Indicators Of Illness Severity Research Articles

Work disability in adults with cystic fibrosis and its relationship to quality of life

With increasing numbers of cystic fibrosis (CF) patients surviving to adulthood, issues related to vocation inevitably arise and warrant specific attention. We examined the percentage of participants with CF currently working and explored risk factors for work disability among adults with CF. Method: We recruited 50 consecutive patients from an adult cystic fibrosis service. Demographic, employment history, illness severity indicators and CF-attributed work disability factors were evaluated. Demographic risk factors for work disability using the illness severity measures of FEV 1, S–K score, CRDQ, and recent hospitalisation as independent variables were determined. Results: Factorial analysis of a disability index (DI) indicated no dependency on FEV 1 or S–K score, but dependency on quality of life indices ( p < 0.05), age ( p < 0.05) and hospital admission rate ( p < 0.05). Hours worked per week were dependent on quality of life ( p < 0.01) (mastery of disease domain), fewer hospital admissions ( p < 0.01) and age ( p < 0.05). Sixty-eight percent of the sample reported that CF resulted in significant impediments to employment. However, few had sought vocational guidance (6%). Conclusion: Determinants of workforce participation shows that hours worked and perceived disability are more dependent on mastery of disease, age, and time in hospital, than on clinical severity scores. Health professionals may assist productivity through career counselling or tailored programs.

Familial Aggregation of Illness Chronicity in Recurrent, Early-Onset Major Depression Pedigrees

The authors used a large sample collected for genetic studies to determine whether a chronic course of illness defines a familial clinical subtype in major depressive disorder. A measure of lifetime chronicity of depressive symptoms (substantial mood symptoms most or all of the time) was tested for familial aggregation in 638 pedigrees from the Genetics of Recurrent Early-Onset Depression (GenRED) project. In subjects with chronic depression, the mean age at illness onset was lower and rates of attempted suicide, panic disorder, and substance abuse were higher than among those with nonchronic depression. Chronicity was assessed in 37.8% of affected first-degree relatives of probands with chronic depression and in 20.2% of relatives of probands with nonchronic depression. Analysis using the generalized estimating equation model yielded an odds ratio of 2.52 (SE=0.39, z=6.02, p<0.0001) for the likelihood of chronicity in a proband predicting chronicity in an affected relative. With stratification by proband age at illness onset, the odds ratio for chronicity in relatives by proband chronicity status was 6.17 (SE=2.09, z=5.35, p<0.0001) in families of probands whose illness onset was before age 13 and 1.92 (SE=0.34, z=3.72, p<0.0001) in families of probands whose illness started at age 13 or later. These findings suggest that chronicity of depressive symptoms is familial, especially in preadolescent-onset illness. Chronicity is also associated with other indicators of illness severity in recurrent, early-onset major depression. Further study using chronicity as a subtype in the genetic analysis of depressive illness is warranted. Refinement of the definition of chronicity in depressive illness may increase the power of such studies.

Familial Aggregation of Illness Chronicity in Recurrent, Early-Onset Major Depression Pedigrees

Objective: The authors used a large sample collected for genetic studies to determine whether a chronic course of illness defines a familial clinical subtype in major depressive disorder. Method: A measure of lifetime chronicity of depressive symptoms (substantial mood symptoms most or all of the time) was tested for familial aggregation in 638 pedigrees from the Genetics of Recurrent Early-Onset Depression (GenRED) project. Results: In subjects with chronic depression, the mean age at illness onset was lower and rates of attempted suicide, panic disorder, and substance abuse were higher than among those with nonchronic depression. Chronicity was assessed in 37.8% of affected first-degree relatives of probands with chronic depression and in 20.2% of relatives of probands with nonchronic depression. Analysis using the generalized estimating equation model yielded an odds ratio of 2.52 (SE=0.39, z=6.02, p<0.0001) for the likelihood of chronicity in a proband predicting chronicity in an affected relative. With stratification by proband age at illness onset, the odds ratio for chronicity in relatives by proband chronicity status was 6.17 (SE=2.09, z=5.35, p<0.0001) in families of probands whose illness onset was before age 13 and 1.92 (SE=0.34, z=3.72, p<0.0001) in families of probands whose illness started at age 13 or later. Conclusions: These findings suggest that chronicity of depressive symptoms is familial, especially in preadolescent-onset illness. Chronicity is also associated with other indicators of illness severity in recurrent, early-onset major depression. Further study using chronicity as a subtype in the genetic analysis of depressive illness is warranted. Refinement of the definition of chronicity in depressive illness may increase the power of such studies.

Which Clinical Indicators and Resident Characteristics Are Associated With Health Care Practitioner Nursing Home Visits or Hospital Transfer for Urinary Tract Infections?

(1) To determine factors associated with practitioner visitation and/or hospital transfer for skilled nursing facility (SNF) patients who develop a urinary tract infection (UTI) and (2) to determine if SNF patients with a Do Not Resuscitate (DNR) directive are less likely to be personally assessed and/or transferred to the hospital in the event of a UTI when compared to patients without a DNR directive. Retrospective cohort study using nursing home medical record review. Participants were 564 residents from 35 nursing homes in 3 states who became acutely ill with UTI during the first 90 days of their nursing home admission. They were identified from 2832 random nursing home Medicare admissions and divided into 2 groups, those with DNR directives (n = 334) and those without (n = 230). Logistic regression was used to determine factors associated with practitioner in-person assessment and/or hospitalization, and to determine differences in the likelihood of practitioner in-person assessment and/or hospitalization among those with DNR directives versus those without DNR directives. Only one third (29%) of patients with unstable vital signs were seen by a practitioner or transferred to a hospital. Factors associated with practitioner assessment or hospital transfer were elevated temperature (OR 1.7, CI 1.04-2.64), pulse more than 100 beats per minute (OR 1.7, CI 1.01-2.99), and delirium (OR 2.1, CI 1.267-3.44). White residents were less likely to be assessed by a practitioner or transferred to a hospital (OR 0.45, CI 0.22-0.95). DNR directives were not significantly associated with fewer in-person assessments (P = .067). Only one third of SNF patients who developed a UTI with unstable vital signs were personally assessed by a practitioner and/or hospitalized. Patients with delirium were twice as likely to be assessed or transferred to a hospital, suggesting that practitioners use delirium as an indicator of illness severity. However, practitioner visit or transfer was also associated with ethnic background. In the absence of good evidence regarding which nursing home residents are likely to benefit from hospitalization or an urgent practitioner visit, these care decisions will continue to be associated with factors that are unknown.

Differences in Clinical Severity between Genotype A and Genotype B Human Metapneumovirus Infection in Children

The clinical spectrum of 69 episodes of metapneumovirus pediatric infection (55 episodes caused by genotype A and 14 episodes caused by genotype B) was analyzed. Diagnosis of pneumonia was more common and the illness severity index (determined on the basis of need for hospitalization, oxygen saturation <90%, and intensive care unit stay) was higher for patients with metapneumovirus genotype A infection.

Validation of the Cumulative Illness Rating Scale (CIRS) in hospitalized nonagenarians

This is a retrospective analysis of patients aged 90–99 years, admitted over a 6-month period to a district hospital. One hundred three patients were included in the study with an average age of 92 years and a male to female ratio of 1:3. Fifty-five percent of the patients hospitalized came from nursing care facilities. Comparisons were made of patient characteristics from nursing homes and the community. The physical burden of illness was measured by the CIRS, Illness Severity Index (SI), and Co-morbidity Index (CI). The average length of stay was 6.3 days for those from nursing care facilities and 10.2 days from the community as compared with 3.3 days for total hospital in-patients. Excluding deceased patients there was a significant ( p < 0.05) correlation between patient's CIRS to length of stay in hospital but was equivocal for SI and CI. There were no association between patient's CIRS, SI, and CI to mode of referral and residence. The mortality rate for this group was 13% as compared with the hospital rate of 10.2%. CIRS, SI, and CI were useful in distinguishing the mortally ill from the morbidly ill; otherwise there were no differences, between patients who hail from nursing care facilities or from the community and whether they were referred by carers, nursing staff, medical practitioners/specialists or themselves. There were significant differences in the CIRS scores between deceased and survivors indicating CIRS is potentially useful tool in predicting outcome. The SI and CI composites performed equally well in predicting outcome.

Perceptual organization in first episode schizophrenia and ultra-high-risk states

Deficits in perceptual organization have been consistently reported in schizophrenia, as has an association between these deficits, disorganized symptoms, and poorer premorbid functioning and prognosis, suggesting that they may be an index of illness severity or progression. It is unclear, however, whether the impairment is present at, or before the first psychotic episode. This study examined perceptual organization in young people considered to be at high-risk for schizophrenia, defined by the “close-in” strategy [Yung, A.R., McGorry, P.D., McFarlane, C.A., Jackson, H.J., Patton, G.C., Rakkar, 1996. Monitoring and care of young people at incipient risk of psychosis. Schizophrenia Bulletin, 22, 283–303]. The high-risk group ( n = 70) was compared to first-episode patients ( n = 54), and nonpatients ( n = 24) using a task with known sensitivity to perceptual organization deficits in schizophrenia, and whose scores have predicted long-term outcome and disorganized symptomatology in past studies [Knight, R.A., Silverstein, S.M., 1998. The role of cognitive psychology in guiding research on cognitive deficits in schizophrenia. In Lenzenweger, M., Dworkin, R.H., (Eds.), Origins and Development of Schizophrenia: Advances in Experimental Psychopathology. APA Press, Washington DC, pp. 247–295.; Silverstein, S.M., Knight, R.A., Schwarzkopf, S.B., West, L.L., Osborn, L.M. Kamin, D., 1996b. Stimulus configuration and context effects in perceptual organization in schizophrenia. Journal of Abnormal Psychology 105, 410–420.; Silverstein, S.M., Schenkel, L.S., Valone, C., Nuernberger, S., 1998a. Cognitive deficits and psychiatric rehabilitation outcomes in schizophrenia. Psychiatric Quarterly 69, 169–191.; Silverstein, S.M., Bakshi, S., Chapman, R.M., Nowlis, G., 1998b. Perceptual organization of configural and nonconfigural visual patterns in schizophrenia: effects of repeated exposure. Cognitive Neuropsychiatry 3, 209–223]. There were no differences between groups, and the first-episode group demonstrated non-significantly more sensitivity to stimulus organization than the other groups. When the high-risk group was broken down into its 3 subgroups (A—family history of psychotic illness and recent drop of 30+ points in the GAF scale; B—history of attenuated psychotic symptoms; C—brief limited intermittent psychotic symptoms), only group A demonstrated evidence of impairment, but this group differed significantly only from first- and young, later-episode schizophrenia patients, not from nonpatients. These findings are consistent with recent data on pre-attentive processes in schizophrenia which indicate that performance is not impaired and may even be enhanced, early in the illness, with dysfunctions beginning with increased chronicity.

352 Serum Thyroid Hormones in Preterm Infants and Relationships to Indices of Severity of Intercurrent Illness

Introduction: In adults a decrease in serum T3 and an increase in rT3 are the most common changes in thyroid hormone levels in response to a variety of acute and chronic illnesses. With more severe illnesses serum T4 levels also decrease and this is associated with a worse prognosis. Thyroid hormone levels in infants are crucially determined by the inter-relationship between gestational and postnatal age but it remains unclear whether changes in thyroid hormone status in response to illness are similar across the wide gestational age range of prematurity. Aim: The purpose of this study was to relate severity of illness at 1, 7, 14 and 28 postnatal days in preterm infant groups 23–27 (n=73), 28–30 (n=160) and 31–34 (n=208) weeks gestation, to the corresponding sera levels of T4, FT4, TBG, TSH, T3, rT3 and T4S. Methods: The British Association of Perinatal Medicine and Neonatal Nurses Association 1992 scoring categories (Arch Dis Child; 67: 868–9) were used as an index of illness severity: Level 1 (maximal intensive care) was compared with Level 2 (high dependency intensive care) combined with Level 3 (special care); infants were scored on 1, 7, 14 and 28 postnatal days. Results: In Level 1 infants there were significant reductions in: T3 at 7 days (28–30 weeks), 14 and 28 days (23–27 and 28–30 weeks); T4 at 7, 14 and 28 days (23–27 weeks), at 14 and 28 days (28–30 weeks), and at day 7 (31–34 weeks); FT4 at 14 days (23–27 weeks). TSH was unchanged in all groups at all ages. Conclusion: The clear message from our data is that T4 and T3 are substantially reduced in infants with severe illness, irrespective of gestational age, yet TSH remains unchanged.

Patient-based Measures of Illness Severity in the Veterans Health Study

The Veterans Health Study (VHS) was designed to produce patient-based measures of health status suitable for monitoring the health of men served by the Veterans Health Administration. This article summarizes the objectives, conceptual framework, and results of 6 substudies of the VHS that were designed to develop disease-focused measures of illness severity, that is, patient-perceived, clinically significant manifestations of disease processes that are associated with decrements in health-related quality of life. Developmental psychometric studies used cross-sectional survey data from the baseline comprehensive evaluations conducted in the VHS. Patients who screened positive for the 6 study medical conditions in the VHS (osteoarthritis of the knee, n = 511; type 2 diabetes, n = 425; chronic lung disease, n = 352; hypertension, n = 996; chronic low-back pain, n = 574; and alcohol-related disorder, n = 175) were administered structured interview modules that assessed symptoms and complications of these chronic diseases. Psychometric analyses were conducted to identify internally coherent and reliable indices, which were validated with respect to their correlations with measures of health-related quality of life (eg, Short Form-36) and the utilization of health services. We constructed 6 indices of illness severity. The severities of osteoarthritis of the knee and chronic lung disease were defined by brief (12 and 6 items, respectively) assessments of symptoms (eg, knee pain and dyspnea). Since diabetes and hypertension are largely asymptomatic, illness severity for these conditions was assessed by ascertaining complications such as angina and vascular disorders. Alcohol-related disorder, which involves both behavioral symptoms and physical complications, was assessed by separate scales for these 2 dimensions of its severity. Chronic low-back pain required a unique solution. Rather than assessing the intensity of back pain, it is more productive to construct a measure that focuses on manifestations of radiculopathy, that is, whether back pain radiated down the leg to below the knee. The 5 symptoms or complication indices and the assessment of radiculopathy in chronic low-back pain were significantly correlated with Short Form-36 scores and intensity of recent use of health services. The 6 measures may complement measures of health-related quality of life in providing more comprehensive assessments of health status in Veterans Affairs patients.

Incidence of adrenal insufficiency within 10 days of traumatic brain injury

Adrenal insufficiency (AI) is common in septic shock, and the physiologic replacement of hydrocortisone improves outcome [1]. Head injury (HI) has been shown to cause AI in the subacute phase (>10 days) with a reported incidence of approximately 15% [2,3], but there are no data on early AI, at times when it is most likely to influence ICU management. Furthermore, analysis of available data is confounded by variations in the definition of AI [4,5]. We aim to describe adrenal function in the first 10 days after injury using various suggested definitions of AI in critical care [4,5]. We retrospectively analysed patients who had a stimulation test performed within 10 days of admission to our neurointensive care unit. Tetracosactide (Synacthen) was administered as a 250 μg bolus and cortisol levels measured at 0, 30 and 60 min. AI was defined as a baseline cortisol level below 414 mmol/l and failure to rise by 250 mmol/l after Synacthen administration. All patients who showed AI or responded clinically to a trial of steroid therapy received 200–400 mg hydrocortisone per day while on vasopressor therapy. One hundred and thirteen patients were analysed. Mean age was 35 ± 15 and 79% were male. Four percent, 25% and 70% had mild, moderate and severe HI defined by the GCS on admission. Mean APACHE II and ISS scores were 15 ± 6 and 24 ± 10. The incidence of AI according to baseline cortisol level was 78%. The cortisol level failed to rise in 48% and 27% of patients at time 30 and 60 min, respectively. Primary adrenal insufficiency defined by both low baseline cortisol and failure to react to synacthen was present in 28% and 13% of patients at time 30 and 60 min. All patients had baseline cortisol levels below 690 mmol/l. Cortisol remained below 500 mmol/l after stimulation in 49% and 22% of patients at 30 and 60 min. The incidence of AI, using any of the definitions in the literature, was unrelated to APACHE II or ISS score or GCS on admission, or to ICU length of stay or outcome (defined using the Glasgow Outcome Score). A 60-min sampling time point may be more appropriate to evaluate the response to Synacthen stimulation. During the first 10 days after HI, secondary AI was present in 78% of patients and primary AI in at least 15%. These incidences might be higher if less stringent definitions are used. Injury and/or illness severity indices do not predict AI. While AI was not predictive of outcome in this study, all subjects with AI received steroid replacement. Such a high incidence of AI may have major therapeutic implications.

Patterns and Quality of Treatment for Patients With Major Depressive Disorder in Routine Psychiatric Practice

Patterns and Quality of Treatment for Patients With Major Depressive Disorder in Routine Psychiatric Practice

Serum Thyroid Hormones in Preterm Infants and Relationships to Indices of Severity of Intercurrent Illness

The purpose of this study was to relate severity of illness at 1, 7, 14, and 28 postnatal days in preterm infants groups, 23-27 (n = 73), 28-30 (n = 160), and 31-34 (n = 208) wk gestation, to the corresponding sera levels of T(4), free T(4), T(4)-binding globulin, TSH, T(3), rT(3), and T(4) sulfate. The British Association of Perinatal Medicine and Neonatal Nurses Association 1992 scoring categories (published elsewhere) were used as an index of illness severity: level 1 (maximal intensive care) was compared with level 2 (high-dependency intensive care) combined with level 3 (special care); infants were scored on 1, 7, 14, and 28 postnatal days. In level 1 infants, there were significant reductions in T(3) at 7 d (28-30 wk), 14, and 28 d (23-27 and 28-30 wk); T(4) at 7, 14, and 28 d (23-27 wk); at 14 and 28 d (28-30 wk); and at 7 d (31-34 wk); and free T(4) at 14 d (23-27 wk). TSH was unchanged in all groups at all ages and with reductions in T(4) and T(3) being the key features of severe illness in extreme preterm infants.

121 A “Stay and Play” Philosophy of Stabilization Leads to Safe and Effective Paediatric Transport

The likelihood of physiological deterioration or adverse events during the retrieval of critically ill children is reduced by dedicated paediatric transport teams. Recently the neonatal transport team based at the Hospital for Sick Children (HSC) has expanded its mandate to retrieve children up to 2 years of age. The Acute Care Transport Services (ACTS) team has translated its neonatal stabilization philosophy of “stay and play” into paediatric critical care transports. However other teams consider a “scoop and run” philosophy to be the most effective and safest means of transporting critically ill children. To investigate if “stay and play” stabilization of critically ill children is associated with physiological deterioration or an increased likelihood of adverse events on transport. Data was prospectively collected on all paediatric transports by ACTS from Nov 2002 to Nov 2003. Details recorded included patient demographics, referral problem, transport mobilization & stabilization times and adverse events during transport. A physiology score based on a modified PRISM score was used as an index of illness severity and recorded on arrival and following departure of the team from the referral hospital. The effectiveness of transport stabilization was assessed by comparing pre-and post-stabilization physiology scores. An intervention score was constructed to assess details of the stabilization process. The relationship between intervention scores and stabilization times was examined using linear regression methods. 35 children were retrieved during the study time-period. The average age at referral was 5.7 months (Range 1.5–24). The referring diagnosis included CNS disease (37%), respiratory failure (34%), septicaemic shock (14%), cardiac disease (8.6%) and others (6.4%). Patients were referred from an emergency department (60%) or paediatric ward (31.4%). The average mobilization and stabilization times for ACTS were 33.4 mins (Range 5–315) and 140 mins (Range 40–320) respectively. 94.3% patients demonstrated improvement or plateau in their physiology score with a significant reduction in physiologic score over the stabilization period from 4.17 to 2.88 (1.875 2.2, p=0.002). There was a positive relationship between the length of stabilization and the calculated intervention score (r=0.61, p<0.001). There were no critical incidents or adverse patient or equipment events during transport. 88.6% patients were admitted to the critical care unit at HSC. This study demonstrates that the physiologic condition of critically ill children is improved and the likelihood of adverse events is reduced following aggressive stabilization by a dedicated “mobile ICU” team.

Antidepressant Treatment and Risk of Suicide Attempt by Adolescents with Major Depressive Disorder

The US FDA has issued an advisory warning of a possible link between antidepressant treatment for paediatric patients with major depressive disorder (MDD) and an increased risk of suicidal behaviour. A large database of paid health insurance claims for adolescents with MDD provided the opportunity to examine this possible relationship. To examine the potential empirical link between antidepressant treatment and suicide attempts among adolescents aged 12-18 years using a community sample of managed care enrollees across the US. A retrospective longitudinal cohort using paid insurance claims for all healthcare and prescription fills for adolescents who were newly diagnosed with MDD and had at least 6 months of follow-up data. A multivariate Cox proportional hazards regression analysis was used to test the hypothesis that antidepressant use increased the risk of suicide attempt, adjusting for propensity for allocation to each treatment group and for demographic and clinical characteristics. Managed care plans including both commercial and Medicaid plans in the east, midwest, south and western regions of the US from January 1997 to March 2003. All adolescent insurance members aged 12-18 years at first diagnosis of MDD. Suicide attempts as indicated by medical utilisation with International Classification of Diseases (9th edition) [ICD-9] or 10th edition (ICD-10) codes in any healthcare setting or by any covered provider. 24 119 adolescents met inclusion criteria (63% female). Crude suicide attempt rates ranged from 0.0-2.3% by index treatment group. Treatment with SSRIs (hazard ratio) [HR] = 1.59; CI 0.89, 2.82), other antidepressants (HR = 1.03; CI 0.43, 2.44), or multiple antidepressants (HR = 1.43; CI 0.70, 2.89) after index MDD diagnosis resulted in no statistically increased risk of suicide attempt. Treatment with antidepressant medication for at least 180 days (6 months) reduced the likelihood of suicide attempt compared with antidepressant treatment for <55 days (8 weeks) [HR = 0.34; CI 0.21, 0.55]. Other variables that were independently associated with greater risk of suicide attempts included female gender, severity of illness indicators, younger age at time of MDD diagnosis, and living in the midwest or west. Antidepressant medication use had no statistically significant effect on the likelihood of suicide attempt in a large cohort of adolescents across the US after propensity adjustment for treatment allocation and controlling for other factors. The relationship between suicidal behaviour and antidepressant medication use is complex and requires further investigation.

The relationship between illness severity, sociodemographic factors, general self-concept, and illness-specific attitude in Swedish adolescents with epilepsy

Purpose: The aim of this study was to describe the relationship between the epilepsy condition (illness severity), sociodemographic factors, general self-concept, and illness-specific attitude in adolescents with uncomplicated epilepsy. Methods: Adolescents, aged 13–22, fulfilling criteria registered in four Swedish hospitals, answered questionnaires ( n=149). The instruments “I think I am” and “Sense of coherence” measured the patients’ general self-concept. The “Child Attitude Toward Illness Scale” measured illness-specific attitude. A summary score (index) calculated from seizure frequency, seizure type, and antiepileptic drug (AED) with side effects measured “Illness Severity”. Results: Illness severity was significantly related to the participants’ general self-concept, as well as to their attitude toward their condition; i.e. higher illness severity scores were correlated with lower sense of coherence (SOC), poorer self-esteem, and a more negative attitude towards the epilepsy condition. Females had more severe illness according to the Illness Severity Index, with almost 80% found in the moderate and high severity groups as compared to 63% of males in the moderate/high severity groups. Conclusions: It was concluded that the severity of the epilepsy condition was related to the adolescents’ general self-concept and illness-specific attitude, but further research is needed to understand the causality of the relationship. The brief assessment of illness severity, constructed and used in this study should be addressed and developed further.

Factors constraining adherence to referral advice for severely ill children managed by the Integrated Management of Childhood Illness approach in Imbabura Province, Ecuador.

Low referral completion rates in developing countries undermine the Integrated Management of Childhood Illness (IMCI) strategy for lowering child mortality. This study sought to identify factors constraining adherence to referral advice in a health system using the IMCI approach. Caregivers of 160 children urgently referred to hospital were prospectively interviewed. Caregivers who accessed and did not access hospital were compared for potential referral constraining factors, including demographics, family dynamics, the severity of their child's illness, their interaction with the health system, self-perceived problems, and physical and financial access. 67/160 (42%) referred children did not access hospital. Six factors were associated with non-access, including two health worker actions: not being given a referral slip [adjusted odds ratio (OR)= 15.3, 95% confidence interval (95% CI) 4.4-64.6] and not being told to go to the hospital immediately (adjusted OR = 5.3, 95% CI 1.9-16.3). Receiving both of these interventions reduced the risk of not accessing hospital to 19%, from 96% for those who received neither intervention. Several indicators of illness severity, including caregivers' ranking of their children's illness severity, the presence of severe illness signs and mortality, were investigated and found not to be important explanatory factors. Providing a referral slip and counseling the caregivers of severely ill children to go to the hospital immediately appear to be powerful tools for increasing successful referral outcomes.

Protein-energy undernutrition and life-threatening complications among the hospitalized elderly.

To determine whether elderly patients with protein-energy undernutrition at admission are at increased risk for subsequent life-threatening events after controlling for illness severity. Prospective cohort study. University-affiliated Department of Veterans Affairs hospital. Five hundred eighty-six nonterminal patients (mean age 74 +/- 6 [SD] years, 98% male, 86% white) with a length of stay of 3 days or more. Life-threatening complications. Subsequent to admission, 37 subjects (6.3%) experienced at least 1 life-threatening complication. All of the putative nutrition variables examined and many non-nutrition, illness severity measures were strongly correlated with the risk of a life-threatening complication by univariate analyses (P <.05 for all analyses). After controlling for illness severity, admission serum albumin, prealbumin, and cholesterol were no longer significantly correlated with the outcome. In contrast, weight loss (>5% within 6 months), body mass index, mid-arm circumference, and suprailiac skinfold thickness remained strong independent predictors. The adjusted relative risk of a life-threatening complication ranged from 2.9 (95% confidence interval [CI], 1.3 to 6.4) for a body mass index <22 kg/m2 to 7.1(95% CI, 2.0 to 25.7) for a suprailiac skinfold thickness in the lower tertile for the study population. The putative nutrition and illness severity variables were highly intercorrelated. There is a complex interrelationship between nutritional status, illness severity, and clinical outcomes among the hospitalized elderly. The serum secretory proteins and cholesterol are correlated with other indicators of illness severity and adverse outcomes, but may not be good markers of nutritional risk. In contrast, weight loss, a low body mass index, and other indicators of lean and fat mass depletion appear to place the patient at increased risk for adverse outcomes independent of illness severity. Whether it is possible to reverse such established nutritional deficits and reduce complication risk in the acute care setting remains to be determined.

CV1: THE VALUE OF COMPLIANCE: EVIDENCE FROM TWO PATIENT COHORTS

OBJECTIVES: To identify the association between compliance and the direct costs of care for two different clinical patient cohorts. METHODS: Using administrative claims data from Medstat MarketScan (tm) we assessed the association between prescription drug compliance and direct costs of care for two patient groups: a cohort of non-Medicare patients diagnosed as diabetics (N = 9960) and second cohort of non-Medicare patients diagnosed with congestive heart failure (CHF)(N = 935). Since patients who are more compliant tend to be older and have a greater number of comorbidities, and our goal was to isolate the association between compliance and medical care costs, we statistically controlled for differences in potential confounding variables using OLS regression. Covariates included age, gender, comorbidity indices (Chronic Disease Score and Charlson-Deyo), and ICD-9-based severity of illness indicators. Compliance was defined by calculating % days supply over a period of one year. Compliance was then converted to 7 ordinal categories in the regression model in order to identify dose-response associations or threshold/inflection points. RESULTS: Among diabetics, those who did not use any prescription medication showed the lowest total costs of care. However, among those patients who needed prescription medication to manage their illness, increased prescription drug costs among the most compliant are more than offset by decreases in medical care costs, for an estimated return on investment (ROI) of more than two-fold. A similar, but stronger, pattern was found among patients with CHF where the estimated ROI was three-fold or greater. CONCLUSIONS: For some medical conditions, the additional costs associated with increased compliance may be offset by lower medical costs, resulting in an ROI greater than one.

The development of the THROAT: the holistic and reliable oral assessment tool

Objectives: To develop and establish the validity, intra and inter-rater reliability of a new tool for oral assessment in older medically ill hospitalized patients.Design: A cross-sectional study. The oral cavities of older patients at a single time point were assessed by four different raters with repeated measures for one rater.Setting: A North West teaching hospital.Participants: All of the patients who were present on three acute elderly wards and the acute stroke unit and who were able to provide consent. The raters included the Stroke Specialist Nurse, a dental hygienist, a staff nurse and a student nurse.Results: A total of 91 patients were present on the four areas on the day of the study. Fifty patients were included of whom 24 were males (median age of 84, Interquartile range (IQR) 80–89 years; median Barthel, Activities of Daily Living Index of 16, IQR 8–19; median Charlson, Index of Illness severity of 2, IQR 2–2.25; median length of stay 11.5 days, IQR 6–21.25. When examining scores on the individual items of the tool, the intra-rater agreement was good (Weighted Kappa=0.69–0.96) for all items except floor of the mouth and smell (Weighted Kappa=0). Furthermore, whilst inter-rater agreement was poor across all raters (Kappa<0.30) it was good between pairs of raters (Weighted Kappa=0.68–0.89) apart from teeth and dentures (Weighted Kappa=0.46–0.70). When unreliable items had been removed and total scores were examined, the intra-rater agreement was good (Weighted Kappa=0.69–0.96) and the inter-rater agreement was very good (Weighted Kappa=0.95–0.97).Conclusion: The THROAT was reliable both within and between raters, on individual items and on total score. The THROAT has potential as an assessment tool, and possibly as an outcome indicator, for oral hygiene in older medically ill patients.

Accuracy and reliability of APACHE II scoring in two intensive care units Problems and pitfalls in the use of APACHE II and suggestions for improvement.

Acute Physiology and Chronic Health Evaluation (APACHE) II scoring is widely used as an index of illness severity, for outcome prediction, in research protocols and to assess intensive care unit performance and quality of care. Despite its widespread use, little is known about the reliability and validity of APACHE II scores generated in everyday clinical practice. We retrospectively re-assessed APACHE II scores from the charts of 186 randomly selected patients admitted to our medical and surgical intensive care units. These 'new' scores were compared with the original scores calculated by the attending physician. We found that most scores calculated retrospectively were lower than the original scores; 51% of our patients would have received a lower score, 26% a higher score and only 23% would have remained unchanged. Overall, the original scores changed by an average of 6.4 points. We identified various sources of error and concluded that wide variability exists in APACHE II scoring in everyday clinical practice, with the score being generally overestimated. Accurate use of the APACHE II scoring system requires adherence to strict guidelines and regular training of medical staff using the system.