Primary prophylaxis of variceal bleeding in cirrhosis: a cost-effectiveness analysis

BACKGROUND & AIMS: Prophylaxis against the first variceal bleeding has been proposed to reduce morbidity and mortality in cirrhotic patients. No previous information is available regarding the cost-effectiveness of prophylaxis. The aim of this study was to compare the cost-effectiveness of variceal bleeding prophylaxis with propranolol, sclerotherapy, and shunt surgery in cirrhotic patients stratified by bleeding risk. METHODS: A hypothetical cohort was stratified according to bleeding risk. The natural history of cirrhosis with esophageal varices was simulated using a Markov model. Transitional probabilities extracted from published studies and costs were obtained from our institution's billing department. Sensitivity analyses were performed for important variables. RESULTS: Propranolol results in cost savings ranging between $450 and $14,600 over a 5-year period. The extent of cost savings depended on the individual patient's bleeding risk. In addition, propranolol increased the quality-adjusted life expectancy by 0.1-0.4 years. Sclerotherapy was significantly less cost-effective than propranolol and had no advantage on quality of life. Shunt surgery was effective therapy for prevention of bleeding but decreased life expectancy and quality of life in some risk groups and was not cost-effective. CONCLUSIONS: Propranolol is the only cost-effective form of prophylactic therapy for preventing initial variceal bleeding in cirrhosis regardless of bleeding risk.     

Zolpidem (Ambien): a pediatric case series

BACKGROUND: In 1993, the nonbenzodiazepine sedative-hypnotic zolpidem tartrate (Ambien) was approved for use in the US. Zolpidem has an imidazopyridine structure and possesses a rapid onset of action and a short half-life. The toxic threshold and profile have not been well established in the pediatric population. METHODS: All pediatric zolpidem exposures reported to a regional poison information center over 24 months were reviewed retrospectively from the American Association of Poison Control Centers Toxic Exposure Surveillance System data collection forms. RESULTS: Twelve pediatric zolpidem exposures were reported. Seven were unintentional (ages 20 mon-5 y) and five were intentional misuse/suicide (ages 12-16 y). The regional poison information center was contacted within 1 h in ten cases with onset of symptoms within 10 to 60 min (mean 31.6 min). One child had no effect with 2.5 mg. As little as 5 mg caused symptoms with minor outcome in six unintentional ingestions (5-30 mg). Minor to moderate symptoms were reported 1-4 h after intentional ingestions (12.5-150 mg). The duration of symptoms in the unintentional cases ranged from less than 60 min up to 4 h (mean 2.4 h) and 6-10 h (mean 7.5 h) in the intentional exposures. Treatment consisted of observation (4), syrup of ipecac (1), lavage and activated charcoal (1), activated charcoal alone (5), and unknown (1). CONCLUSION: Due to the very rapid onset of central nervous system symptoms in children, emesis is not a treatment option. Supportive care, activated charcoal in large ingestions, and observation until symptoms resolve may be sufficient in most pediatric cases.     

The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity

The Toxic Exposure Surveillance System or TESS is a comprehensive poisoning surveillance database maintained by the American Association of Poison Control Centers. It now includes data on more than 20.3 million human poison exposures reported to US poison centres. TESS data are submitted by 67 of the 75 US poison control centres, covering 87% of the US population. Reports to US poison centres included in TESS originate both from the general public and from health professionals (12.9%) and include both patients managed at home or at the site of the exposure (73.6%) and those managed in hospitals, emergency departments, or other healthcare facilities (22.8%). TESS data are used by the pharmaceutical industry to monitor or defend product safety, by regulatory agencies proposing new regulations or considering new approvals or over-the-counter switches, and by clinical researchers attempting to characterise toxicity profiles or determine treatment protocols. TESS is a key component of an effective post-marketing surveillance programme, allowing early identification of previously unsuspected hazards, and early changes in formulations, labelling, or packaging when needed, thereby minimising injuries, deaths and product liability. Deaths, severe outcomes and comparisons of poisoning outcomes and hospitalisation rates between products or product categories are used to identify safety outliers. TESS data for each case of poisoning include identification of the substances implicated (including brand and formulation where known), patient age, outcome, specific clinical effects, exposure route, reason for the exposure (unintentional, suicidal, therapeutic error, etc.), antidotes used and the level of healthcare intervention utilised. Pharmaceuticals are implicated in 42% of TESS poisoning cases. About 53% of all cases of poisoning occur in children under 6 years of age. Of the more than 2.1 million cases reported to TESS in 1996, 123,095 (5.7%) were therapeutic errors and 32,866 (1.5%) were adverse reactions to pharmaceuticals. TESS is an essential but under-utilised resource for product-specific toxicity and safety data. Use of TESS data to identify hazards, followed by remedial action to reformulate, repackage, re-label, or recall, will protect patients and consumers from needless hazards, and prevent unnecessary product-related morbidity and mortality.     

Soluble markers of endothelial cell function

Influenza is a serious cause of morbidity and mortality, particularly in the older adult, and it represents a significant economic burden for health-care services. We have reviewed the published literature relating to influenza vaccine effectiveness and the cost-effectiveness of influenza vaccination in comparison with other health-care interventions and conclude that influenza vaccination is one of the most cost-effective interventions possible in the older adult population.     

State of the national's poison centers: 1995 American Association of Poison Control Centers Survey of US Poison Centers

The American Association of Poison Control Centers (AAPCC) 1995 annual survey is summarized. A decline in the total number of poison centers was noted (from 104 in 1991 to 83 in 1995). The 83 US poison centers handled 2,431, 599 human exposure cases. Certified centers (44) served 63.1% of the US population, handled 72.5% of all poison exposures handled by poison centers nationally, and achieved higher utilization rates within their regions (10.9 vs 7.4 human exposure cases handled/1,000 population). Certified centers had superior staff credentials as measured, by passing the certification examinations for specialists in poison information or board certification for medical and managing directors. Funding for poison centers in 1995 to-total $74.6 million, although this funding level was recognized to be inadequate as only 63.1% of the population was served by certified centers and utilization of poison centers was not optimal. The annual cost of covering the entire US with adequate poison control services (meeting AAPCC certification standards and with utilization at a level of 15 human exposures per thousand population) is estimated at $120 million. Funding difficulties were prevalent. Thirty-five centers indicated that closure had been a real threat at least once in the previous 5 years. Analysis of cost per human exposure case by center volume demonstrated that economies of scale were achieved when a center handled at least 20,000 to 30,000 human exposure calls/year. Increasing human exposure volume beyond 30,000/year did not lead to a reduction in the average cost per human exposure case.     

A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma

BACKGROUND: Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalization for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy. OBJECTIVE: To evaluate the medical and cost-effectiveness, patient satisfaction, and quality of life of patients receiving EDTU care for acute asthma compared with inpatient care. METHODS: A prospective, randomized clinical trial performed at 2 urban public hospitals enrolled patients with acute asthma (age range, 18-55 years) not meeting discharge criteria after 3 hours of emergency department therapy. Patients were treated with inhaled adrenergic agonists and steroids in an EDTU for up to 9 hours after randomization or with routine therapy in a hospital ward. Patients were followed up for 8 weeks. MAIN OUTCOME MEASURES: Discharge rate from the EDTU, length of stay, relapse rates, days missed from work or school, days incapacitated during waking hours, symptom-free days and nights, nocturnal awakenings, direct medical costs, patients satisfaction, and patient quality of life. RESULTS: The study consisted of 222 patients with asthma. Sixty-five patients (59%) treated in an EDTU were discharged home; the remainder were admitted to the hospital. There were no differences during the follow-up period in relapse rates (P = .74) or in any other morbidities between the EDTU and inpatient groups. There were significant differences in the length of stay, patient satisfaction, and quality of life favoring EDTU care. The mean (+/-SD) cost per patient in the EDTU group was $1202.79 +/- $1343.96, compared with $2247.32 +/- $1110.18 for the control group (P < .001). CONCLUSIONS: Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.     

Investigation of milk-borne Streptococcus zooepidemicus infection associated with glomerulonephritis in Australia

OBJECTIVES: The aim of this study was to estimate the cost-effectiveness of antihypertensive treatment in elderly people based on the results of the Swedish Trial in Old Patients with Hypertension (STOP Hypertension). DESIGN: The STOP Hypertension study was a randomized trial comparing active antihypertensive treatment with a placebo. The risk of stroke, cardiovascular disease and total mortality was significantly reduced in the actively treated group compared to placebo. SETTING: One hundred and sixteen primary health care centres in Sweden. SUBJECTS: A total of 1627 hypertensive patients aged 70-84. No patient was lost to follow-up. INTERVENTIONS: Antihypertensive treatment with beta blockers and diuretics for a mean follow-up of 25 months. MAIN OUTCOME MEASURE: The cost-effectiveness ratio estimated as the net cost (the treatment cost minus saved costs of reduced cardiovascular morbidity) divided by the number of life-years gained (the increase in life expectancy from treatment). RESULTS: The cost per life-year gained was estimated as SEK 5000 for men and SEK 15,000 for women ($1 = SEK 6; 1 pound = SEK 10). The cost per life-year gained did not exceed SEK 100,000 in any of the sensitivity analyses. CONCLUSIONS: It is concluded that treatment of elderly hypertensive patients with beta blockers and/or diuretics is cost-effective according to the results of the STOP Hypertension study.     

Differential subcellular localization of the survival motor neuron protein in spinal cord and skeletal muscle

OBJECTIVE: To determine the outcome, safety, and possible cost savings of patients undergoing weekend or holiday exercise treadmill testing. DESIGN: Medical records of all 195 patients scheduled for weekend and holiday exercise testing were reviewed, and 77.9% of patients were contacted by telephone to ascertain medical outcomes and need for further emergency department or inpatient care. Costs were calculated from estimates of days of hospitalization saved and incremental costs incurred in conjunction with weekend or holiday testing. SETTING: Urban tertiary care academic medical center. PATIENTS: A total of 195 patients were scheduled for testing, and 181 tests were performed. Over three quarters (75.1%) of patients underwent testing for assessment of chest pain. Other indications included risk stratification after myocardial infarction or coronary angioplasty or prior to noncardiac surgery, or evaluation for arrhythmias, dyspnea, or syncope. MEASUREMENTS AND MAIN RESULTS: Outcomes included results and complications of testing, hospital course after testing, subsequent emergency department visits and readmissions, myocardial infarction, need for cardiac catheterization or revascularization, and mortality. No complications were noted during testing. In 136 patients tested for the indication of chest pain, 90 (66.2%) had negative tests, 39 (28. 7%) were intermediate, and 6 (4.4%) were positive for ischemia. Same day discharge occurred in 115 (84.6%) of the patients, saving an estimated 185 days of hospitalization ($316.83 per patient tested). Event rates over the 6 months following discharge were low. CONCLUSIONS: Weekend and holiday exercise testing is a safe and effective means of risk stratification prior to hospital discharge for patients with chest pain. It also reduces length of stay and is cost saving.     

Cost-effectiveness comparison of sequential ofloxacin versus standard switch therapy

OBJECTIVE: To compare the cost-effectiveness of sequential intravenous-to-oral ofloxacin versus intravenous-to-oral standard switch therapy for the treatment of patients with sepsis who are hospitalized with bacterial infections. DESIGN: Cost-effectiveness analysis from a provider perspective, including resources important to an integrated healthcare network, of a randomized, open-label, controlled, clinical trial. SETTING: Millard Fillmore Health System, Buffalo, NY. PATIENTS: Hospitalized adults requiring parenteral antibiotics for a complicated urinary tract infection, lower respiratory tract infection, or skin and soft tissue infection. INTERVENTIONS: Sequential intravenous-to-oral ofloxacin or standard intravenous-to-oral switch antibiotics. OUTCOME MEASURES: Clinical outcomes and direct costs associated with hospitalization, primary physician services, specialist physician services, and outpatient care. RESULTS: Eighty-two of 89 patients randomized into the two treatment groups were evaluable. Standard switch therapy failed with 12 patients versus 10 patients receiving ofloxacin. Complete economic data were available for 74 patients. Sequential ofloxacin therapy resulted in a 1-day-shorter antibiotic-related hospitalization without evidence of recurrent infection during the posttherapy follow-up evaluations. An average cost savings of $399 per patient was achieved in the sequential ofloxacin group. Although this difference did not attain statistical significance (probably due to the large variance), it is an economically significant finding. The cost-effectiveness ratios were $5735 per successful outcome for the standard switch therapy group versus $5126 per successful outcome in the sequential ofloxacin group. CONCLUSIONS: Sequential ofloxacin was as effective and consistently less expensive than standard switch antibiotics in the initial evaluation and in the sensitivity analysis of room cost and drug acquisition cost. Standard switch therapy would have to be greater than 25% more effective than sequential ofloxacin therapy to change the economic decision.     

Pediatric coin ingestion: a home-based survey

To improve understanding of the natural history of pediatric coin ingestions, an anonymous, home-based mail survey of parents followed by a five-physician private pediatric practice in suburban Maryland was conducted. Of 2,263 families surveyed, 798 (35.3%) responded, representing 1,510 children. Sixty-one (4.0%, 95% confidence interval: 3.1% to 5.1%) children had swallowed a coin, at a mean age of 2.8 years. Fifty-two (85%) coin ingestions were managed at home, usually without calling a physician or poison control center. Only 9 (15%) children were examined by a physician. No child (95% confidence interval: 0% to 4.9%) underwent a removal procedure or had an adverse outcome. Most coin ingestions were found to have been managed at home, often without calling a physician or poison control center. Hospital- or poison control center-based studies underestimate coin ingestion incidence and overestimate the frequency of complications.     

Association of symptoms of depression with diagnostic test charges among older adults

BACKGROUND: Previous studies have documented greater use of health services by depressed persons and have postulated that health care costs could be reduced overall through better recognition and treatment of depression. OBJECTIVE: To determine whether a greater burden of medical illness contributes to excess charges for diagnostic tests among older adults with symptoms of depression. DESIGN: Prospective cohort study. SETTING: A primary care group practice at an academic institution. PATIENTS: 3767 patients 60 years of age and older who completed testing on the Centers for Epidemiologic Studies Depression Scale (CES-D) during routine office visits. MEASUREMENTS: Charges for all inpatient and ambulatory diagnostic testing for 2 years, including clinical pathology, diagnostic imaging, and special procedures; number of visits to the ambulatory care center or emergency department; and number of hospitalizations. The Ambulatory Care Group case-mix approach, which is based on ambulatory diagnoses, was used as a measure of health status and expected resource consumption. RESULTS: Patients with symptoms of depression (CES-D scores > or = 16) were significantly younger (66.6 compared with 68.1 years; P < 0.001), more likely to be white (50.5% compared with 33.9%; P = 0.001), and more likely to be female (75.8% compared with 67.6%; P = 0.001) than were those without these symptoms (CES-D scores < 16). They also had more nonpsychiatric comorbid conditions, had more visits to the ambulatory care center (9.2 compared with 7.8; P < 0.001), were more likely to use the emergency department (52.3% compared with 40%; P = 0.001), were more likely to be hospitalized (22.4% compared with 17%; P = 0.002), and had greater median total diagnostic test charges for a period of 1 year ($583 compared with $387; P < 0.001). The difference in charges, most of which were clinical pathology charges (54.2%), persisted into the second year. Ambulatory Care Group assignment was independently associated with diagnostic test charges. The CES-D summary score was not independently associated with diagnostic test charges when controlling for Ambulatory Care Group assignment. CONCLUSIONS: Patients with symptoms of depression accrue greater average diagnostic test charges. However, these data suggest that such patients also have a greater burden of comorbid nonpsychiatric illness. Efforts to improve outcome and decrease cost for patients who have late-life depression must target interventions to improve the care of psychiatric and medical illness concurrently.     

Cost effectiveness of misoprostol therapy in prevention of NSAID-induced stomach ulcers

The efficacy of 400 micrograms misoprostol daily in the prevention of NSAID (non-steroidal anti-inflammatory drug)-induced gastric ulcer has been proven. We calculated the cost-effectiveness of a 3-month course of treatment of 200 micrograms twice daily for patients of the sick fund "Wiener Gebietskrankenkasse", based on charges of the year 1993. Since efficacy in preventing NSAID-induced gastric ulcers has not yet been proven for any other drug, we compared misoprostol-treated patients with untreated controls. The model was based on the following assumptions: 70% compliance with respect to misoprostol treatment, 5.6% incidence of gastric ulcer in patients protected with misoprostol, 21.7% incidence among unprotected NSAID users, 20% hospitalisation among patients with gastric ulcer. When using "Kassenpreis" (drug price paid by the sick funds) misoprostol treatment is cost-effective at costs of AS 64,100,--for inpatient care, upwards and at costs of AS 43,361,-upwards when using "Apothekeneinstandspreis" (drug price paid by pharmacies to wholesalers). In Austria costing system of inpatient care is based on a per diem fee. In 1993 the above costs corresponded to an average of 13 and 9 days, respectively, of inpatient care in Vienna. But costs of care increase by almost 25% per year and, hence, this conclusion is only temporarily valid and already in 1994 cost-effectiveness will be reached in less days of inpatient care. Sensitivity analysis shows that cost-effectiveness mainly varies according to the incidence of gastric ulcer among unprotected adults, and the hospitalisation rate of gastric ulcer patients. Efficacy (gastric ulcer rate among misoprostol treated patients) and compliance have a relatively low impact.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cost-effectiveness of thrombolytic therapy for acute myocardial infarction

OBJECTIVE: To estimate the cost-effectiveness of thrombolytic therapy versus no thrombolytic therapy for patients following acute myocardial infarction, focusing on the impact of time to treatment on outcome. METHODS: A decision model was developed to assess the benefits, risks, and costs associated with thrombolytic therapy for treatment of acute myocardial infarction compared with standard nonthrombolytic therapy. The model used pooled data from a recent study of nine large randomized, controlled clinical trials and 12-month outcome data from a recently published meta-analysis of thrombolytic therapy trial data. Outcomes were expressed in terms of survival to hospital discharge and survival to 1 year after discharge. The risks of treatment that led to death, morbidity, or added costs were estimated. The model determined excess and marginal costs per death averted to hospital discharge and at 1 year. Results were also estimated in terms of cost per year of life saved. Sensitivity analyses included variations in time to treatment and drug cost. RESULTS: The marginal cost of thrombolytic therapy per death averted at 1 year was $222,344, or $14,438 per year of life saved. For patients treated within 6 hours of acute myocardial infarction, the marginal cost per death averted was $181,536 at 1 year, or $11,788 per year of life saved. CONCLUSIONS: Thrombolytic therapy is significantly more cost-effective than many other cardiovascular interventions and compares favorably with other forms of medical therapy. Results suggest that shortening the time to treatment has a critical impact on the cost-effectiveness of thrombolytic therapy.     

A logistic regression model when some events precede treatment: the effect of thrombolytic therapy for acute myocardial infarction on the risk of cardiac arrest

When outcomes occur in clinical trials before treatment can be given, neither intent-to-treat nor according-to-protocol analyses give optimal estimates of the treatment effect. A better approach employs a time-dependent variable for treatment. Intent-to-treat analyses are conservative, biasing against treatment; according-to-protocol analyses bias in favor of treatment. We show how to measure the effect of a time-dependent variable in a logistic regression using person-time intervals as units of measurement and describe appropriate methods for reporting model performance. The method is applied to develop a model to predict the probability that a patient with a myocardial infarction will have a sudden cardiac arrest within 48 hours of presentation to emergency medical services both when treated with thrombolysis and when not treated. We use a time-dependent treatment variable because many patients went into cardiac arrest while awaiting treatment. This technique has been programmed into an electrocardiograph for real-time use in an emergency department.     

The mental health of hospital nurses in Tasmania as measured by the 12-item General Health Questionnaire

The goal of this study was to examine the clinical and economic outcomes of alternative diagnostic strategies for differentiating benign from malignant adrenal masses. METHODS: We used cost-effectiveness assessment derived from decision analysis and the economic perspective of the payer of health care services. One-time evaluation with fine-needle aspiration (FNA) and combinations of chemical-shift MRI, noncontrast CT, 131I-6beta-iodomethylnorcholesterol (NP-59) scintigraphy, with or without FNA, in a hypothetical cohort of 1000 patients with incidentally discovered unilateral, nonhypersecretory adrenal masses. We calculated and compared the diagnostic effectiveness, costs and cost-effectiveness of the alternative strategies based on estimates from published literature and institutional charge data. RESULTS: At an assumed baseline malignancy rate of 0.25, diagnostic utility varied from 0.31 (CT0) to 0.965 (NP-59) and diagnostic accuracy from 0.655 [noncontrast CT using a cut-off attenuation value of > or = 0 (CT0)] to 0.983 (NP-59). The average cost per patient per strategy ranged from $746 (NP-59) to $1745 (MRI +/- FNA). The best and worst potential cost-to-diagnostic utility ratios were 773 (NP-59) and 2839 (CT0) and 759 (NP-59) and 1982 (MRI +/- FNA) for cost and diagnostic accuracy, respectively. The NP-59 strategy was the optimal choice regardless of the expected outcome examined: cost, diagnostic utility, diagnostic accuracy or cost-effectiveness. Varying the prevalence of malignancy did not alter the cost-effectiveness advantage of NP-59 over the other diagnostic modalities. CONCLUSION: Based on available estimates of reimbursement costs and diagnostic test performance and using reasonable clinical assumptions, our results indicate that the NP-59 strategy is the most cost-effective diagnostic tool for evaluating adrenal incidentalomas over a wide range of malignancy rates and that additional clinical studies are warranted to confirm this cost-effectiveness advantage.     

Risperidone versus haloperidol: II. Cost-effectiveness

Australia and Canada are currently the only Western nations with government guidelines for analyzing the cost-effectiveness of drugs. We used guidelines issued by the Australian Pharmaceutical Benefits Advisory Committee to construct a model for comparing the cost-effectiveness of risperidone and haloperidol over a 2-year period in patients with chronic schizophrenia. Use of clozapine was also included in the analysis as an alternative treatment given to patients who proved unresponsive to therapy with haloperidol or risperidone. Results are expressed in Australian dollars. Cost-effectiveness was determined by using decision-analytic modeling to compare clinical outcomes and costs. The analytic model contained a decision tree for each of the compared agents that tracked the distribution of patients between treatment outcome pathways (i.e., scenarios). Distributions were based on probabilities derived from our meta-analysis results reported elsewhere and from other sources. Each scenario had an associated monetary cost that included all significant direct costs (i.e., hospital costs; outpatient costs; and the cost of drugs, the services of health care professionals, and government-subsidized hostel accommodation). The cost for a given outcome was the sum of costs for all scenarios leading to that outcome. Cost-effectiveness was expressed as the total cost per favorable outcome. The definition of a favorable outcome was one in which the patient was in a response phase at the end of the 2-year period. The probability of a patient experiencing a favorable outcome at the end of 2 years was 78.9% for risperidone versus 58.9% for haloperidol. The total cost of treatment for 2 years was $15,549.00 for risperidone versus $18,332.00 for haloperidol. The expected cost per favorable outcome was $19,709.00 for risperidone and $31,104.00 for haloperidol. Risperidone was more cost-effective than haloperidol and therefore was "dominant" in pharmacoeconomic terms because it produced a higher proportion of favorable outcomes at lower cost. Sensitivity analysis showed that the difference in clinical response rate was a key determinant of cost-effectiveness.     

Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing

BACKGROUND: Community-acquired bacterial meningitis causes substantial morbidity and mortality in adults. OBJECTIVE: To create and test a prognostic model for persons with community-acquired bacterial meningitis and to determine whether antibiotic timing influences clinical outcome. DESIGN: Retrospective cohort study; patients were divided into derivation and validation samples. SETTING: Four hospitals in Connecticut. PATIENTS: 269 persons who, between 1970 and 1995, had community-acquired bacterial meningitis microbiologically proven by a lumbar puncture done within 24 hours of presentation in the emergency department. MEASUREMENTS: Baseline clinical and laboratory features and times of arrival in the emergency department, performance of lumbar puncture, and administration of antibiotics. The target end point was the development of an adverse clinical outcome (death or neurologic deficit at discharge). RESULTS: For the total group, the hospital mortality rate was 27%. Fifty-six of 269 patients (21 %) developed a neurologic deficit, and in 9% the neurologic deficit persisted at discharge. Three baseline clinical features (hypotension, altered mental status, and seizures) were independently associated with adverse clinical outcome and were used to create a prognostic model from the derivation sample. The prediction accuracy of the model was determined by using the concordance index (c-index). For both the derivation sample (c-index, 0.73 [95% CI, 0.65 to 0.81]) and the validation sample (c-index, 0.81 [CI, 0.71 to 0.92]), the model predicted adverse clinical outcome significantly better than chance. For the total group, the model stratified patients into three prognostic stages: low risk for adverse clinical outcome (9%; stage I), intermediate risk (33%; stage II), and high risk (56%; stage III) (P=0.001). Adverse clinical outcome was more common for patients in whom the prognostic stage advanced from low risk (P=0.008) or intermediate risk (P=0.003) at arrival in the emergency department to high risk before administration of antibiotics. CONCLUSIONS: In persons with community-acquired bacterial meningitis, three baseline clinical features of disease severity predicted adverse clinical outcome and stratified patients into three stages of prognostic severity. Delay in therapy after arrival in the emergency department was associated with adverse clinical outcome when the patient's condition advanced to the highest stage of prognostic severity before the initial antibiotic dose was given.     

Osteoporosis in men

The study described here is part of an evaluation of a pilot project concerning the implementation of three psychiatric crisis units in general hospitals in Belgium. The purpose was to evaluate the short-term outcome of a multidisciplinary crisis intervention for psychiatric patients referred to the emergency department. Patients were assessed with the General Health Questionnaire (GHQ-28) at the time of referral to the emergency department and again 1 month later. Patients referred for a psychiatric crisis intervention were compared with patients receiving short-term psychiatric inpatient treatment in another hospital. Patients referred to the emergency department showed a considerable degree of psychiatric disturbance. The General Health Questionnaire appeared to be a good measure for assessment of the "state" aspect of a psychiatric disturbance. The state of distress was significantly reduced one month after referral in both treatment conditions. Nevertheless, an important proportion of patients remained in a state of considerable distress. The results indicate that a short hospital-based crisis intervention approach is comparable with more traditional acute inpatient treatment. However, in the case of more severely distressed patients it may be insufficient. Several limitations of this study are also discussed (risk of overestimation of improvement, influence of time or pre-existing differences).     

Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients

OBJECTIVE: Relationships among different dimensions of patient satisfaction and selected demographic, clinical, and outcome variables were explored in a sample of severely ill people receiving inpatient psychiatric services. METHOD: The sample consisted of 81 patients admitted to and discharged from an inpatient psychiatric unit at a midwestern Veterans Affairs medical center. Stepwise multiple regression was used to examine the relationship between patient satisfaction and self-reported changes in quality of life, symptomatology, and level of functioning as measured by the Treatment Outcome Profile. Other variables such as diagnosis, length of stay, employment, living situation, and prior psychiatric and substance abuse treatment were also considered. A subsample of the most satisfied and dissatisfied patients was chosen to further explore variables contributing to satisfaction with services. RESULTS: Patient satisfaction was related to initial level of functioning, certain diagnoses, and treatment gains. Clinicians were highly accurate in identifying patients who were satisfied, based on blind chart reviews. CONCLUSIONS: This study underscores the significant relationships between patient satisfaction, psychiatric diagnosis, and other outcome measures, and argues for the validity and utility of patient satisfaction measures in assessing the efficacy of inpatient care.