treatment than the remainder. Our results confirm the comparatively poor outcome subsequent to remission that has been reported in recent literature, in spite of the availability of modern methods of treatment. The clustering of relapses in the first 10 months gives some support to the distinction between relapse and later recurrence.

Life events, social support and marital relationships in the outcome of severe depression.

The effects of life events, social support and marital relationships on outcome were examined in a predominantly recurrent in-patient sample of depressives studied longitudinally every 3 months to remission and up to 15 months thereafter. Outcomes examined were length of time to remission, presence of residual symptoms at remission, and subsequent relapse. There were few associations between these outcomes and the social variables. These findings add to other recent evidence that psychosocial factors are relatively unimportant in the subsequent course of severe and recurrent depressions, in contrast to their contribution to onset of such depressions and subsequent outcome of milder depressions.

Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults.

IMPORTANCE Major postoperative complications and delirium contribute independently to adverse outcomes and high resource use in patients who undergo major surgery; however, their interrelationship is not well examined. OBJECTIVE To evaluate the association of major postoperative complications and delirium, alone and combined, with adverse outcomes after surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study in 2 large academic medical centers of 566 patients who were 70 years or older without recognized dementia or a history of delirium and underwent elective major orthopedic, vascular, or abdominal surgical procedures with a minimum 3-day hospitalization between June 18, 2010, and August 8, 2013. Data analysis took place from December 13, 2013, through May 1, 2015. MAIN OUTCOMES AND MEASURES Major postoperative complications, defined as life-altering or life-threatening events (Accordion Severity grade 2 or higher), were identified by expert-panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated medical record review method. The following 4 subgroups were analyzed: (1) no complications or delirium; (2) complications only; (3) delirium only; and (4) complications and delirium. Adverse outcomes included a length of stay (LOS) of more than 5 days, institutional discharge, and rehospitalization within 30 days of discharge. RESULTS In the 566 participants, the mean (SD) age was 76.7 (5.2) years, 236 (41.7%) were male, and 523 (92.4%) were white. Forty-seven patients (8.3%) developed major complications and 135 (23.9%) developed delirium. Compared with no complications or delirium as the reference group, major complications only contributed to prolonged LOS only (relative risk [RR], 2.8; 95% CI, 1.9-4.0); by contrast, delirium only significantly increased all adverse outcomes, including prolonged LOS (RR, 1.9; 95% CI, 1.4-2.7), institutional discharge (RR, 1.5; 95% CI, 1.3-1.7), and 30-day readmission (RR, 2.3; 95% CI, 1.4-3.7). The subgroup with complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR, 3.4; 95% CI, 2.3-4.8), institutional discharge (RR, 1.8; 95% CI, 1.4-2.5), and 30-day readmission (RR, 3.0; 95% CI, 1.3-6.8). Delirium exerted the highest attributable risk at the population level (5.8%; 95% CI, 4.7-6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission). CONCLUSIONS AND RELEVANCE Major postoperative complications and delirium are separately associated with adverse events and demonstrate a combined effect. Delirium occurs more frequently and has a greater effect at the population level than other major complications.

The excess morbidity and mortality of emergency general surgery.

BACKGROUND Emergency general surgery (EGS) carries a disproportionate burden of risk from medical errors, complications, and death compared with non-EGS (NEGS). Previous studies have been limited by patient and procedure heterogeneity but suggest worse outcome in EGS patients because of preoperative risk factors. The aim of this study was to quantify the excess burden of morbidity and mortality associated with EGS by controlling for patient-specific factors. We hypothesized that EGS is an independent risk factor for morbidity and mortality. METHODS We retrospectively analyzed data from the American College of Surgeons-National Surgical Quality Improvement Program. Fourteen procedures common to both EGS and NEGS from 2008 through 2012 were included. Patients were stratified based on emergency status. The primary outcome was death within 30 days of operation. Secondary outcomes were postoperative complications. Variables from the American College of Surgeons-National Surgical Quality Improvement Program preoperative risk assessment were analyzed. &khgr;2 and Wilcoxon signed-rank tests were used to compare variables. Multivariate logistic regression was used to identify independent risk factors for mortality and complications. RESULTS Of 66,665 patients, 24,068 were EGS and 42,597 were NEGS. Mortality was 12.50% for EGS patients and 2.66% for NEGS patients (p < 0.0001). Major complications occurred in 32.80% of EGS patients and 12.74% of NEGS patients (p < 0.0001). When preoperative variables and procedure type were controlled, EGS was independently associated with death (odds ratio, 1.39; p = 0.029) and major complications (odds ratio, 1.31; p = 0.001). CONCLUSION EGS is an independent risk factor for death and postoperative complications. The excess morbidity and mortality of EGS are not fully explained by preoperative risk factors, making EGS an excellent target for quality improvement projects. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Injury in the aged: geriatric trauma care at the crossroads

In the 2010 US Census, the number of persons age 65 years and older constituted 13% of the population and is projected to constitute 22% of the population by 2020.1 As the US population ages, there is an increasing volume of GTPs; injury is now the seventh leading cause of death for those age 65 years.2 Geriatric trauma is increasing both in absolute number and as a proportion of annual volume presenting to trauma centers. Based on the National Trauma Data Bank, the proportion of trauma patients aged 65 years or older in Level I and II trauma centers increased from 23% in 2003 to 30% in 2009. This is likely a significant underestimate because most GTPs are treated at lower-level or nontrauma centers.3,4 In Washington State, for example, the annual number of GTPs in the state registry has increased from 4,266 in 2000 to 11,226 in 2012, an increase from 30% to 42% of the total trauma population. Clearly, the management of injury in geriatric patients will continue to be a major challenge for trauma care providers. In his presidential address to the AAST entitled “For the care of the undeserved,” Dr. Robert Mackersie identified the growing population of elderly injured patients as medically underserved in terms of limited trauma center access, age-related treatment biases, and as a result, deprived of many of the recent advances in modern trauma care.5 To specifically address these inequalities, he convened an Ad Hoc Geriatric Committee and charged it, “To advise the AAST regarding the problems, issues, and needs of the geriatric patient.” What follows is the work product of the Committee in responding to President Mackersie’s charge. The initial priority was to survey the membership of the AAST to better understand the current conditions under which hospitalized GTPs are receiving care. The second task of the Committee was to enumerate the major problems associated with the care of GTPs and to suggest potential solutions to the identified problems. While the Committee does not presume infallibility in its pronouncements, the material presented is intended to initiate discussion, stimulate research, and to ultimately result in evidence-based guidelines that will better serve this “underserved” segment of our population.

Measuring critical deficits in shared decision making before elective surgery

OBJECTIVE Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of deficiencies in informed surgical consent and shared decision-making in preoperative patients. METHODS Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings. RESULTS 13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits. CONCLUSION Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process. PRACTICE IMPLICATIONS Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.

Withdrawal of life-sustaining therapy in injured patients: variations between trauma centers and nontrauma centers.

BACKGROUND We sought to identify patient and institutional variables predictive of a withdrawal of care order (WOCO) in trauma patients. We hypothesized that the frequency of WOCO would be higher at trauma centers. METHODS Data from the National Study on the Costs and Outcomes of Trauma were used to determine associations between WOCO status and patient characteristics, institutional characteristics, and hospital course. chi, t tests, and multivariate analysis were used to identify variables predictive of WOCO. RESULTS Of 14,190 patients, 618 (4.4%) had WOCO, which accounted for 60.9% of patients who died in hospital. Age (p = <0.001), race (p = <0.001), comorbidity (p = <0.001), and injury mechanism were associated with WOCO (p = 0.03). WOCO patients had higher New Injury Severity Score (p = <0.001), lower Glasgow Coma Scale motor scores (p = <0.001), and higher incidence of midline shift on head computed tomography (p = 0.01). Trauma center status (odds ratio, 1.56; 95% confidence interval, 1.06-2.30) and closed intensive care units (odds ratio, 1.53; 95% confidence interval, 1.03-2.25) were also predictive of a WOCO. There was a sizable variation (0%-16%) in the percentage of patients with WOCO across centers. CONCLUSION Most trauma patients who die in hospital do so after a WOCO. Although trauma center status and closed intensive care units are predictive of a WOCO, variation in the percentage of patients with WOCO across all centers speaks to the complexity of these decisions. Further investigation is needed to understand how a WOCO is applied to trauma patients.

Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions.

OBJECTIVE To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies. SUMMARY BACKGROUND DATA Improved communication is increasingly recognized as a central element in providing goal-concordant care and reducing health care utilization and costs among seriously ill older patients. Given high rates of surgery in the last weeks of life, high risk of poor outcomes after emergency operations in these patients, and barriers to quality communication in the acute setting, we sought to create a framework to support surgeons in communicating with seriously ill, older patients with surgical emergencies. METHODS An interdisciplinary panel of 23 national leaders was convened for a 1-day conference at Harvard Medical School to provide input on concept, content, format, and usability of a communication framework. A prototype framework was created. RESULTS Participants supported the concept of a structured approach to communication in these scenarios, and delineated 9 key elements of a framework: (1) formulating prognosis, (2) creating a personal connection, (3) disclosing information regarding the acute problem in the context of the underlying illness, (4) establishing a shared understanding of the patients condition, (5) allowing silence and dealing with emotion, (6) describing surgical and palliative treatment options, (7) eliciting patients goals and priorities, (8) making a treatment recommendation, and (9) affirming ongoing support for the patient and family. CONCLUSIONS Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.

Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery

IMPORTANCE Hospital readmission rates following surgery are increasingly being used as a marker of quality of care and are used in pay-for-performance metrics. To our knowledge, comprehensive data on readmissions to the initial hospital or a different hospital after emergency general surgery (EGS) procedures do not exist. OBJECTIVE To define readmission rates and identify risk factors for readmission after common EGS procedures. DESIGN, SETTING, AND PARTICIPANTS Patients undergoing EGS, as defined by the American Association for the Surgery of Trauma, were identified in the California State Inpatient Database (2007-2011) on January 15, 2015. Patients were 18 years and older. We identified the 5 most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Patient demographics (sex, age, race/ethnicity, and insurance type) as well as Charlson Comorbidity Index score, length of stay, complications, and discharge disposition were collected. Factors associated with readmission were determined using multivariate logistic regression models analysis. MAIN OUTCOMES AND MEASURES Thirty-day hospital readmission. RESULTS Among 177,511 patients meeting inclusion criteria, 57.1% were white, 48.8% were privately insured, and most were 45 years and older (51.3%). Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures. The overall 30-day readmission rate was 5.91%. Readmission rates ranged from 4.1% (upper gastrointestinal) to 16.8% (cardiothoracic). Of readmitted patients, 16.8% were readmitted at a different hospital. Predictors of readmission included Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio: 2.26 [95% CI, 2.14-2.39]), leaving against medical advice (adjusted odds ratio: 2.24 [95% CI, 1.89-2.66]), and public insurance (adjusted odds ratio: 1.55 [95% CI, 1.47-1.64]). The most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%). CONCLUSIONS AND RELEVANCE Readmission after EGS procedures is common and varies widely depending on patient factors and diagnosis categories. One in 5 readmitted patients will go to a different hospital, causing fragmentation of care and potentially obscuring the utility of readmission as a quality metric. Assisting socially vulnerable patients and reducing postoperative complications, including infections, are targets to reduce readmissions.