Community clinics offer potential for timelier outbreak detection and monitoring than emergency departments. However, the accuracy of syndrome definitions used in surveillance has never been evaluated in community settings. This study's objective was to assess the accuracy of syndrome definitions based on diagnostic codes in physician claims for identifying 5 syndromes (fever, gastrointestinal, neurological, rash, and respiratory including influenza-like illness) in community clinics.
We selected a random sample of 3,600 community-based primary care physicians who practiced in the fee-for-service system in the province of Quebec, Canada in 2005-2007. We randomly selected 10 visits per physician from their claims, stratifying on syndrome type and presence, diagnosis, and month. Double-blinded chart reviews were conducted by telephone with consenting physicians to obtain information on patient diagnoses for each sampled visit. The sensitivity, specificity, and positive predictive value (PPV) of physician claims were estimated by comparison to chart review.
1,098 (30.5%) physicians completed the chart review. A chart entry on the date of the corresponding claim was found for 10,529 (95.9%) visits. The sensitivity of syndrome definitions based on diagnostic codes in physician claims was low, ranging from 0.11 (fever) to 0.44 (respiratory), the specificity was high, and the PPV was moderate to high, ranging from 0.59 (fever) to 0.85 (respiratory). We found that rarely used diagnostic codes had a higher probability of being false-positives, and that more commonly used diagnostic codes had a higher PPV.
Future research should identify physician, patient, and encounter characteristics associated with the accuracy of diagnostic codes in physician claims. This would enable public health to improve syndromic surveillance, either by focusing on physician claims whose diagnostic code is more likely to be accurate, or by using all physician claims and weighing each according to the likelihood that its diagnostic code is accurate.
Cites: Proc AMIA Symp. 2001;:164-811833477
Cites: J Am Med Inform Assoc. 2010 Sep-Oct;17(5):595-60120819870
Cites: Ann Intern Med. 2004 Jun 1;140(11):910-2215172906
Cites: Biometrics. 1983 Mar;39(1):207-156871349
Cites: Med Care. 1991 Oct;29(10):977-881921530
Cites: Am J Epidemiol. 1994 Oct 15;140(8):759-697942777
Cites: CMAJ. 1998 Sep 8;159(5):525-89757182
Cites: J Fam Pract. 1998 Nov;47(5):366-99834772
Cites: J Am Med Inform Assoc. 2005 Nov-Dec;12(6):618-2916049227
The purpose of this article is to investigate the performance of scales to assess the work environment of hospital professional staff, other than nurses or physicians.
A survey was conducted among professional (non-nursing or medical) staff at a 300-bed urban, university-affiliated Canadian hospital. A total of 24 work environment items were adapted from a scale previously validated among nursing staff. Scales were developed based on a principal components analysis, and were compared among four groups of staff. The relationships between the scales and the following measures were then explored using univariate and multivariate analyses: satisfaction with the work environment, perceived quality of patient care, perceived frequency of patient/family complaints, work-related injuries, and verbal abuse of staff.
The survey response rate was 154/200 (76.6 percent). Four scales were identified (with corresponding Cronbach's alpha), assessing the following aspects of the work environment: supervisory support (0.88), team-work (0.84), professionalism (0.77), and interdisciplinary relations (0.64). In multivariate analyses, there were significant differences between the job groups in all four scales. One or more of the scales was significantly associated with overall satisfaction, perceived quality, and adverse incidents, even after adjustment for other staff characteristics.
Limitations include: the cross-sectional design, subjective measurement of quality of care, small sample sizes in some groups of staff, and the single study site.
The scales developed in this study may be used by managers to assess hospital staff perceptions of the work environment.
The four proposed scales appear to measure meaningful aspects of the working environment that are important in determining overall satisfaction with the work environment and are related to quality of care.
Emergency department (ED) use in Quebec may be measured from varied sources, eg, patient's self-reports, hospital medical charts, and provincial health insurance claims databases. Determining the relative validity of each source is complicated because none is a gold standard.
We sought to compare the validity of different measures of ED use without arbitrarily assuming one is perfect.
Data were obtained from a nursing liaison intervention study for frail seniors visiting EDs at 4 university-affiliated hospitals in Montreal.
The number of ED visits during 2 consecutive follow-up periods of 1 and 4 months after baseline was obtained from patient interviews, from medical charts of participating hospitals, and from the provincial health insurance claims database.
Latent class analysis was used to estimate the validity of each source. The impact of the following covariates on validity was evaluated: hospital visited, patient's demographic/clinical characteristics, risk of functional decline, nursing liaison intervention, duration of recall, previous ED use, and previous hospitalization.
The patient's self-report was found to be the least accurate (sensitivity: 70%, specificity: 88%). Claims databases had the greatest validity, especially after defining claims made on consecutive days as part of the same ED visit (sensitivity: 98%, specificity: 98%). The validity of the medical chart was intermediate. Lower sensitivity (or under-reporting) on the self-report appeared to be associated with higher age, low comorbidity and shorter length of recall.
The claims database is the most valid method of measuring ED use among seniors in Quebec compared with hospital medical charts and patient-reported use.
: We determine the cost-effectiveness of a 2-stage emergency department intervention in addition to usual ED care compared with that of usual care alone.
The intervention comprises 2 steps: (1) identification of high-risk patients by using a screening tool and (2) a brief standardized nursing assessment to identify unresolved problems, followed by referral to an appropriate community provider. The patient population was composed of individuals aged 65 years and older to be released from the EDs of 4 Montreal hospitals. Patients were randomized by day of ED visit. The perspective of the study is societal, including patients, caregivers, and the formal health care (government-funded) system. Outcomes, measured from randomization to 4 months after randomization, included (1) functional decline, as measured by an activities of daily living instrument, or death, and (2) changes in depressive symptoms. Costs include post-ED care, including hospitalization, physician services, community care, outpatient drugs, and patient and caregiver costs. Cost items were measured with administrative databases and self-reported questionnaires. Unit costs for these items were either province-wide rates or else were estimated directly by using provider data. Cost-effectiveness is assessed in qualitative terms, such that outcomes and costs are compared separately.
The intervention was associated with a reduced rate of functional decline (including death) at 4 months. There was no effect of the intervention on change in the patient's depressive symptoms at 4 months relative to baseline. The estimated ratio of overall costs per patient in the intervention versus the control group, adjusted for covariates, was 0.94 (95% credible interval 0.75 to 1.17). Among patients who had visited the ED during the 30 days before the index visit, the ratio was 0.66 (95% credible interval 0.44 to 0.97).
In this study setting, the intervention is preferred over usual care because beneficial functional outcomes were observed, and overall societal costs were no higher than if usual care only was given.
To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium.
Prospective cohort study.
Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal.
Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital.
Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the in-hospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality.
Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.
Cites: Ann Intern Med. 1990 Dec 15;113(12):941-82240918
To determine the effects of prevalent and incident delirium on length of hospital stay.
Prospective cohort study, comparing (1). length of stay after admission in cases of prevalent delirium versus controls without prevalent delirium with (2). length of stay after diagnosis in cases of incident delirium versus controls matched by day of diagnosis.
The medical services of a primary, acute care hospital.
Medical admissions of patients aged 65 and older from the emergency department with delirium diagnosed during the first week in hospital. Patients admitted to intensive care or oncology and those with a primary diagnosis of stroke were excluded. A sample of those without delirium was also enrolled.
Delirium was diagnosed using the Confusion Assessment Method. Data on length of stay and diagnosis-related groups (DRGs) were abstracted from administrative data. Measures of covariates included the Informant Questionnaire on Cognitive Decline in the Elderly, the Delirium Index, the instrumental activities of daily living questionnaire from the Older American Resources and Services project, the Charlson Comorbidity Index, the Clinical Severity Scale, and the Acute Physiology Score.
The study sample comprised 359 patients: 204 with prevalent delirium, 37 with incident delirium, and 118 without delirium. After controlling for covariates, prevalent delirium was not associated with a significantly longer hospital stay, but incident delirium was associated with an excess stay after diagnosis of 7.78 days (95% confidence interval=3.07, 12.48). Similar results were obtained using log-transformed or DRG-adjusted estimates of length of stay.
In older medical inpatients, incident but not prevalent delirium is an important predictor of longer hospital stay. Interventions to prevent incident delirium may reduce length of stay.
The purpose of this study was to test the value of gait speed, a clinical marker for frailty, to improve the prediction of mortality and major morbidity in elderly patients undergoing cardiac surgery.
It is increasingly difficult to predict the elderly patient's risk posed by cardiac surgery because existing risk assessment tools are incomplete.
A multicenter prospective cohort of elderly patients undergoing cardiac surgery was assembled at 4 tertiary care hospitals between 2008 and 2009. Patients were eligible if they were 70 years of age or older and were scheduled for coronary artery bypass and/or valve replacement or repair. The primary predictor was slow gait speed, defined as a time taken to walk 5 m of = 6 s. The primary end point was a composite of in-hospital post-operative mortality or major morbidity.
The cohort consisted of 131 patients with a mean age of 75.8 ± 4.4 years; 34% were female patients. Sixty patients (46%) were classified as slow walkers before cardiac surgery. Slow walkers were more likely to be female (43% vs. 25%, p = 0.03) and diabetic (50% vs. 28%, p = 0.01). Thirty patients (23%) experienced the primary composite end point of mortality or major morbidity after cardiac surgery. Slow gait speed was an independent predictor of the composite end point after adjusting for the Society of Thoracic Surgeons risk score (odds ratio: 3.05; 95% confidence interval: 1.23 to 7.54).
Gait speed is a simple and effective test that may identify a subset of vulnerable elderly patients at incrementally higher risk of mortality and major morbidity after cardiac surgery.
Comment In: J Am Coll Cardiol. 2010 Nov 9;56(20):1677-821050979
Comment In: J Am Coll Cardiol. 2011 Aug 9;58(7):776; author reply 77721816319
OBJECTIVES: The objective is to assess the impact of geographical variations in mortality on risk selection in patients after acute myocardial infarction. METHOD: Mortality analysis is used with an actuarial methodology applied to follow-up studies based on data from randomized clinical trial and observational cohort studies of acute myocardial infarction patients from different geographic areas. Observed mortality was calculated as geometric average annual rate (q) and compared to the expected geometric average annual mortality (q') mortality calculated from different life tables. This comparison was expressed as mortality ratios (MR). Values of q and MR were averaged within each country grouping. Variance, standard deviation, and variation coefficient (CV) were calculated. RESULTS: Geometric average annual mortality rates varied by country. The lowest rate (2.7%) was observed in Japan, and the highest rates (7.5%) were seen in studies from the United Kingdom and Northern Europe (Denmark, Sweden, Finland). The average annual mortality rate was 4.9%. Mortality ratios averaged within countries vary from 182% to 212%, with an overall average value of 198%. Coefficient of variation (CV) was 36% for geometric average annual mortality rates and 6% for mortality ratios. CONCLUSION: Although annual mortality rates from all causes vary greatly between countries, mortality ratios do not vary and remain relatively constant. This highlights the interest of risk assessment using mortality analysis methodology, which makes the geographic variation in post-myocardial infarction mortality disappear.
To evaluate the validity of the Identification of Seniors at Risk (ISAR) screening tool for detecting severe functional impairment and depression and predicting increased depressive symptoms and increased utilization of health services.
Four university-affiliated hospitals in Montreal.
Data from two previous studies were available: Study 1, in which the ISAR scale was developed (n=1,122), and Study 2, in which it was used to identify patients for a randomized trial of a nursing intervention (n=1,889 with administrative data, of which 520 also had clinical data).
Patients aged 65 and older who were to be released from an emergency department (ED).
Baseline validation criteria included premorbid functional status in both studies and depression in Study 2 only. Increase in depressive symptoms at 4-month follow-up was assessed in Study 2. Information on health services utilization during the 5 months after the ED visit (repeat ED visits and hospitalization in both studies, visits to community health centers in Study 2) was available by linkage with administrative databases.
Estimates of the area under the receiver operating characteristic curve (AUC) for concurrent validity of the ISAR scale for severe functional impairment and depression ranged from 0.65 to 0.86. Estimates of the AUC for predictive validity for increased depressive symptoms and high utilization of health services ranged from 0.61 to 0.71.
The ISAR scale has acceptable to excellent concurrent and predictive validity for a variety of outcomes, including clinical measures and utilization of health services.
To i) estimate how large the mortality reductions would be if women were offered screening from age 50 until age 69; ii) to do so using the same trials and participation rates considered by the Canadian Task Force; iii) but to be guided in our analyses by the critical differences between cancer screening and therapeutics, by the time-pattern that characterizes the mortality reductions produced by a limited number of screens, and by the year-by-year mortality data in the appropriate segment of follow-up within each trial; and thereby iv) to avoid the serious underestimates that stem from including inappropriate segments of follow-up, i.e., too soon after study entry and too late after discontinuation of screening.
We focused on yearly mortality rate ratios in the follow-up years where, based on the screening regimen employed, mortality deficits would be expected. Because the regimens differed from trial to trial, we did not aggregate the yearly data across trials. To avoid statistical extremes arising from the small numbers of yearly deaths in each trial, we calculated rate ratios for 3-year moving windows.
We were able to extract year-specific data from the reports of five of the trials. The data are limited for the most part by the few rounds of screening. Nevertheless, they suggest that screening from age 50 until age 69 would, at each age from 55 to 74, result in breast cancer mortality reductions much larger than the estimate of 21% that the Canadian Task Force report is based on.
By ignoring key features of cancer screening, several of the contemporary analyses have seriously underestimated the impact to be expected from such a program of breast cancer screening.
Comment In: Can J Public Health. 2013 Nov-Dec;104(7):e435-624495833