The Connecticut Cardiovascular Consortium: a unique, state-wide research collaboration to advance clinical outcomes in patients with heart disease.

The establishment of "best clinical practices" founded upon evidence-based medicine has become an increasingly important priority. Frequently, management guidelines are derived from published research data and disseminated among practitioners to help optimize patient care. The ultimate clinical impact of these guidelines in the "real world," however, is often clouded by an incomplete assessment of patient outcomes throughout the continuum of health-care delivery models. In order to address this gap in clinical outcome assessment, we propose to establish the Connecticut Cardiovascular Consortium. The Consortium will consist of a collaborative partnership among all 31 Connecticut hospitals working in concert with Connecticut Office of Health Care Access (OHCA). The primary objective of the Consortium will be to assess, compare, and optimize clinical outcomes among Connecticut residents with cardiovascular disease. As an initial goal for the Consortium, we further propose to undertake a prospective, observational study of Connecticut residents who present with ST Segment Elevation Acute Myocardial Infarction (STEMI). Recent advances in pharmacologic and mechanical reperfusion for STEMI have resulted in a need to define the optimal use of these therapies in the community at large. The primary purpose of this study will be to determine the relative merits of different treatment patterns for STEMI with regard to the use of fibrinolytic therapy and percutaneous coronary intervention (PCI). Particular emphasis will be placed on assessing the relative benefits of urgent mechanical revascularization performed at the state's seven tertiary facilities with PCI capability compared to all other treatment modalities. Successful completion of this unique collaborative endeavor is expected to have significant impact on improved patient care and on current health-care policy for medical resource allocation. Moreover, continued collaboration of health-care providers within the Connecticut Cardiovascular Consortium infrastructure should serve as a useful mechanism for ongoing improvements in evidence-based cardiovascular medicine and clinical research in the state of Connecticut.

Effectiveness of reminder systems on appointment adherence rates.

The aim of this study was to determine the impact of reminder systems on appointment nonadherence rates in an low-income inner-city clinic population. A total of 2,304 consenting patients were randomly assigned to one of three groups: (1) automated telephone reminder, (2) postcard reminder, or (3) no reminder. In contrast with research on other populations, the results of this study demonstrated no significant difference in appointment adherence rates among the three groups. To aid in the development of more effective interventions in the future, individuals not attending their scheduled appointments were interviewed by telephone to determine reason for nonadherence.

The impact of depressive symptoms on the functional status of inner-city patients with asthma.

BACKGROUND: Functional deficits are common in patients with asthma. If there is cooccurring depression, these deficits may be more severe and/or more persistent. OBJECTIVE: This study was undertaken to determine 1) the prevalence and severity of depressive symptoms in a sample of inner-city patients being treated for asthma and 2) the impact of these symptoms on functional status. METHODS: Three hundred seventeen enrollees in an inner-city asthma program were evaluated using the health status questionnaire and the Center for Epidemiologic Studies Depression Scale (CES-D) at baseline and at 3- and 6-month follow-ups. Two groups were created based on patients' CES-D baseline scores, using a commonly used cutpoint to define "caseness" for depression. The two groups were compared using ANOVA, chi2, and the general linear model for repeated measures. RESULTS: Of the sample, 55.01% had a CES-D score greater than the cutpoint for depression. The mean was 29.3 +/- 11.95, well above the scores commonly used to indicate the presence of depression. The depressed group had lower scores on many measures of functional capacity at baseline; whereas both depressed and nondepressed patients improved over time on the physical performance measure (the physical performance measure subscale of the health status questionnaire), the mean score for the depressed group was consistently lower. CONCLUSIONS: The prevalence of depressive symptoms was greater than expected. Depression was persistent and had a major impact on functional capacity. Routine depression screening may be especially important in inner-city patients and other groups thought to be at increased risk for poor outcome.

Factors predicting 12-month outcome of elderly patients admitted with hip fracture to an acute care hospital.

Elderly patients (n = 121) with hip fracture were followed to determine if: (1) outcomes measured 12 months post-fracture differed significantly from pre-fracture measures, and (2) patient characteristics on hospital admission predicted three outcomes (site of residence, function, and walking status) 12 months later. At 12 months fewer patients resided at home. They had declined functionally. Baseline cognition, residence site, function, and walking individually predicted outcomes. However, outcomes were predicted best by multiple variables. These findings can be used to educate patients, their families, and the public on outcomes and their determinants after hip fracture.

Ratings of physical function obtained by interview are legitimate for patients hospitalized after stroke.

This study was conducted to examine the legitimacy of Barthel Index (BI) scores and subset of Functional Independence Measure (FIM) scores obtained by interview from patients hospitalized after stroke. This study included 82 patients with stroke. Interviews by a trained study coordinator were conducted to obtain BI and FIM subset (transfer, locomotion, feeding) scores from patients or a knowledgeable proxy. In addition, therapists' observational FIM scores on subset items recorded in the medical record were retrieved. The reliability, responsiveness, and validity of the BI and FIM subset were examined using Cronbach's alpha, effect size calculations, Wilcoxon tests, Spearman (r(S)) correlations, and regression analysis. Statistical analysis indicated that the post-stroke interview BI (.952) and FIM subset (.939) scores had excellent internal consistency. Large effect sizes and Wilcoxon test results between the prestroke and poststroke interview scores for the BI and FIM subset (z, -3.739 to -6.168) indicated that these 2 instruments were responsive to changes in patients' physical function status that accompanied stroke. Excellent correlations were found between BI and FIM interview scores poststroke (r(s), .913 to .971). The FIM subset interview scores and therapists' scores showed correlations that were moderate to good (r(s), .508 to .754). Length of stay correlated significantly with both the interview BI score (r(s), -.604) and the interview FIM subset score (r(s), -.583). Length of stay was correlated also with the National Institutes of Health Stroke Scale scores (r(s), .484). The regression analysis depicted the BI interview scores as the best predictor of the length of stay. Results provide support for the use of functional scores obtained by interview from hospitalized stroke patients. Both the BI and the FIM subset examined in this study are legitimate for this purpose.

Design and implementation of an outcomes management model.

In today's capitation-based reimbursement environment, acute care staff nurses must coordinate patient care considering the full continuum of care. To do so effectively, staff nurses need tools to accurately predict patient needs, adjust service intensity accordingly, and evaluate the outcomes of the care provided. The design and implementation of a model to support acute care staff nurses in that effort is described. The model's implementation was evaluated, in part, using a ten-item pre- and post-implementation survey. The survey showed that staff nurses who participated in the final educational offering on the model increased significantly their reported use of aggregate data for planning care. To achieve the greatest impact, the model needs to evolve so that it is applied earlier in the care process than at initial hospitalization. Ideally, this should occur during a wellness visit or enrollment in a health plan.

Critical Path education: necessary components and effective strategies.

Proper use of Critical Paths based on a solid educational foundation aids caregivers in meeting the ultimate challenge of today's healthcare environment: to provide a higher quality of care at a lower cost. The components for a comprehensive educational program for Critical Paths include general principles, Path contents, Path development, guidelines for documentation, variance data collection and evaluation. A strategy to provide large numbers of staff with background information is through the use of self-learning packets; the case study approach is an appropriate strategy for Path specific education. Evaluation data indicate that both strategies are effective in assisting staff to develop and implement Critical Paths.