Standards of diabetic care successes and failures of a patient education policy

Objective. To determine: (i) some aspects of the quality of medical care provided for adult diabetic patients in primary care settings; and (ii) changes in these variables 1 year after attending a specialist diabetes clinic that provided 2 - 3 hours of self-care education. Design. An analysis of the prevalences of obesity, uncontrolled diabetes, hypertension and hypercholesterolaemia at entry and 1 year later.Setting. Diabetes Clinic, Johannesburg Hospital, South Africa.Patients. Ninety randomly selected adult diabetic patients (46 black), with duration of diabetes ≥1 year at the first assessment.Results. At entry insulin-treated (N = 46) and non-insulintreated (N = 44) subjects showed prevalences of obesity (body mass index > 30) of 17% and 36%, respectively; there was unsatisfactory glycaemic control (haemoglobin A1C ≥ 9.5%) in 72% and 64%; untreated hypertension (blood pressure > 160/90 mmHg) in 24% and 23%; and untreated hypercholesterolaemia (> 7.0 mmol/l) in 15% and 11%. One year later weight had increased only in the non-insulintreated patients (+ 1.9 kg, P < 0.01). Mean HbA1C had improved (P < 0.D1 in both groups), but remained unsatisfactory in 49% of patients. Blood pressure control was poor in 14 of the 22 hypertensive patients; and hypercholesterolaemia persisted in 11 subjects. At presentation the patterns of poor control were similar in black and white patients, and the rates of improvement were comparable.Conclusion. There was a low rate of overall metabolic control of diabetes and its associations in primary care settings, with only limited improvements as a result of attending a dedicated diabetes clinic

Gallop Rhythm of the Heart:

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Fatalities due to intestinal obstruction following the ingestion of foreign bodies

Two fatalities due to an occlusive ileus following the ingestion of foreign bodies in patients with psychiatric disorders are described. A severely mentally handicapped young man developed a temperature and died 1 h after admission to a surgical ward. At autopsy, not, vert, similar 2000 cm3 of foreign material, including broken glass and porcelain, branches, buttons, parts of clothing and other material were found in the gastrointestinal tract, leading to a complete obstruction of the distal intestine and colon with resulting faecal vomiting. The other case was even more unusual as a hair fetishist had swallowed a thick strand of his own hair, 50 cm long, also resulting in mechanical obstruction of the distal intestine

Survival Rates in Trauma Patients Following Health Care Reform in Massachusetts

IMPORTANCE: Massachusetts introduced health care reform (HCR) in 2006, expecting to expand health insurance coverage and improve outcomes. Because traumatic injury is a common acute condition with important health, disability, and economic consequences, examination of the effect of HCR on patients hospitalized following injury may help inform the national HCR debate. OBJECTIVE: To examine the effect of Massachusetts HCR on survival rates of injured patients. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 1,520,599 patients hospitalized following traumatic injury in Massachusetts or New York during the 10 years (2002-2011) surrounding Massachusetts HCR using data from the State Inpatient Databases. We assessed the effect of HCR on mortality rates using a difference-in-differences approach to control for temporal trends in mortality. INTERVENTION: Health care reform in Massachusetts in 2006. MAIN OUTCOME AND MEASURE: Survival until hospital discharge. RESULTS: During the 10-year study period, the rates of uninsured trauma patients in Massachusetts decreased steadily from 14.9% in 2002 to 5.0.% in 2011. In New York, the rates of uninsured trauma patients fell from 14.9% in 2002 to 10.5% in 2011. The risk-adjusted difference-in-difference assessment revealed a transient increase of 604 excess deaths (95% CI, 419-790) in Massachusetts in the 3 years following implementation of HCR. CONCLUSIONS AND RELEVANCE: Health care reform did not affect health insurance coverage for patients hospitalized following injury but was associated with a transient increase in adjusted mortality rates. Reducing mortality rates for acutely injured patients may require more comprehensive interventions than simply promoting health insurance coverage through legislation

Impact of date stamping on patient safety measurement in patients undergoing CABG: Experience with the AHRQ Patient Safety Indicators

<p>Abstract</p> <p>Background</p> <p>The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) provide information on hospital risk-adjusted rates for potentially preventable adverse events. Although designed to work with routine administrative data, it is unknown whether the PSIs can accurately distinguish between complications and pre-existing conditions. The objective of this study is to examine whether the AHRQ PSIs accurately measure hospital complication rates, using the data with present-on-admission (POA) codes to distinguish between complications and pre-existing conditions</p> <p>Methods</p> <p>Retrospective cohort study of patients undergoing isolated CABG surgery in California conducted using the 1998–2000 California State Inpatient Database. We calculated the positive predictive value of selected AHRQ PSIs using information from the POA as the gold standard, and the intra-class correlation coefficient to assess the level of agreement between the hospital risk-adjusted PSI rates with and without the information contained in the POA modifier.</p> <p>Results</p> <p>The false positive error rate, defined as one minus the positive predictive value, was greater than or equal to 20% for four of the eight PSIs examined: decubitus ulcer, failure-to-rescue, postoperative physiologic and metabolic derangement, and postoperative pulmonary embolism or deep venous thrombosis. Pairwise comparison of the hospital risk-adjusted PSI rates, with and without POA information, demonstrated almost perfect agreement for five of the eight PSI's. For decubitus ulcer, failure-to-rescue, and postoperative pulmonary embolism or DVT, the intraclass-correlation coefficient ranged between 0.63 to 0.79.</p> <p>Conclusion</p> <p>For some of the AHRQ Patient Safety Indicators, there are significant differences in the risk-adjusted rates of adverse events depending on whether the POA indicator is used to distinguish between pre-existing conditions and complications. The use of the POA indicator will increase the accuracy of the AHRQ PSIs as measures of adverse outcomes.</p