Lumbar Spinal Stenosis Severity by CT or MRI Does Not Predict Response to Epidural Corticosteroid versus Lidocaine Injections

BACKGROUND AND PURPOSE

Epidural steroid injections may offer little-to-no short-term benefit in the overall population of patients with symptomatic spinal stenosis compared with lidocaine alone. We investigated whether imaging could identify subgroups of patients who might benefit most.

MATERIALS AND METHODS

A secondary analysis of the Lumbar Epidural Steroid Injections for Spinal Stenosis prospective, double-blind trial was performed, and patients were randomized to receive an epidural injection of lidocaine with or without corticosteroids. Patients (n = 350) were evaluated for qualitative and quantitative MR imaging or CT measures of lumbar spinal stenosis. The primary clinical end points were the Roland-Morris Disability Questionnaire and the leg pain numeric rating scale at 3 weeks following injection. ANCOVA was used to assess the significance of interaction terms between imaging measures of spinal stenosis and injectate type on clinical improvement.

RESULTS

There was no difference in the improvement of disability or leg pain scores at 3 weeks between patients injected with epidural lidocaine alone compared with corticosteroid and lidocaine when accounting for the primary imaging measures of qualitative spinal stenosis assessment (interaction coefficients for disability score, -0.1; 95% CI, -1.3 to 1.2; P = .90; and for the leg pain score, 0.1; 95% CI, -0.6 to 0.8; P = .81) or the quantitative minimum thecal sac cross-sectional area (interaction coefficients for disability score, 0.01; 95% CI, -0.01 to 0.03; P = .40; and for the leg pain score, 0.01; 95% CI, -0.01 to 0.03; P = .33).

CONCLUSIONS

Imaging measures of spinal stenosis are not associated with differential clinical responses following epidural corticosteroid injection.

The NASS lumbar spine outcome assessment instrument: Large sample assessment and sub-scale identification

BACKGROUND

Accurately assessing patient-reported pain and functional ability is essential to measuring quality of care.

PURPOSE

Evaluating the instruments used in assessing quality of care is often overlooked. The North American Spine Society Lumbar Spine Outcome Assessment (NASS-LS) instrument measures patient-reported pain and function in a combined scale. We evaluated the original instrument and assessed separate pain and function subscales based on a set of the items in the original instrument.

STUDY DESIGN/SETTING

Data were collected from seven spine clinics in the United States participating in the Spinal Surgery Consortium for Outcomes Research Project. Consenting patients were enrolled in the project and asked to complete the NASS instrument when arriving for a surgical consult.

PATIENT SAMPLE

Data from 811 lumbar spine patients were used.

METHODS

Analyses were conducted on the original instrument to determine its internal consistency and to determine the structural existence of any underlying scales. Internal consistency of the original and new scales were assessed with Cronbach's coefficient alpha.

RESULTS

The original scale was found to be a useful measure of pain and functional ability. Important subscales of pain and functional ability were also identified allowing us to report more meaningful results.

CONCLUSION

The original instrument is useful for assessing low-back pain and function as a combined concept. The separate pain and function scales may prove useful assessing varying outcome levels and/or different decisions about subsequent follow-up care.

Capacities and limitations of information systems as data sources on quality of care at the end of life

Assessing quality of care at the end of life involves measurements in several domains-use of evidence-based guidelines, patient and family satisfaction, quality of life, and incidence of adverse events, among others. There are several different data sources from which to calculate quality measures. Each data source has a balance of strengths and weaknesses, and not all data sources are available in all possible settings of care. This paper describes how various data sources can be used to obtain the key data elements required for quality of care measures, as well as the challenges to linking data elements across sites and levels of care. There are some important quality domains (e.g., interpersonal and spiritual aspects of care) that are very difficult to assess using readily available data; primary data collection through interview and survey methods will be required to assess quality in these areas.

Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit

OBJECTIVE

To establish the validity and reliability of a new sedation scale, the Motor Activity Assessment Scale (MAAS).

DESIGN

Prospective, psychometric evaluation.

SETTING

Sixteen-bed surgical intensive care unit (SICU) of a 937-bed tertiary care, university-affiliated teaching hospital.

PATIENTS

Twenty-five randomly selected, adult, mechanically ventilated, nonneurosurgical patients who were admitted to the SICU > or = 12 hrs after surgery and were not receiving neuromuscular blockers.

INTERVENTION

Four hundred assessments (eight per patient) were completed consecutively but independently, in pairs, at standardized times (both day and night) by two nurses who were preselected for each assessment from a pool of 32 pretrained SICU nurses.

MEASUREMENTS AND MAIN RESULTS

To estimate validity, paired assessments (four/patient) compared the MAAS result with the subjective assessment using a 10-cm visual analog sedation scale, the percent change in blood pressure and heart rate from the previous 4-hr baselines, and the number of recent agitation-related sequelae. To estimate reliability, paired assessments (four/patient) measured correlation between assessments of the same type (e.g., MAAS-MAAS). Generalized estimating equations, which accounted for the four repeated measures in each patient, supported MAAS validity by finding a linear trend between MAAS and the visual analog scale (p < .001), blood pressure (p < .001), heart rate (p < .001), and agitation-related sequelae (p < .001) end points. The MAAS (kappa = 0.83 [95% confidence interval, 0.72 to 0.94]) was found to be more reliable than subjective assessment using the visual analog scale (intraclass correlation coefficient = 0.32 [95% confidence interval, 0.05 to 0.55]).

CONCLUSIONS

The MAAS is a valid and reliable sedation scale for use with mechanically ventilated patients in the SICU. Further studies are warranted regarding the effect of MAAS implementation in our SICU on patient outcomes, such as quality of sedation and length of mechanical ventilation, as well as the use of the MAAS in other patient populations (e.g., medical).

Accountability for health outcomes and the proper unit of analysis: what do the experts think?

BACKGROUND

An invitational conference was held in Dearborn, MI, in April of 1998 to discuss technical and conceptual issues related to the general topic of using outcomes data to compare plans, networks, and providers. Approximately 150 researchers, clinicians, purchasers, and representatives of accreditation bodies and government agencies attended. SURVEY OF PARTICIPANTS: At the opening session, attendees participated in an electronic survey exercise designed to identify areas of agreement or disagreement on controversial issues related to the main conference topic.

MAIN FINDINGS

There was general agreement about the basic concept of health plan and provider accountability for health outcomes, and about the need for further development of data sources and case-mix adjustment models. There was disagreement about other issues, including questions of who should bear the cost of collecting outcomes data and whether results should be analyzed at health plan, network, or individual clinician level.

CONCLUSION

A group of experts agreed on the importance of reporting comparative outcomes data, but disagreed on many of the technical details of how that could best be done.

Prophylaxis for stress-related gastrointestinal hemorrhage: a cost effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to the intensive care unit.

DESIGN

Decision model of the cost and efficacy of sucralfate and cimetidine, two commonly used drugs for prophylaxis of stress-related hemorrhage. Outcome estimates were based on data from published studies. Cost data were based on cost of medications and costs of treatment protocols at our institutions.

MEASUREMENTS AND MAIN RESULTS

The marginal cost-effectiveness of prophylaxis, as compare with no prophylaxis, was calculated separately for sucralfate and cimetidine and expressed as cost per bleeding episode averted. An incremental cost-effectiveness analysis was subsequently employed to compare the two agents. Sensitivity analyses of the effects of the major clinical outcomes on the cost per bleeding episode averted were performed. At the base-case assumptions of 6% risk of developing stress-related hemorrhage and 50% risk-reduction due to prophylaxis, the cost of sucralfate was $1,144 per bleeding episode averted. The cost per bleeding episode averted was highly dependent on the risk of hemorrhage and, to a lesser degree, on the efficacy of sucralfate prophylaxis, ranging from a cost per bleeding episode averted of $103,725 for low-risk patients to cost savings for very high-risk patients. The cost per bleeding episode averted increased significantly if the risk of nosocomial pneumonia was included in the analysis. The effect of pneumonia was greater for populations at low risk of hemorrhage. Assuming equal efficacy, the cost per bleeding episode averted of cimetidine was 6.5-fold greater than the cost per bleeding episode averted of sucralfate.

CONCLUSIONS

The cost of prophylaxis in patients at low risk of stress-related hemorrhage is substantial, and may be prohibitive. Further research is needed to identify patient populations that are at high risk of developing stress-related hemorrhage, and to determine whether prophylaxis increases the risk of nosocomial pneumonia.

Primary care research from a health system perspective

Vertically integrated systems of health care share a set of interests with academic health services researchers. These interests include questions about: the appropriate size and scope of the various system components; mechanisms for coordinating care across component parts; and "what works" in terms of clinical effectiveness within components. Primary care is a key system component in which all of these questions apply. Traditional research designs, however, are often difficult to apply in a health system context. The problems are (1) the rapid pace at which organizational change occurs, which renders some research findings obsolete before they are published, and (2) the difficulty in generalizing across a complex set of local environmental factors that vary from system to system. Useful research from a system perspective will either focus on problems of wide generalizability over place and time or be conducted according to new methodologies that offer much faster "cycle time" from design to findings.

Health status of populations as a measure of health system performance

This article describes the assessment of self-reported health status as one indicator of the performance of health care delivery systems. This work took place in the context of a larger effort to measure performance in health care. The Consortium Research on Indicators of System Performance (CRISP) project is developing measures of the performance of integrated health care systems, rather than plans or providers. The system focus leads to measurement of the health status of defined populations and an analysis of health care episodes and processes extending beyond the physician's office or hospital that relate directly to patient outcomes and satisfaction. This focus provides opportunities for application of performance measures to quality improvement efforts, since outcomes can be logically linked to identifiable and measurable processes. After a discussion of the purpose and the history of CRISP and how populations were defined within the systems, some preliminary data on the health status of populations are presented.

Consortium Research on Indicators of System Performance (CRISP)

Since the CRISP project is in its early stages, reports of performance indicator data are not yet available. It will be late in 1994 before we have sufficient experience with our measures to encourage their use for both internal quality improvement and external evaluation. Some of our participating systems are quite far along in the development of individual indicators and have some experience with their fluctuations over time, but we are just beginning the process of studying cross-system comparisons. Use of measures in comparing the performance of integrated delivery systems is still an unproved technology, no matter how successful the measures may have been in other contexts. We believe that our approach to measuring system performance fits very well with the current direction of health care reform. We hope that the project will allow integrated systems of care to take a lead role in defining and testing measures of performance.

A comprehensive payment model for short- and long-stay psychiatric patients

In this article, a payment model is developed for a hospital system with both acute- and chronic-stay psychiatric patients. "Transition pricing" provides a balance between the incentives of an episode-based system and the necessity of per diem long-term payments. Payment is dependent on two new psychiatric resident classification systems for short- and long-term stays. Data on per diem cost of inpatient care, by day of stay, was computed from a sample of 2,968 patients from 100 psychiatric units in 51 Department of Veterans Affairs (VA) Medical Centers. Using a 9-month cohort of all VA psychiatric discharges nationwide (79,337 with non-chronic stays), profits and losses were simulated.

What are the essentials of system integration?

In summary, the Luke article is a solid starting point for understanding the relationships between existing hospital systems, developing regional systems, and ultimate benefits to patients, their employers, and their communities. We clearly have a long way to go though, and the attention should turn to some of the key functional features of integrated systems.

Ongoing assessment of health status in patients with diabetes mellitus

In 1990, the Division of Endocrinology and Metabolism of Henry Ford Hospital established an Outcomes Management data base for patients with Type I and Type II diabetes. A first cohort of 117 patients completed a baseline and 6-month follow-up assessment; a second cohort of 116 patients completed the baseline assessment. Assessment at each time point includes: the Short Form--36 Questions (SF-36) health status instrument; a set of clinical variables known as the Diabetes TyPE scale Form 2.2 abstracted from the medical record; and the physicians' ratings of patient's health status along the major dimensions of the SF-36. Success with both face-to-face and mailed administration of the SF-36 has been good, with response rates of over 85% using both methods. Comparison of patient and physician ratings of patient health status indicated a significant discrepancy on ratings of general health status, with physicians' ratings higher than those of patients themselves. "Tight" glycemic control (as measured by glycosylated hemoglobin) was associated with somewhat lower ratings on the various SF-36 dimensions for all patients in the first cohort and for Type I patients in the second cohort. However, this effect did not seem to be attributable to those features of a complex regimen used to achieve tight control, but rather reflected a complex combination of age, education level, and number of daily injections associated with achieving good control.

Clinical activities and satisfaction of general internists, cardiologists, and ophthalmologists

To define factors that affect the levels of practice satisfaction of different specialities, an observer recorded the activities of 15 physicians in practice (nine general internists, three cardiologists, and three ophthalmologists) as they examined 304 clinic patients. General internists reported less satisfaction with their clinics than did the other physicians and attributed their satisfaction primarily to successful social interaction in 54% of visits, while cardiologists most often derived satisfaction from intellectual stimulation (50%) and ophthalmologists from medical success (81%). The general internists whom the authors observed are less satisfied with clinical encounters than are cardiologists and ophthalmologists and derive satisfaction mostly from social interaction, not biomedical aspects of care.

A randomized, controlled trial of an attending staff service in general internal medicine

This study, a prospective, randomized trial comparing two inpatient staffing models, was undertaken to compare clinical and financial outcomes for general medicine inpatients assigned to resident (teaching) or staff (nonteaching) service. Key outcome measures included: 1) length of stay; 2) total charges; 3) laboratory, radiology, pharmacy, and supplies charges; 4) in-hospital mortality and mortality within 6 months of admission; and 5) 15-day readmission rate. The study took place at Henry Ford Hospital, a 937-bed urban teaching hospital in Detroit, Michigan; the subjects included all general internal medicine patients admitted to a single nursing unit of Henry Ford Hospital between October 1, 1987 and September 30, 1988. When the unit was fully staffed and operational, patients admitted to the Staff Service had a 1.7-day lower average length of stay than patients admitted to the Resident Service (P greater than 0.005), lower average total charges of $1,681 (P greater than 0.01), and significantly lower laboratory and pharmacy charges. No statistically significant differences in mortality rates or readmission rates were found. Even though personnel costs are invariably higher on an attending service, this staffing arrangement can be financially viable because of more efficient patterns of care. Shorter length of stay may be translated either into cost savings or increased revenues in order to offset higher salary costs. Teaching hospitals may wish to consider an attending service as one way to reduce house officer work loads, offer more opportunities for training in ambulatory settings, and adjust to a smaller pool of applicants for residency positions.

The behavioral dynamics of clinical trials

Two ways of approaching the design of long-term clinical trials are presented and contrasted. The first, termed the "static" view, emphasizes close adherence to formal rules of study design. The second, termed the "dynamic" view, emphasizes the behavioral aspects of patient participation in trials of long duration. The dynamic view is discussed in detail, with discussion of how recruitment of participants, random assignment to conditions, compliance with protocol, and measurement of outcomes are affected by behavioral dynamics. Data from a recently completed tamoxifen toxicity trial are used to illustrate the points and to focus the discussion of behavioral dynamics on the design of a chemoprevention trial for breast cancer using tamoxifen.

A classification system for long-staying psychiatric patients

Data on a sample of 890 Veteran's Administration long-staying psychiatric patients were studied to develop a classification system that explains actual daily resource use. Disturbed patients with lengths of stay of less than three years and those with psychotic conditions who are not withdrawn represent the two groups found to use significantly more resources in their daily care. The Long-Stay Psychiatric Patient Classification (LPPC) System, with six categories, explains 11.4% of the variability in per diem resource use and can be used for case-mix adjustment of payments for psychiatric care.

A psychiatric patient classification system. An alternative to diagnosis-related groups

It is generally accepted that diagnosis-related groups (DRGs) for alcohol, drug, and mental disorders are inappropriate for inpatient prospective payment. To address this issue, the Veterans Administration (VA) supported a project to construct alternative classes that are more clinically meaningful, more homogeneous in their resource use, and that account for more variation in resource use among psychiatric and substance use cases than existing DRGs. This paper reports on this project. Using a data set containing universally available discharge data plus behavioral, social, and functional information obtained by a survey of 116,191 discharges from VA psychiatric beds, and with AUTOGRP as the classifying algorithm, a classification system was formed. Twelve psychiatric diagnostic groupings (PDGs) were identified, analogous to major diagnostic groups in the DRG system. Within each PDG, from 4 to 9 terminal groups of Psychiatric Patient Classes (PPCs) were formed and validated. The 12 substance abuse PPCs explain greater than 31% of the variation in length of stay; for the mental disorder PPCs the variance explanation is greater than 11%, a substantial improvement over DRGs that, for the same data set, explain less than 2 and 3%, respectively. With the addition of only 5 variables beyond those presently included in discharge data sets, greater precision for payment purposes can be achieved. Implications for adoption of this classification system are discussed.

Side effects and emotional distress during cancer chemotherapy

Chemotherapy side effects, patient distress, and patient-practitioner communication were evaluated in an inception sample of 238 patients with breast cancer or malignant lymphoma. Participants were interviewed at five points during their first six cycles of therapy, and a subsample kept brief daily symptom diaries. Nausea, hair loss, and tiredness were each experienced by more than 80% of patients. By cycle 6, 46% of patients had thoughts about quitting therapy, but only a few had told medical staff. Patients' ratings of the objective difficulty of treatment increased over time, varied by treatment regimen, and were predicted by the experience of side effects, with the number of different side effects serving as the best predictor. In contrast, emotional distress was less sensitive to the directly assessable characteristics of treatment. Communication between patient and practitioner was found to be inadequate in a number of respects (i.e., patients did not fully anticipate the toxicities of treatment and did not report their concerns to medical staff). Communication may be impeded by inaccuracies in a patient's recall of treatment difficulties and by a patient's inability or unwillingness to attend to all presented information. More frequent opportunities for patient-practitioner discussion are necessary.

The role of motion sickness in predicting anticipatory nausea

Susceptibility to motion sickness has been demonstrated to be a predictor of anticipatory nausea in cancer patients receiving chemotherapy. However, previous research did not test whether motion sickness increases anticipatory nausea only by increasing the base rate of posttreatment nausea and vomiting (which has traditionally served as the unconditioned stimulus in the conditioning model for anticipatory nausea) or, alternatively, whether motion sickness might facilitate the association of external stimuli to posttreatment nausea and vomiting. Using two different analytic approaches--a series of logistic analyses that controlled for drug-induced nausea and vomiting following the initial injection, along with an event history analysis which allows for updating on the posttreatment nausea and vomiting factors--motion sickness was found to be an independent predictor of anticipatory nausea. Further, the predictive power of motion sickness is also independent of the effects of pretreatment anxiety, taste during injection, and age.

Psychosocial consequences of cancer chemotherapy for elderly patients

The purpose of this study was to determine whether elderly patients receiving cancer chemotherapy experience more emotional distress, difficulty with side effects, and disruption in activities than younger patients. A sample of 217 patients receiving initial chemotherapy treatment for breast cancer or lymphoma was interviewed several times over the first 6 months of treatment. Patients ranged in age from 19 to 83. Included in the interviews were questions on presence, duration, and severity of side effects; response of disease to treatment; and 0-10 ratings of emotional distress, difficulty, and life disruption due to chemotherapy. Information on drugs given, doses, and schedules was obtained from medical charts. In general, elderly patients reported no more difficulty with treatment or emotional distress than did younger patients. This general pattern held across disease types, with some exceptions. These results, combined with previously published studies on the physiological effects of chemotherapy in the elderly, indicate that aggressive treatment should not be withheld from older patients simply because of their age.

Anxiety and drug taste as predictors of anticipatory nausea in cancer chemotherapy

Interview data from 192 patients receiving cytotoxic chemotherapy for the first time were analyzed to identify factors predictive of the development of anticipatory nausea. Posttreatment nausea and vomiting (particularly vomiting), tastes of drugs during injections, and anxiety before injections were all associated with an increased probability of anticipatory nausea. An index consisting of those three variables, plus age, was found to have good predictive power, even when the predictor variables were assessed only at the first chemotherapy administration and the index was used to predict the development of anticipatory nausea at any time during the first six chemotherapy cycles.

Factors associated with active participation in a Cancer Prevention Clinic

To investigate factors that influence individuals at higher than average risk for cancer to seek preventive care, we studied 78 people by questionnaires designed to assess a variety of psychological, familial, and personal demographic variables. Twenty-six of these subjects (probands) had actively sought the services provided by a Cancer Prevention Clinic whereas the other subjects (nonprobands) did not initiate contact with the clinic. The results of a discriminant analysis indicate that prior involvement in cancer preventive activities, interest in cancer-specific information, and level of perceived susceptibility to cancer all contributed significantly to active participation in the Cancer Prevention Clinic. Level of psychological discomfort was found to be associated with cancer-specific variables, but did not contribute significantly to proband status. Involvement in preventive behaviors and perceived cancer susceptibility were most highly associated with familial factors, such as the proportion of first-degree relatives with cancer, whereas interest in cancer information was primarily related to perceived risk level.

Factors contributing to emotional distress during cancer chemotherapy

Recent studies have demonstrated that patients receiving cancer chemotherapy are more likely to have a successful treatment outcome if they receive optimal doses of drug continually. The current study was designed as a first step toward discovering factors that are associated with emotional distress during treatment and subsequent decisions by patients to delay, reduce, or terminate treatment. Interviews were conducted with 61 patients receiving chemotherapy for malignant lymphoma. Patients reported on side effects of treatment and their efforts to control them, their knowledge and beliefs about their illness, their strategies for monitoring the effectiveness of treatment, and the extent to which they had been prepared for the experiences of chemotherapy. Ratings of emotional distress were obtained on an 11-point self-report scale, and information about treatment schedules was obtained from medical records. The number of side effects experienced, but not the duration or severity, was positively correlated with distress. Vague, diffuse side effects such as tiredness and pain were more likely to be associated with distress than were acute, specific side effects such as nausea and vomiting. Patients who reported either unsuccessful attempts to cope with side effects or no attempts at all had greater distress than those who were coping successfully. Patients who developed conditioned nausea during treatment reported higher distress than those who did not.

Components of aggression in chickens and conceptualizations of aggression in general

A refined analysis of the peck order in chickens was offered as a test of the notion that for this species, different responses such as leaping and various types of pecking need not be interchangeable indexes of aggression. Indeed, tests showed that particular response types of the birds were differentially mediated by organismic or environmental factors. In large cages pecking at the body was most frequent by birds that had a home-cage advantage. Contrarily, rates of aggressive leaping were independent of this environmental influence, with males having an advantage over females. Males showed more head pecking than females, but the profile for this sex difference did not resemble the profile for leaping. Correlational analyses revealed that whereas head pecking between testmates was not matched in frequency, leaping was positively related. Finally, the behavior of birds tested in small cages differed from that of the large-cage subjects. Although there was more head pecking in the small cages, males did not have an edge, and leaping was infrequent. Such results indicate that these responses cannot be viewed as interchangeable indicators of aggression in fowl.

Components of aggression in chickens and conceptualizations of aggression in general

A refined analysis of the peck order in chickens was offered as a test of the notion that for this species, different responses such as leaping and various types of pecking need not be interchangeable indexes of aggression. Indeed, tests showed that particular response types of the birds were differentially mediated by organismic or environmental factors. In large cages pecking at the body was most frequent by birds that had a home-cage advantage. Contrarily, rates of aggressive leaping were independent of this environmental influence, with males having an advantage over females. Males showed more head pecking than females, but the profile for this sex difference did not resemble the profile for leaping. Correlational analyses revealed that whereas head pecking between testmates was not matched in frequency, leaping was positively related. Finally, the behavior of birds tested in small cages differed from that of the large-cage subjects. Although there was more head pecking in the small cages, males did not have an edge, and leaping was infrequent. Such results indicate that these responses cannot be viewed as interchangeable indicators of aggression in fowl.