CUSHING'S SYNDROME, A RISK FACTOR FOR VENOUS THROMBOEMBOLISM IS A CANDIDATE FOR GUIDELINES.

OBJECTIVES: The present paper aims to review important contemporary information about VTE risk in endogenous and exogenous CS, as a substantial discrepancy exists between the results of a recent meta-analysis confirming the increased risk for VTE and the absence of CS in VTE guidelines. METHODS: An extensive search of relevant databases (e.g. PubMed, Google Scholar, and Scopus) was performed in order to establish the interconnectedness of the following terms: Cushing's syndrome, venous thromboembolism, deep vein thrombosis, pulmonary embolism. RESULTS: The analysis demonstrated that patients with CS have about ten times the risk for VTE, particularly during the first year following the diagnosis of CS. Oral glucocorticoid users (with iatrogenic CS) have a 3-fold increase in risk of VTE in comparison with non-users. The most recent 2019 meta-analysis encompassed 7142 patients with endogenous CS (including Cushing's disease) undergoing transsphenoidal surgery or adrenalectomy, and their risk of unprovoked VTE was almost 18 times higher in comparison with a healthy population. CONCLUSION: Over the past 50 years considerable evidence of increased VTE risk in CS has been accumulated. It pertains to both endogenous and exogenous type of CS and has been confirmed in the vast majority, if not all the available studies, including meta-analyses. Nevertheless, official CS guidelines make no mention of CS as a VTE risk factor, even though it is important that not only physicians who treat CS, but also physicians who manage patients with suspected VTE be aware of increased VTE risk.

Health outcomes. New quality measure for Medicare.

OBJECTIVE: A new measurement of health care quality for Medicare beneficiaries has been implemented by the Health Care Financing Administration (HCFA). This paper describes the program, presents baseline data and highlights associated issues. DESIGN: The Health Outcomes Survey (HOS) is a longitudinal cohort mail survey. Changes in population health status after 2 years will be evaluated on an individual plan level. SETTING: Two-hundred and eighty-seven US Medicare managed care plans. MAIN OUTCOMES MEASURES: Physical component and mental component summary scales derived from the SF-36. FINDINGS: Baseline data documented lower health status in older populations, while functional limitations and disease prevalence were higher. Among different plans, mean functional levels were found to be similar, although a few plans contained populations with exceptionally low levels. These data do not support the assertion that enrolees in for-profit plans are healthier than non-profit plans. CONCLUSIONS/IMPLICATIONS: The HOS is the first large-scale program to evaluate health outcomes among older Americans. HCFA recognizes several technical and policy issues. Technical issues include possible biased reporting for subpopulations, the validity of proxy responses and respondent burden. Policy issues concern the appropriateness of using a generic measure such as the SF-36 and how much change in health status can be attributed to quality of health care. HCFA plans to extend the HOS to beneficiaries in traditional Medicare. The HOS project is expected to encourage more efforts to maintain or improve the health status of the Medicare managed care population.

Outcomes assessment in clinical settings: a consensus statement on principles and best practices in project management.

BACKGROUND: The focus of this article is on health-related outcomes particularly reducing symptoms and improving health status. Public policy, purchaser demand, quality assurance/quality improvement, clinical research, and the computerized medical record have all fed the increasing interest in outcomes. "Outcomes assessment" refers to the measurement, monitoring, and feedback of outcomes. In implementing outcomes assessment, the bulk of the work is concentrated in managing individual projects. From May 1992 through March 1993, under a grant from the Functional Outcomes Program of the New England Medical Center (Boston), the directors of five major health outcomes assessment programs held a series of meetings to share their experiences in implementation. Principles and recommended best practices for project management are provided here. Implementing an outcomes project: Making a commitment to begin includes identifying a condition or procedure to investigate, assembling a project team, and naming a coordinator. Designing a project entails defining its purpose and scope, developing the measurement instruments, and establishing a logistical protocol for data collection. Managing the data entails collecting the data, entering the data into a database, maintaining quality control over the data, and storing the data. Using the data entails analyzing the data, providing feedback and interpretation to clinicians, and linking outcomes to the clinical process. CASE STUDY: For a typical outcomes project--total hip replacement--the sequence of activities in the project and the staffing and resources needed are all described.