Medical care
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Multicenter Study Comparative Study
Impact of different measures of comorbid disease on predicted mortality of intensive care unit patients.
Valid comparison of patient survival across ICUs requires adjustment for burden of chronic illness. The optimal measure of comorbidity in this setting remains uncertain. ⋯ Independently weighted comorbid conditions identified through computerized discharge abstracts can contribute significantly to ICU risk adjustment models.
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Comparative Study
Can administrative data be used to compare postoperative complication rates across hospitals?
Several quality assessment systems use administrative data to identify postoperative complications, with uncertain validity. ⋯ ICD-9-CM complications were underreported among diskectomy patients, especially at hospitals with low risk-adjusted complication rates. The validity of using coded complications to compare provider performance is questionable, even with careful efforts to identify serious events, although these results must be confirmed using more recent data.
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It is unclear whether publicly reporting hospitals' risk-adjusted mortality leads to improvements in outcomes. ⋯ During Cleveland's experiment with hospital report cards, deaths shifted from in hospital to the period immediately after discharge with little or no net reduction in 30-day mortality for most conditions. Hospital profiling remains an unproven strategy for improving outcomes of care for medical conditions. Using in-hospital mortality rates to monitor trends in outcomes for hospitalized patients may lead to spurious conclusions.
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To examine whether process of hospital care differs among Hispanic, black, and white VA beneficiaries. ⋯ In contrast to findings in other studies, process of inpatient care was generally similar in Hispanic patients, black patients, and white patients. Our findings may reflect several characteristics of veterans' hospitals that may lead to care that is more equitable.
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Voluntary informed consent is a hard problem--one that inheres in the domain of research. The standard definition requires four criteria for consent to be morally valid: disclosure, understanding, voluntariness, and competence. These standards apply across the continuum of activities that comprise research. ⋯ The literature indicates that many of these subjects enroll in research on the basis of feelings of hope or trust. This finding bypasses the careful weighing of risks and benefits that the model of informed consent is based upon. This paper explores how the requirements of candor need to be balanced with those of kindness.