Differences In Types Of Patients Research Articles

1030: OCCULT HYPOXEMIA AND PULSE OXIMETRY PERFORMANCE ACROSS SKIN PIGMENTATION GROUPS

Introduction: Pulse oximetry accuracy reportedly varies by race (Henry et al. Crit Care Med 2022; Sjoding et al. N Engl J Med 2021). However, since race correlates weakly with skin pigmentation, it is more precise to evaluate pulse oximeter performance by skin pigmentation (He et al, J Am Acad Dermatol 2014). The purpose of this analysis was to assess Nellcor™ pulse oximetry performance across varying skin pigmentations for blood oxygen saturations between 80-92%, when occult hypoxemia, with errors of ≥4% occur between SpO2 and SaO2, can occur (Henry et al. Crit Care Med 2022). Methods: This retrospective analysis included Medtronic-sponsored healthy adult volunteer studies conducted between July 2003 and February 2017. In each study, a Nellcor™ pulse oximeter (MAXA, MAXN, MAXFAST, or FLEXMAX) measured arterial blood oxygenation, in comparison to co-oximeter-measured SaO2 (ISO 80601-2-61 aligned) during controlled hypoxia. Skin pigmentation was visually assessed using a 4-level scale: very light, olive, dark olive, and extremely dark. Results: 69 very light or olive volunteers (light skin pigmentation) and 19 dark olive or extremely dark volunteers (dark skin pigmentation) were included. For arterial oxygen saturations between 80-92%, the light and dark skin pigmentation groups had bias of 0.05% (95%CI 0.01-0.09) and 0.30% (95%CI 0.22-0.38); precision of 1.39% (95%CI 1.36-1.41) and 1.54% (95%CI 1.49-1.60); and root-mean square deviation (RMSD) of 1.39% and 1.57%. The percentage of data points with SpO2-SaO2 error ≥4%, the minimum required for occult hypoxemia, was 0.79% (N=40/5098) and 0.54% (N=8/1518) for the light and dark skin pigmentation groups. Conclusions: In both groups, RMSD remained within device specifications (±2), with increased error in individuals with dark skin pigmentation. For both skin pigmentation groups, observed errors of ≥4% occurred < 1% between 80-92% SpO2, whereas the literature has reported occult hypoxemia rates of 3.6%-6.6% (Henry et al. Crit Care Med 2022). This discrepancy may be due to differences in patient type, timing of SpO2/SaO2 readings, the amount of motion noise across studies, and the limited sample size in this retrospective analysis. Additional research is needed to characterize pulse oximetry performance and ensure accuracy across all skin pigmentations.

The association between payment model and specialist physicians' selection of patients with diabetes: a descriptive study.

As the number of people with chronic diseases increases, understanding the impact of payment model on the types of patients seen by specialists has implications for improving the quality and value of care. We sought to determine if there is an association between specialist physician payment model and the types of patients seen. In this descriptive study, we used administrative data to compare demographic characteristics, illness severity and visit indication of patients with diabetes seen by fee-for-service and salary-based internal medicine and diabetes specialists in Calgary and Edmonton between April 2011 and September 2014. The study cohort included all newly referred adults with diabetes (no appointment with a specialist in prior 4 yr). Diabetes was identified using a validated algorithm that excludes gestational diabetes. Patients managed by salary-based physicians (n = 2736) were sicker than those managed by fee-for-service physicians (n = 21 218). Patients managed by salary-based specialists were more likely to have 5 or more comorbidities (23.0% [n = 628] v. 18.1% [n = 3843]) and to have been admitted to hospital or seen in an emergency department for an ambulatory care sensitive condition in the year before their index visit, probably reflecting poorer disease control or barriers to optimal outpatient care. A higher proportion of visits to salary-based physicians were for appropriate indications (65.2% [n = 744] v. 55.6% [n = 5553]; risk ratio 1.17, 95% confidence interval 1.09-1.27). Salary-based specialists were more likely to see patients with a clear indication for a specialist visit, while fee-for-service specialists were more likely to see healthier patients. Future research is needed to determine if the differences in types of patients are attributable to payment model or other provider- or system-level factors.

Hospital performance indicators in the Netherlands: a preterm delivery

Information on the performance of physicians and hospitals is increasingly used by health authorities to monitor and improve health care. Two general types of health care assessments exist: those that measure outcome and those that measure process. Examples of outcome-based reporting include those of US cardiac surgeons’ and hospitals’ mortality rates following coronary artery bypass graft (CABG) surgery.2 Outcome-based reporting may seem to provide objective measures of performance. However, given the many variables that impact on clinical outcomes, most importantly the differences in types of patients and referral patterns (‘case-mix’) among hospitals, these parameters may at the same time be misleading.3 Process-based assessments, frequently called quality indicators, report on rates of medical interventions, such as screening tests and medication use, which are assumed to be related to outcomes.

Are Comparisons of Consumer Satisfaction With Providers Biased by Nonresponse or Case-Mix Differences?

Are Comparisons of Consumer Satisfaction With Providers Biased by Nonresponse or Case-Mix Differences?

Malaria in travelers: a review of the GeoSentinel surveillance network.

Malaria is a common and important infection in travelers. We have examined data reported to the GeoSentinel surveillance network to highlight characteristics of malaria in travelers. A total of 1140 malaria cases were reported (60% of cases were due to Plasmodium falciparum, 24% were due to Plasmodium vivax). Male subjects constituted 69% of the study population. The median duration of travel was 34 days; however, 37% of subjects had a travel duration of < or =4 weeks. The majority of travellers did not have a pretravel encounter with a health care provider. Most cases occurred in travelers (39%) or immigrants/refugees (38%). The most common reasons for travel were to visit friends/relatives (35%) or for tourism (26%). Three-quarters of infections were acquired in sub-Saharan Africa. Severe and/or complicated malaria occurred in 33 cases, with 3 deaths. Compared with others in the GeoSentinel database, patients with malaria had traveled to sub-Saharan Africa more often, were more commonly visiting friends/relatives, had traveled for longer periods, presented sooner after return, were more likely to have a fever at presentation, and were less likely to have had a pretravel encounter. In contrast to immigrants and visitors of friends or relatives, a higher proportion (73%) of the missionary/volunteer group who developed malaria had a pretravel encounter with a health care provider. Travel to sub-Saharan Africa and Oceania was associated with the greatest relative risk of acquiring malaria. We have used a global database to identify patient and travel characteristics associated with malaria acquisition and characterized differences in patient type, destinations visited, travel duration, and malaria species acquired.

Interpretation of hospital-specific outcome measures based on routine data.

Hospital-specific outcome measures based on routine data are useful for stimulating interest in quality of care and for suggesting avenues for more in-depth analyses. They might also identify serious, once-in-a-lifetime failures of health care. However, such analyses are not definitive. They are a way of screening large amounts of routine data and, like all screening tools, they can generate false positives and false negatives. This is because differences in outcome measures across hospitals can be due to differences in types of patients seen (casemix), differences in data quality, and the play of chance; rather than differences in the quality of care. End-users of such analyses should be aware of these technical difficulties, otherwise skilled health workers in high-quality hospitals might be subjected to unwarranted criticism.

Interventions for the treatment of burning mouth syndrome.

The complaint of a burning sensation in the mouth can be said to be a symptom of other disease or a syndrome in its own right of unknown aetiology. In patients where no underlying dental or medical causes are identified and no oral signs are found, the term burning mouth syndrome (BMS) should be used. The prominent feature is the symptom of burning pain which can be localised just to the tongue and/or lips but can be more widespread and involve the whole of the oral cavity. Reported prevalence rates in general populations vary from 0.7% to 15%. Many of these patients show evidence of anxiety, depression and personality disorders. The objectives of this review are to determine the effectiveness and safety of any intervention versus placebo for relief of symptoms and improvement in quality of life and to assess the quality of the studies. Electronic databases (The Cochrane Library, the Cochrane Oral Health Group's Specialised Register, MEDLINE, EMBASE), Clinical Evidence Issue No. 3, conference proceedings and bibliographies of identified publications were searched to identify the relevant literature, irrespective of language of publication. Studies were selected if they met the following criteria: study design - randomised controlled trials (RCTs) and controlled clinical trials (CCTs) which compared a placebo against one or more treatments; participants - patients with burning mouth syndrome, that is, oral mucosal pain with no dental or medical cause for such symptoms; interventions - all treatments that were evaluated in placebo-controlled trials; primary outcome - relief of burning/discomfort Articles were screened independently by two reviewers to confirm eligibility and extract data. The reviewers were not blinded to the identity of the studies. The quality of the included trials was assessed independently by two reviewers, with particular attention given to allocation concealment, blinding and the handling of withdrawals and drop-outs. Due to differences in patient type, treatment and outcome measures, statistical pooling of the data was inappropriate. Six trials were included in the review. The interventions examined were antidepressants (two trials), cognitive behavioural therapy (one trial), analgesics (one trial), hormone replacement therapy (one trial) and vitamin complexes (one trial). The participants included in the six identified trials reported suffering from BMS from six months to 20 years. Diagnostic criteria were not always clearly reported. Out of the six trials included in the review, only two interventions demonstrated a reduction in BMS symptoms; vitamin complexes and cognitive behavioural therapy. Neither of these studies reported using blind outcome assessment. Although none of the other treatments examined in the included studies demonstrated a significant reduction in BMS symptoms, this may be due to methodological flaws in the trial design, or small sample size, rather than a true lack of effect. Given the chronic nature of BMS, the need to identify an effective mode of treatment for sufferers is vital. However, there is little research evidence that provides clear guidance for those treating patients with BMS. Further trials, of high methodological quality, need to be undertaken in order to establish effective forms of treatment for patients suffering from BMS.

The Descriptive Assessment for Psychiatric Art (DAPA): update and further research.

Painting and drawing is used as a treatment modality in psychiatry; however, assessments presently lack valid and reliable measures. We used the DAPA, a published quantitative measure of adult psychiatric artwork on a sample of painting produced in naturalistic conditions by 86 inpatients with four major categories of disabling psychiatric disorders and 23 controls. The replication was successful. Clear broad differences between psychiatric patients and controls and discrete differences in patient type can be differentiated when the conditions under which the patients produce their work are not controlled.

Audit of outpatients: entering the loop.

To develop and test a method for routine data collection to observe current practice in outpatient pain clinics. Prospective questionnaire survey completed by consultants on each patient seen during October 1989 to May 1990. Outpatient pain clinics of five teaching and five district general hospitals in Scotland and northern England. Number of new referrals and their source, and characteristics of pain at presentation. 4354 forms were completed by 21 consultants over 29 weeks, corresponding to 2241 patients, of whom 981 were new referrals. The proportion of consultations at which new referrals were seen varied among the 10 clinics from 15% to 34%. The difference could not be accounted for by type of hospital. Sources of new referrals varied widely between the clinics (for example, range 22% to 78% for general practitioner referrals), as did new referrals by the type of pain (range 10.8% to 55.2% for low back pain, 10.5% to 32.5% for pain associated with surgery). However, these differences in types of patients seen could not be accounted for by variations in referral patterns among clinics. Problems identified in performing an audit of outpatients included the difficulty of obtaining firm diagnoses, the need for a method to link successive patient contacts, and the complexity of the presenting problem in many patients. It is possible to collect data for audit routinely in outpatient clinics. Observation of current practice in the clinics suggested possible unmet need or inappropriate management, which may require changes in practice.

Economic aspects of patterns of mental health care: Cost variation by setting

The paper examines the evidence regarding the extent to which differences exist in health and mental health status of psychiatric patients treated in the specialty mental health, general medical, and informal care sectors. Differences in types of patients treated in the three sectors are important to identify since there are dramatic differences in the average costs of treatment. We use data from the Baltimore Epidemiological Catchment Area Survey to estimate a statistical model of treatment setting choice. Our results suggest that there is little support for attributing major differences in treatment costs across sectors to differences in the health and mental health status of patients.