The effect of hospital volume on the in-hospital complication rate in knee replacement patients.

OBJECTIVE: To examine the effect of hospital volume on in-hospital surgical outcomes for knee replacement using six years of Medicare claims data. DATA SOURCES/STUDY SETTING: The data include inpatient claims for a 100 percent sample of Medicare patients who underwent primary knee replacement during 1985-1990. We supplemented these data with information from HCFA's denominator files, the Area Resource File, and the American Hospital Association survey files. STUDY DESIGN: We estimated the probability that a patient has an in-hospital complication in the initial hospitalization for the first primary knee replacement, using a Logit model, for three definitions of complication. The models controlled for hospital volume, other hospital characteristics, patient demographics, and patient health status. We tested for the endogeneity of hospital volume. DATA COLLECTION/EXTRACTION METHODS: A panel of two orthopaedic surgeons and two internists reviewed diagnosis codes to determine whether a complication was likely, possible, or due to anemia. After removing the few observations with bad or missing data, the final population has 295,473 observations. PRINCIPAL FINDINGS: The probability of a likely in-hospital complication declines rapidly from 53 through 107 operations per year, then levels off. Statistical tests imply that hospital volume is exogenous in this patient-level data. Complication rates increased steadily through the study period. Although obesity appeared to lower the probability of a complication, a counterintuitive result, further investigation revealed this to be an artifact of the claims data limit of listing no more than five diagnoses. Controlling for this restriction reversed the effect of obesity. CONCLUSIONS: Rather than uncontrolled expansion of knee surgery to small hospitals, decentralization to regional centers where at least about 50, and preferably about 100, operations per year are assured appears to be the optimal policy to reduce in-hospital complications.

Patient outcomes after knee replacement.

A prospective, observational cohort investigation was performed to help understand the impact of knee replacement on patients with knee osteoarthritis in community practice. Of those, 291 patients (330 knees) were eligible and willing to participate. Forty-eight orthopaedic surgeons referred 563 patients from 25 institutions within the state of Indiana. Demographics, patient completed health status, satisfaction, independent radiographic measures, surgeon reported intraoperative factors, hospital discharge factors, and independent physical examinations were recorded. A minimum 2-year followup was obtained in 92% of the patients. At followup, 88% were satisfied, 3% were neutral, and 9% were dissatisfied with the results of their knee surgery. The physical composite score improved from 27.4 +/- 0.4 (range, 13.3-50.3) to 37.7 +/- 0.7 (range, 12.9-61.3) at two years. Maximal improvement in physical composite score was seen in patients who had their surgery performed in institutions that performed greater than 50 knee replacements per year in patients with Medicare insurance; who had a better mental health status at baseline; who had surgery performed on Monday, Friday, or Saturday; who were older; who were treated with a posterior cruciate sparing device; and who had worse preoperative function. A lower likelihood of complications were found with surgeons who performed greater than 20 knee replacements per year; midweek surgeries; in patients with more severe preoperative knee dysfunction; patients with fewer comorbidities; patients with less preoperative stiffness; patients being treated by younger surgeons; and in patients undergoing unilateral knee replacement. Among voluntarily participating physicians, knee replacement can be a highly effective medical technology with high levels of patient satisfaction and low rates of complications.

Comparison of general internists, family physicians, and rheumatologists managing patients with symptoms of osteoarthritis of the knee.

OBJECTIVE: To evaluate the nature, risks, and benefits of osteoarthritis (OA) management by primary care physicians and rheumatologists. METHODS: Subjects were 419 patients followed for symptoms of knee OA by either a specialist in family medicine (FM) or general internal medicine (GIM) or by a rheumatologist (RH). Management practices were characterized by in-home documentation by a visiting nurse of drugs taken to relieve OA pain or to prevent gastrointestinal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and by patient report (self-administered survey) of nonpharmacologic treatments. Changes in outcomes (knee pain and physical function) over 6 months were measured with the Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS: Patients of RHs were 2-3 years older (P = 0.035) and tended to exhibit greater radiographic severity of OA (P = 0.064) and poorer physical function (P = 0.076) at baseline than the other 2 groups. In all 3 groups, knee pain and physical function improved slightly over 6 months; however, between-group differences were not significant. Compared to drug management of knee pain by FMs or RHs, that by the GIMs was distinguished by greater utilization of acetaminophen and nonacetylated salicylates (P = 0.008), lower prescribed doses of NSAIDs (P = 0.007), and, therefore, lower risk of iatrogenic gastroenteropathy (P < 0.001). In contrast, patients of RHs were more likely than those of FMs and GIMs to report that they had been instructed in use of isometric quadriceps and range-of-motion exercises (P < or = 0.001), application of heat (P = 0.051) and cold (P < 0.001) packs, and in the principles of joint protection (P = 0.016). Neither physician specialty nor specific management practices accounted for variations in patient outcomes. CONCLUSION: This observational study identified specialty-related variability in key aspects of the management of knee OA in the community (i.e., frequency and dosing of NSAIDs, use of nonpharmacologic modalities) that bear strong implications for long-term safety and cost. However, changes in knee pain and function over 6 months were unrelated to variations in management practices.

The risk of hospitalization for congestive heart failure among older adults.

OBJECTIVES: The purpose of the study was to estimate the 8-year rate of hospitalization for congestive heart failure (CHF), to report the resources consumed, and to evaluate previously reported risk factors in a nationally representative sample of 7,286 older white and black adults. METHODS: Secondary analysis of baseline interview data was linked to Medicare hospitalization and death records for 1984 to 1991. Hospitalization for CHF was defined as having one or more episodes with an International Classification of Diseases (ninth revision, clinical modification) discharge code of 428. Combined and separate analyses of first-listed and second-through fifth-listed CHF discharge diagnoses were conducted. Multivariable proportional hazards models were used to evaluate the risks in pooled analyses of all white and black men and women and in separate stratified analyses of white men and white women. RESULTS: Over the 8-year period, 1,102 or 15.1% of the 7,286 older white and black adults were hospitalized for CHF (7.1% with first-listed and 8.1% with second- through fifth-listed diagnoses). The 1- and 5-year combined postdischarge mortality rates were 34.7% and 69.0%, respectively. In descending order, the major risk factors for being hospitalized for CHF in the combined, pooled analysis were age, being a white man, having lower body functional limitations, and having self-reported medical histories of coronary heart disease, heart attack, diabetes, and angina. The increased risk associated with age was not linear, and it diminished significantly over the course of life. Some significant differences were observed in the risk factors for hospitalization for first-listed versus second- through fifth-listed CHF and in the risk factors for white women versus white men. CONCLUSIONS: Hospitalization for CHF among older adults is a common, costly event with a poor prognosis. The differential risk for white men remains unexplained and warrants further study.

The sequelae of hospitalization for congestive heart failure among older adults.

OBJECTIVES: To estimate the independent effect of hospitalization for congestive heart failure (CHF) on subsequent mortality, readmission for CHF, rehospitalization for any reason, and change in functional status. DESIGN: Secondary analysis of the nationally representative Longitudinal Study on Aging, Baseline (1984) interview data are linked to Medicare hospitalization and death records for 1984-1991 and to functional status reports at three biennial follow-ups. SETTING: In-home and telephone interviews. PARTICIPANTS: a total of 7527 noninstitutionalized older adults aged 70 years or older at baseline. MEASUREMENTS: Hospitalization for CHF was defined as having one or more episodes with primary or secondary discharge ICD9-CM codes of 428. Multivariable proportional hazards, logistic and linear regression, as well as multiple classification analysis, were used to estimate the independent effects of having been hospitalized for CHF. RESULTS: The adjusted risk ratios for having a primary or secondary hospital discharge diagnosis of CHF on mortality (compared with not having any CHF hospital discharge diagnoses) were 1.58 (CI95% = 1.40 to 1.78) and 1.29 (CI95% = 1.15 to 1.45), respectively (P < .001). CHF readmission and rehospitalization rates were substantial, ranging from 16.0 to 47.5% at 1 year, depending on the criteria employed. The adjusted odds ratios for having any subsequent hospitalizations associated with having a primary or secondary hospital discharge diagnosis of CHF (compared with not having any CHF hospital discharge diagnoses) were 7.70 (CI95% = 6.20 to 9.57) and 2.99 (CI95% = 2.51 to 3.56), respectively (P < .001). The percent increases in the number of hospital episodes, total charges, and total length of stay attributable to having been hospitalized for CHF were significant (P < .001) and ranged from 15.5 to 66.7%. Having been hospitalized for CHF was also related significantly to greater increases in the mean number of functional limitations at follow-up. CONCLUSION: Hospitalization for CHF among older adults increases substantially the risk of subsequent mortality, readmission for CHF, rehospitalization for any reason, and greater functional decline. Therefore, greater attention to the prevention and management of CHF is needed.

Is obesity a barrier to physician screening for cervical cancer?

OBJECTIVE: To determine if obese and morbidly obese women are as likely to receive Papanicolaou (Pap) smears as nonobese women. PATIENTS AND METHODS: A secondary analysis was conducted of data collected during a prospective, controlled trial of computer-generated reminders to improve preventive care. The site was a large, academic general medicine practice providing primary care to an urban population at a university-affiliated municipal teaching hospital. Data were analyzed from 15 faculty and 77 resident physicians who delivered care to 1,321 women who were eligible for Pap smears. Patient data were obtained from a computerized medical record system. RESULTS: Outcomes were physician reports of Pap smear performance and reasons for nonperformance of Pap smears in eligible women. Pap smear performance was 21% for nonobese women, 20% for obese women, and 20% for morbidly obese women (P = NS). After adjusting for age and race, odds ratios for omission of Pap smear were 1.20 for both obese (95% confidence interval [CI] 0.86 to 1.67; P = NS) and morbidly obese women (95% CI, 0.58 to 2.47; P = NS). A significant dose-response relationship was found between increasing patient weight and physician responses that the Pap smear was delayed due to patient's acute illness, vaginitis, or menstruation (odds ratios [OR] 1.73 for obese, OR 4.59 for morbidly obese women; P < 0.005). CONCLUSIONS: In our general medicine practice, obesity does not appear to be associated with less Pap smear performance. Physicians are more likely to report delaying obese patients' Pap smears due to acute illness, vaginitis, or menstruation.

Resolution of lung abscess due to Pseudomonas aeruginosa with oral ciprofloxacin: case report.

A case of lung abscess due to Pseudomonas aeruginosa is presented that did not resolve with the use of conventional antipseudomonal antibiotics, including tobramycin with ticarcillin-clavulanate and ceftazidime with gentamicin and ticarcillin-clavulanate. Oral ciprofloxacin was administered for 12 weeks, and the infection was resolved. No resistance occurred, and there was no recurrence of abscess within 18 months following therapy.

Thyrotoxicosis induced sick sinus syndrome: medical therapy may avoid permanent pacing.

A 65-year-old white female developed sick sinus syndrome associated with thyrotoxicosis which resolved upon achieving a euthyroid state, thus obviating the need for permanent pacemaker implantation. TSH was less than 0.1 ng/dL, and 24-hour iodine uptake was 28%. After correction of the hyperthyroid state with propylthiouracil and potassium iodine, sinoatrial pauses up to 6 seconds resolved over 10 days. A subsequent sinus node recovery time was normal and no symptoms recurred over 22 months.

Semantic desensitization: a paradigmatic intervention approach to anxiety disorders.

Studied the effectiveness of semantic desensitization in alleviating public speaking anxiety. Thirty speech-anxious clients, matched on the severity of their problem, were assigned randomly to one of the following treatment conditions: (a) semantic desensitization; (b) attention placebo; and (c) waiting list control. The semantic desensitization group received a self-instructional, anticipatory-anxiety hierarchy paired with visually induced, relaxing, pleasant scenes. Semantic desensitization therapy resulted in significant reductions of both the affective and behavioral components of anxiety as compared to the two controls. The placebo control also showed improvement in several indices of subjective anxiety as compared to the no-treatment waiting list control. The beneficial effects of semantic desensitization therapy were maintained on follow-up.