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Title: Hypoglycemia in patients with type 2 diabetes mellitus.
Publication: Archives of Internal Medicine 2001;161:1653-59.
Authors: Miller CD et al.
Grant Number: HS09722.
Principal Investigator: Lawrence Phillips.
Project Officer: Yen-Pin Chiang.
Abstract: BACKGROUND: Although hypoglycemia is the most common complication of intensive diabetes therapy, there is little information about risk factors for hypoglycemia in patients with type 2 diabetes mellitus. OBJECTIVE: To determine the prevalence and predisposing factors for hypoglycemia in patients with type 2 diabetes. METHODS: Retrospective, cross-sectional analysis set in an outpatient specialty diabetes clinic. We included those patients who had baseline and followup visits from April 1 through October 31, 1999. Hypoglycemia was defined as typical symptoms relieved by eating, and/or blood glucose level of less than 60 mg/dL (<3.3 mmol/L). Univariate and multivariate logistic regression were used to determine the contributions to hypoglycemia of age, sex, diabetes duration, body mass index (calculated as weight in kilograms divided by the square of height in meters), fasting plasma glucose level, glycosylated hemoglobin (HbA(1c)) level, type of therapy, and previous episodes at the followup visit. RESULTS: We studied 1,055 patients. Prevalence of hypoglycemic symptoms was 12 percent (9/76) for patients treated with diet alone, 16 percent (56/346) for those using oral agents alone, and 30 percent (193/633) for those using any insulin (P<.001). Severe hypoglycemia occurred in only five patients (0.5 percent), all using insulin. Multiple logistic regression analysis demonstrated that insulin therapy, lower HbA(1c) level at followup, younger age, and report of hypoglycemia at the baseline visit were independently associated with increased prevalence of hypoglycemia. There were no significant predictors of severe hypoglycemia. CONCLUSIONS: Mild hypoglycemia is common in patients with type 2 diabetes undergoing aggressive diabetes management, but severe hypoglycemia is rare. Concerns about hypoglycemia should not deter efforts to achieve tight glycemic control in most patients with type 2 diabetes.
Title: Comorbidity and Glycemic Control in Patients with Type 2 Diabetes.
Publication: Archives of Internal Medicine 2001 May; 161:1295-1300.
Authors: El-Kebbi IM et al.
Grant Number: HS09722.
Principal Investigator: Lawrence Phillips.
Project Officer: Yen-Pin Chiang.
Abstract: BACKGROUND: It is commonly believed that good glycemic control is hard to achieve in patients with diabetes mellitus and concurrent chronic illnesses. OBJECTIVE: To determine the impact of comorbidity on glycemic control at presentation and subsequent followup in patients with type 2 diabetes. METHODS: We studied 654 consecutive patients who presented to a diabetes clinic in 1997. Comorbidity was rated using the Chronic Disease Score (CDS) index, which is a validated, weighted score that takes into account the patient's age, sex, and classes of medications. Univariate and multivariate linear regressions were used to determine the contribution of age, body mass index (calculated as weight in kilograms divided by the square of height in meters), diabetes duration, type of therapy, and CDS to initial hemoglobin A(1c) (HbA(1c)) level. A similar analysis was performed for the 169 patients with followup HbA(1c) levels 6 months after presentation. RESULTS: Patients were 90 percent African American, and 66 percent female, with average age of 53 years. Average diabetes duration was 5 years; body mass index, 33; HbA(1c) level, 8.8 percent; and CDS, 1121 (range, 232-7953). At presentation, patients with higher CDSs tended to be older and to have a lower HbA(1c) level, but multivariate linear regression showed that receiving pharmacological therapy, younger age, and having a lower C-peptide level were the only significant contributors to HbA(1c) level. In the 169 followup patients, presenting characteristics were not significantly different from those of the full cohort: average initial HbA(1c) level was 8.8 percent; CDS, 1073. Their HbA(1c) level at 6 months averaged 7.5 percent and the CDS had no significant impact on their followup HbA(1c) level. CONCLUSION: Comorbidity does not appear to limit achievement of good glycemic control in patients with type 2 diabetes.
Title: Physician Assistant Students and Diabetes: Evaluation of Attitudes and Beliefs.
Publication: Diabetes Educator Jan/Feb 2001;27(1):111-18.
Authors: Fisk DM et al.
Grant Number: HS09722.
Principal Investigator: Lawrence Phillips.
Project Officer: Yen-pin Chiang.
Abstract: Physician assistant students had favorable attitudes regarding type 2 diabetes. However, deficits appear to exist in understanding when to advance therapy. More studies on physician assistant students' knowledge of diabetes standards of care are required.
Title: The potentially poor response to outpatient diabetes care in urban African-Americans.
Publication: Diabetes Care 2001 Feb;24(2):209-15.
Authors: Cook CB et al.
Grant Number: HS09722.
Principal Investigator: Lawrence Phillips.
Project Officer: Yen-pin Chiang.
Abstract: OBJECTIVE: HbA1c levels can be reduced in populations of diabetic patients, but some individuals may exhibit little improvement. To search for reasons underlying differences in HbA1c outcome, we analyzed patients managed in an outpatient diabetes clinic. RESEARCH DESIGN AND METHODS: African-Americans with type 2 diabetes were categorized as responders, intermediate responders or poor responders according to their HbA1c level after 1 year of care. Logistical regression was used to determine baseline characteristics that distinguished poor responders from responders. Therapeutic strategies were examined for each of the response categories. RESULTS: The 447 patients had a mean age and disease duration of 58 and 5 years, respectively, and BMI of 32 kg/m2. Overall, the mean HbA1c level fell from 9.6 to 8.1 percent after 12 months. Mean HbA1c levels improved from 8.8 to 6.2 percent in responders, and from 9.5 to 7.9 percent in intermediate responders. In poor responders, the average HbA1c level was 10.8 percent on presentation and 10.9 percent at 1 year. The odds of being a poor responder were significantly increased with longer disease duration, higher initial HbA1c level, and greater BMI. Although doses of oral agents and insulin were significantly higher among poor responders at most visits, the acceleration of insulin therapy did not occur until late in the followup period. CONCLUSIONS: Clinical diabetes programs need to devise methods to identify patients who are at risk for persistent hyperglycemia. Whereas patient characteristics explain some heterogeneity of HbA1c outcome (and may aid in earlier identification of patients who potentially may not respond to conventional treatment), insufficient intensification of therapy may also be a component underlying the failure to achieve glycemic goals.
Title: Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.
Publication: American Journal of Kidney Diseases 2001 Sep;38(3):494-501.
Authors: Astor BC et al.
Grant Number: HS08365.
Prinicple Investigator: Niel Powe.
Project Officer: Yen-pin Chiang.
Abstract: Recent clinical practice guidelines recommend the creation of an arteriovenous (AV) vascular access (i.e., native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. We report on the association of referral to a nephrologist with duration of dialysis-catheter use and type of vascular access used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Center Study. Patients who reported being seen by a nephrologist at least 1 month before starting hemodialysis therapy (75 percent) were more likely than those referred later to use an AV access at initiation (39 percent versus 10 percent; P < 0.001) and 6 months after starting hemodialysis therapy (74 percent versus 56 percent; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a median of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis therapy, respectively (P trend < 0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients referred later to use an AV fistula, rather than a synthetic graft, as their first AV access (45 percent versus 31 percent; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, insurance coverage, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist substantially increases the likelihood of dialysis-catheter use at the initiation of hemodialysis therapy and is associated with prolonged catheter use. Regardless of the time of referral, only a minority of patients used an AV access at the initiation of treatment, and greater than 25 percent had not used an AV access 6 months after initiation. Thus, further efforts to improve both referral patterns and preparation for dialysis after referral are needed.
Title: Patients, populations and policy: patient outcomes in chronic kidney disease.
Publication: Trans Am Clin Climatol Assoc 2001;112:224-32; discussion 232-4.
Authors: Powe NR.
Grant Number: HS08365.
Principal Investigator: Neil Powe.
Project Officer: Yen-pin Chiang.
Abstract: Chronic kidney disease represents an interesting illustration for evaluating an epidemic of chronic illness, the impact of care processes and technology on health outcomes, the impact of financial incentives and cost containment on health outcomes, and the choices society must consider in
responding to a chronic illness. The evidence suggests that strong economic pressures exist in the care of chronic kidney disease and that cost containment is important. The results in large part reflect the impact of economic pressures on clinical decision making in the absence of good evidence on outcomes. To improve clinical decision making we need valid evidence linking specific processes of care to patient outcomes. Specific processes amenable to study include the provision of preventive services, physician and nurse technical and interpersonal care and adherence to clinical practice guidelines. The ESRD Quality Study (EQUAL) currently underway and supported by the National Institutes of Diabetes and Digestive and Kidney Diseases, may help to guide physicians and centers in caring for their patients with chronic kidney disease. This investigation examines the relation between process of care and outcomes and expands outcomes measure to include disease-specific quality-of-life measures and patient satisfaction and accounts for case mix using the Index of Co-Existent Disease, a measure of the extent of different comorbid diseases as well as their severity (18,19,20). Better data on how processes of care are linked to health outcomes can inform decision making and allow educated cost cutting and quality maintenance.
Title: U.S. nephrologists' attitudes towards renal transplantation: results from a national survey.
Publication: Transplantation 2001 Jan 27;71(2):281-8.
Authors: Thamer M et al.
Grant Number: HS08365.
Principal Investigator: Neil Powe.
Project Officer: Yen-pin Chiang.
Abstract: BACKGROUND: Renal transplantation is the optimal treatment for persons with end-stage renal disease (ESRD). A shortage of kidneys in the United States has focused increasing attention on the process by which kidneys are allocated. A national survey was undertaken to determine the relative importance of both clinical and nonclinical factors in the recommendation for renal transplantation by U.S. nephrologists. METHODS: We conducted a national random survey of 271 U.S. nephrologists using hypothetical patient scenarios to determine their recommendation for renal transplantation based on demographic, clinical, and social factors. Specifically, eight unique patient scenarios were randomly distributed to each survey respondent. RESULTS: According to responding nephrologists (response rate 53 percent), females were less likely than males to be recommended for renal transplantation [adjusted odds ratio (OR)=0.41; confidence interval (CI) 0.21, 0.79; for whites]. Asian males were less likely than white males to be recommended for transplantation (OR=0.46, CI 0.24, 0.91). Black-white differences in rates of recommendation were not found. Other factors associated with low rates of recommendation for renal transplantation included history of noncompliance (OR=0.17, CI 0.13, 0.23), <25 percent cardiac ejection fraction (OR=0.15, CI 0.10, 0.21), HIV infection (OR=0.01, CI 0.00, 0.01), and being >200 lbs (OR=0.73, CI 0.56, 0.95). CONCLUSIONS: Female gender, and Asian but not black race, were associated with a decreased likelihood that nephrologists would recommend renal transplantation for patients with end stage renal disease. The well-documented black-white disparities in use of renal transplantation may be due to unaccounted for factors or may arise at a subsequent step in the transplantation process.
Title: Developing a health-related quality-of-life measure for end-stage renal disease: The CHOICE Health Experience questionnaire.
Publication: American Journal of Kidney Diseases 2001 Jan;37(1):11-21.
Authors: Wu AW et al.
Grant Number: HS08365.
Principal Investigator: Neil Powe.
Project Officer: Yen-pin Chiang.
Abstract: The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease ([ESRD] CHOICE) Study was designed to evaluate the effectiveness of alternative dialysis prescriptions. As part of CHOICE, we developed an instrument for measuring health-related quality of life (HRQOL) for patients with ESRD that would complement the Medical Outcomes Study 36-Item Short-Form Survey (SF-36) and be sensitive to differences in dialysis modality (hemodialysis [HD] and peritoneal dialysis [PD]) and dialysis dose. The selection of HRQOL domains to be included was based on: (1) a structured literature review of 47 articles describing 53 different instruments; (2) content analysis of five focus groups with HD and PD patients, nephrologists, and other providers; (3) a survey of 110 dialysis providers about features of different modalities that affect patient HRQOL; and (4) a semistructured
survey of 25 patients with ESRD on the effects of dialysis on functioning and HRQOL. To help prioritize domains and items identified by these methods, a representative sample of 136 dialysis patients rated each item for frequency and bother. A panel of nephrologists provided advice about the salience of items to modality or dose. Items and scales were selected with a preference for existing measures tested in patients with ESRD and were tested for reliability and validity. The first four steps yielded 22 HRQOL domains that included 96 items: 8 generic domains in the SF-36 (health perceptions, physical, social, physical and emotional role function, pain, mental health, and energy); 8 additional generic domains (cognitive functioning, sexual functioning, sleep, work, recreation, travel, finances, and general quality of life); and 6 ESRD-specific domains (diet, freedom, time, body image, dialysis access [catheters and/or vascular], and symptoms). New items were developed or adapted to assess ESRD-specific domains. Scales for these items showed adequate internal consistency (Cronbach's alpha > 0.70, except for time [alpha = 0.57] and quality of life [alpha = 0.68]), as well as convergent and discriminant construct validity in a sample of 928 patients. The final questionnaire included 21domains (time was deleted) and 83 items. We have designed a patient-centered instrument, the CHOICE Health Experience Questionnaire, that addresses domains that may be sensitive to differences in dialysis modality and dose and shows evidence for reliability and validity as a measure of HRQOL in ESRD.
Title: Attitudes of parents and health care professionals toward active treatment of extremely premature infants.
Publication: Pediatrics 2001 Jul; 108:152-7.
Authors: Streiner DL et al.
Grant Number: HS08385.
Principal Investigator: Nigel Paneth.
Project Officer: Steven Fox.
Abstract: OBJECTIVES: To compare the attitudes of neonatologists, neonatal nurses, the parents of extremely low birth weight (ELBW) children, and the parents of normal birth weight children toward saving infants of borderline viability and who should be involved in the decision-making process and to compare physicians' and nurses' estimates of the proportion of infants who are born at various gestational ages with regard to survival, morbidity, and treatment. METHODS: A questionnaire was given to 169 parents of ELBW children and 123 parents of term children, who were part of a longitudinal study of the outcome of ELBW infants. A similar questionnaire was completed by 98 Canadian neonatologists and 99 neonatal nurses. RESULTS: Physicians tended to be more optimistic than nurses regarding the probability of survival and freedom from serious disabilities and would recommend to parents life-saving interventions for their child at earlier gestational ages. A significant majority of parents believed that attempts should be made to save all infants, irrespective of condition or weight at birth, compared with only 6percent of health
professionals who endorsed this. In contrast to parents, health professionals believed that economic costs to society should be a factor in deciding whether to save an ELBW infant. However, health professionals did not believe that the economic status of the parents should be a factor, although the stress of raising an infant with disabilities should be. Most respondents believed that the parents and physicians should make the final decision but that other bodies, such as ethics committees or the courts, should not. CONCLUSION: Health care professionals must recognize that their attitudes toward saving ELBW infants differ from those of parents. Parents, whether of term or extremely premature children, are more in favor of intervening to save the infant
irrespective of its weight or condition at birth than are professionals. It therefore is imperative that there be joint decision making, combining the knowledge of the physician with the wishes of the parents.
Title: Hypocapnia and other ventilation-related risk factors for cerebral palsy in low birthweight infants.
Publication: Pediatric Research Dec 2001;50(6):712-9.
Authors: Collins MP et al.
Grant Number: HS08385.
Principal Investigator: Nigel Paneth.
Project Officer: Steven Fox.
Abstract: Ventilatory management patterns in very low birth weight newborns, particularly iatrogenic hypocapnia, have occasionally been implicated in perinatal brain damage. However, such relationships have not been explored in large representative populations. To examine the risk of disabling cerebral palsy in mechanically ventilated very low birth weight infants in relation to
hypocapnia and other ventilation-related variables, we conducted a population-based prospective cohort study of 1105 newborns with birth weights of 500-2000 g born in New Jersey from mid-1984 through 1987, among whom 777 of 902 survivors (86percent) had at least one neurodevelopmental assessment at age 2 y or older. Six hundred fifty-seven of 777 assessed survivors (85percent), of whom 400 had been mechanically ventilated, had blood gases obtained during the neonatal period. Hypocapnia was defined as the highest quintile of cumulative exposure to arterial PCO(2) levels <35 mm Hg during the neonatal period. Disabling cerebral palsy was diagnosed in six of 257 unventilated newborns (2.3percent), 30 of 320 ventilated newborns without hypocapnia (9.4percent), and 22 of 80 ventilated newborns with hypocapnia (27.5percent). Two additional ventilatory risk factors for disabling cerebral palsy were found-hyperoxia and prolonged duration of ventilation. In a multivariate analysis, each of the three ventilatory variables independently contributed a 2- to 3-fold increase in risk of disabling cerebral palsy. These risks were additive. Although duration of mechanical ventilation in very low birth weight newborns likely represents severity of illness, both hypocapnia and hyperoxia are largely controlled by ventilatory practice. Avoidance of arterial PCO(2) levels <35 mm Hg and arterial PO(2) levels >60 mm Hg in mechanically ventilated very low birth weight infants would seem prudent.
Title: Comparison of management strategies for extreme prematurity in New Jersey and the Netherlands: Outcomes and resource expenditure.
Publication: Pediatrics Dec 2001;108(6):1269-74.
Authors: Lorenz JM et al.
Grant Number: HS08385.
Principal Investigator: Nigel Paneth.
Project Officer: Steven Fox.
Abstract: OBJECTIVE: To quantify differences in resource expenditure in the perinatal period and long-term outcome of extremely premature infants who received systematically different approaches to neonatal intensive care. METHODS: Perinatal management, mortality, prevalence of disabling cerebral palsy (DCP), and resource expenditure of 2 population-based inception cohorts of extremely premature infants born in the mid-1980s were compared. Electronic fetal monitoring, tocolysis, cesarean section delivery, and assisted ventilation were used to characterize management approaches. Participants included all live births at 23 to 26 weeks' gestation in a 3-county area of central New Jersey (NJ) from 1984 to 1987 (N = 146) and throughout the
Netherlands (NETH) in 1983 (N = 142). Mortality and the prevalence of DCP were the primary outcomes. Numbers of hospital days with and without assisted ventilation were the measures of resource expenditure. RESULTS: Electronic fetal monitoring (100percent vs 38percent), cesarean section (28percent vs 6percent), and assisted ventilation (95percent vs 64percent) were all more commonly used in NJ than in NETH. Ten percent of NJ deaths occurred without assisted ventilation, compared with 45percent of Dutch deaths. A total of 1820 ventilator days were expended per 100 live births in NJ, compared with 448 in NETH. The increase in the number of nonventilator days (3174 vs 2265 days per 100 live births) did not reach statistical significance. Survival to age 2 (46 vs 22percent) and the prevalence of DCP among survivors (17.2 vs 3.4percent) were significantly greater in NJ at age 2 than in NETH at age 5. CONCLUSIONS: Near universal initiation of intensive care in NJ, compared with selective
initiation of intensive care in NETH, was associated with 24.1 additional survivors per 100 live births, 7.2 additional cases of DCP per 100 live births, and a cost of 1372 additional ventilator days per 100 live births.
Title: A randomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African American women.
Publication: American Journal of Public Health 2001Jan;91(1):105-11.
Authors: Klerman LV et al.
Grant Number: 290-92-0055.
Principal Investigator: Robert Goldenberg.
Project Officer: Heddy Hubbard.
Abstract: OBJECTIVES: This project investigated whether augmented prenatal care for high-risk African American women would improve pregnancy outcomes and patients' knowledge of risks, satisfaction with care, and behavior. METHODS: The women enrolled were African American, were eligible for Medicaid, had scored 10 or higher on a risk assessment scale, were 16 years or older, and had no major medical complications. They were randomly assigned to augmented care (n = 318) or usual care (n = 301). Augmented care included educationally oriented peer groups, additional appointments, extended time with clinicians, and other supports. RESULTS: Women in augmented care rated their care as more helpful, knew more about their risk conditions, and spent more time with their nurse-providers than did women in usual care. More smokers in augmented care quit smoking. Pregnancy outcomes did not differ significantly between the groups; however, among patients in augmented care, rates of preterm births were lower and cesarean deliveries and stays in neonatal intensive care units occurred in smaller proportions. Both groups had lower-than-predicted rates of low birthweight. CONCLUSIONS: High-quality prenatal care, emphasizing education, health promotion, and social support, significantly increased women's satisfaction, knowledge of risk conditions, and perceived mastery in their lives, but it did not reduce low birthweight.
Title: Behavioural problems in children who weigh 1000 g or less at birth in four countries.
Publication: Lancet 2001;357:1641-3.
Authors: Hille ETM et al.
Grant Number: HS08385.
Principal Investigator: Nigel Paneth.
Project Officer: Steven Fox.
Abstract: BACKGROUND: The increased survival chances of extremely low-birthweight (ELBW) infants (weighing <1000 grams at birth) has led to concern about their behavioral outcome in childhood. In reports from several countries with different assessments at various ages, investigators have noted a higher frequency of behavioural problems in such infants, but cross-cultural comparisons are lacking. Our aim was to compare behavioural problems in ELBW children of similar ages from four countries. METHODS: We prospectively studied 408 ELBW children aged 8-10 years, whose parents completed the child behaviour checklist. The children came from the Netherlands, Germany, Canada, and United States. The checklist provides a total problem score consisting of eight narrow-band scales. Of these, two (aggressive and delinquent behavior) give a broad-band externalizing score, three (anxious, somatic, and withdrawn behavior) give a broad-band internalizing score, and three (social, thought, and attention problems) indicate difficulties fitting neither broad-band dimension. For each cohort we analyzed scores in ELBW children and those in normal- birthweight controls (two cohorts) or national normative controls (two cohorts). Across countries, we assessed deviations of the ELBW children from normative or control groups. FINDINGS: ELBW children had higher total problem scores than normative or control children, but this increase was only significant in European countries. Narrow-band scores were raised only for the social, thought, and attention difficulty scales, which were 0.5-1.2 SD higher in ELBW children than in others. Except for the increase in internalising scores recorded for one cohort, ELBW children did not differ from normative or control children on internalising or externalising scales. INTERPRETATION: Despite cultural differences, types of behavioural problems seen in ELBW children were very similar in the four countries. This finding suggests that biological mechanisms contribute to behavioural problems of ELBW children.
Title: Physical Growth and Current Health Status of Infants Who Were of Extremely Low Birth Weight and Controls at Adolescence.
Publication: Pediatrics Aug 2001;108(2):407-15.
Authors: Saigal S et al.
Grant Number: HS08385.
Principal Investigator: Nigel Paneth.
Project Officer: Steven Fox.
Abstract: OBJECTIVES: To compare the physical growth, current health status, and utilization of health care resources by extremely low birth weight (ELBW) and control (C) adolescents and to look at changes over time. METHODS: A longitudinal regional cohort study was conducted. Growth measures were converted to z scores on the National Center for Health Statistics growth curves. Information regarding current health status/health care utilization was obtained by parental interviews. RESULTS: A total of 154 (91 percent) of 169 ELBW survivors between 12 and 16 years and 125 (86 percent) of 145 controls participated. Neurosensory impairments were present in 28 percent of ELBW survivors and 2 percent of control participants. Mean z scores for both height and weight were below 0 for ELBW survivors (weight: -0.35; height: -0.55) compared with control participants (weight: 0.40; height: 0.28). However, among ELBW survivors, significant catch-up growth occurred in both parameters between age 8 and adolescence but remained stable among control participants. ELBW survivors had a higher prevalence of visual problems (57 percent vs 21 percent), seizures (7 percent vs 1 percent), developmental delay (26 percent vs 1 percent), learning disabilities (34 percent vs 10 percent), and hyperactivity (9 percent vs 2 percent) and used more specialists and community resources than did control participants. CONCLUSIONS: Although physical growth continues to be compromised and substantial morbidity remains among ELBW survivors at adolescence, there seems to be some catch-up growth, a reduction in the prevalence of acute health problems, and a decrease in the utilization of medical resources.
Title: Clinical findings associated with radiographic pneumonia in nursing home residents.
Publication: Journal of Family Practice 2001 Nov;50(11):931-7.
Authors: David Mehr et al.
Grant Number: HS08551.
Principal Investigator: David Mehr.
Project Officer: Charlotte Mullican.
Abstract: OBJECTIVE: Subtle presentation and the frequent lack of on-site physicians complicate the diagnosis of pneumonia in nursing home residents. We sought to identify clinical findings (signs, symptoms, and simple laboratory studies) associated with radiographic pneumonia in sick
nursing home residents. STUDY DESIGN: This was a prospective cohort study. POPULATION: The residents of 36 nursing homes in central Missouri and the St. Louis area with signs or symptoms suggesting a lower respiratory infection were included. OUTCOME MEASURED: We compared evaluation findings by project nurses with findings reported from chest radiographs. RESULTS: Among 2334 episodes of illness in 1474 nursing home residents, 45percent of the radiograph reports suggested pneumonia (possible=12percent; probable or definite = 33percent). In 80percent of pneumonia episodes, subjects had 3 or fewer respiratory or general symptoms. Eight variables were significant independent predictors of pneumonia (increased pulse, respiratory rate =30, temperature =38 degrees C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, absence of wheezes, and increased white blood count). A simple score (range = -1 to 8) on the basis of these variables identified 33percent of subjects (score > or =3) with more than 50percent probability of pneumonia and an additional 24percent (score of 2) with 44percent probability of pneumonia. CONCLUSIONS: Pneumonia in nursing home residents is usually associated with few symptoms. Nonetheless, a simple clinical prediction rule can identify residents at very high risk of pneumonia. If validated in other studies, physicians could consider treating such residents without obtaining a chest radiograph.
Title: Predicting mortality from lower respiratory infection in nursing home residents: the Missouri LRI Study.
Publication: Journal of the American Medical Association 2001 Nov;286(19):2427-36.
Authors: David Mehr et al.
Grant Number: HS08551.
Principal Investigator: David Mehr.
Project Officer: Charlotte Mullican.
Abstract: Context Lower respiratory tract infection (LRI) is a leading cause of mortality and hospitalization in nursing home residents. Treatment decisions may be aided by a clinical prediction rule that identifies residents at low and high risk of mortality. Objective To identify patient characteristics predictive of 30-day mortality in nursing home residents with an LRI. Design, Setting, and Patients Prospective cohort study of 1406 episodes of LRI in 1044 residents of 36 nursing homes in central Missouri and the St Louis, Mo, area between August 15, 1995, and September 30, 1998. Main Outcome Measure Thirty-day all-cause mortality. Results Thirty-day mortality was 14.7percent (n = 207). In a logistic analysis, using generalized estimating equations to adjust for clustering, we developed an 8-variable model to predict 30-day mortality, including serum urea nitrogen, white blood cell count, body mass index, pulse rate, activities of daily living status, absolute lymphocyte count of less than 800/µL (0.8 109/L), male sex, and deterioration in mood over 90 days. In validation testing, the model exhibited reasonable discrimination (c = .76) and calibration (nonsignificant Hosmer-Lemeshow goodness-of-fit statistic, P = .54). A point score based on this model's variables fit to the entire data set closely matched observed mortality.
Fifty-two percent of residents had low (score of 0-4) or relatively low (score of 5-6) predicted 30-day mortality, with 2.2percent and 6.2percent actual mortality, respectively. Conclusions Our model distinguishes nursing home residents at relatively low risk for mortality due to LRI. If independently validated, our findings could help physicians identify nursing home residents in need of different therapeutic approaches for LRI.