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BACKGROUND: Several instruments commonly are used to assess the quality of medication prescribing. However, little is known about the relationship between these instruments or the concordance of their quality assessments when applied to the same group of patients. METHODS: We assessed 3 indicators of prescribing quality in a cohort of 196 veterans age 65 and older who were taking 5 or more medications. These 3 indicators assessed whether each patient was (1) taking any medication from the drugs-to-avoid criteria of Beers et al, (2) taking any medication with a score of 3 or more on the Medication Appropriateness Index (MAI), and/or (3) taking 9 or more medications (polypharmacy). Kappa statistics were used to assess agreement between measures. RESULTS: Mean age was 74.6 years, and patients used a mean of 8.1 medications. Six percent of drugs were rated inappropriate by the Beers drugs-to-avoid criteria, whereas 23% of drugs received an MAI score of 3 or more. Overall agreement between these metrics was 78%, little more than expected by chance (kappa statistic 0.14, P<0.01). At the level of the patient, the proportion of subjects taking one or more inappropriate drugs was 37% by drugs-to-avoid criteria and 82% by MAI, whereas 37% had polypharmacy of >or=9 drugs. Prescribing was classified as inappropriate by all 3 metrics in 18% of patients and as appropriate by all 3 metrics in 13%. Together, this level of agreement was slightly better than chance (3-way kappa statistic 0.08, P=0.03). Agreement remained low in sensitivity analyses using different cutoffs for the Beers criteria, a range of thresholds for MAI scores, and different definitions of polypharmacy, with kappa statistics

The structure and function of departments of medicine are important for several reasons. First, departments of medicine are the biggest departments in virtually every medical school and in most universities with a medical school, and they are the largest professional units in most academic medical centers. In fact, Petersdorf described them as "the linchpins of medical schools" (1). Departments of medicine account for one-fourth or more of the academic medical enterprise: they include about one-fourth of the faculty of medical school, account for roughly one-fourth of the patient care and clinical revenue of academic medical centers, and their faculty perform a disproportionate share of teaching and research, accounting for up to 45% of National Institutes of Health (NIH) - funded research in some medical schools. Second, the department's ability to fulfill its role and advance its mission depends on its structure and function. Finally, lessons learned from examining the structure and function of departments of medicine may guide other departments and schools of medicine themselves in improving their structure and function. This paper describes the issues that face departments of medicine in 2016. I begin by providing the context for these issues with a definition of a department of medicine, describing briefly the history of departments, and stating their mission., Competing Interests: Potential Conflicts of Interest: None disclosed.

Background: Many older adults become dependent in one or more activities of daily living (ADLs: dressing, bathing, transferring, eating, toileting) when hospitalized, and their prognosis after discharge is unclear., Objective: To develop a prognostic index to estimate one-year probabilities of recovery, dependence or death in older hospitalized patients who are discharged with incident ADL dependence., Design: Retrospective cohort study., Participants: 449 adults aged ≥ 70 years hospitalized for acute illness and discharged with incident ADL dependence., Main Measures: Potential predictors included demographics (age, sex, race, education, marital status), functional measures (ADL dependencies, instrumental activities of daily living [IADL] dependencies, walking ability), chronic conditions (e.g., congestive heart failure, dementia, cancer), reason for admission (e.g., neurologic, cardiovascular), and laboratory values (creatinine, albumin, hematocrit). Multinomial logistic regression was used to develop a prognostic index for estimating the probabilities of recovery, disability or death over 1 year. Discrimination of the index was assessed for each outcome based on the c statistic., Key Results: During the year following hospitalization, 36 % of patients recovered, 27 % remained dependent and 37 % died. Key predictors of recovery, dependence or death were age, sex, number of IADL dependencies 2 weeks prior to admission, number of ADL dependencies at discharge, dementia, cancer, number of other chronic conditions, reason for admission, and creatinine levels. The final prognostic index had good to excellent discrimination for all three outcomes based on the c statistic (recovery: 0.81, dependence: 0.72, death: 0.78)., Conclusions: This index accurately estimated the probabilities of recovery, dependence or death in adults aged 70 years or older who were discharged with incident disability following hospitalization. This tool may be useful in clinical settings to guide care discussions and inform decision-making related to post-hospitalization care.

Context: Few studies have examined the validity of using a single item from the Edmonton Symptom Assessment Scale (ESAS) for screening for depression., Objectives: To examine the screening performance of the single-item depression question from the ESAS in chronically ill hospitalized patients., Methods: A total of 162 chronically ill inpatients aged 65 and older completed a survey after admission that included the well-validated, 15-item Geriatric Depression Scale (GDS-15) and four single-item screening questions for depression based on the ESAS question, using two different time frames ("now" and "in the past 24 hours") and two response categories (a 0-10 numeric rating scale [NRS] and a categorical scale: none, mild, moderate, and severe)., Results: The GDS-15 categorized 20% (n = 33) of participants as possibly being depressed with a score ≥ 6. The NRS for depression "now" achieved the highest level of sensitivity at a cutoff ≥ 1 (68.8%), and an acceptable level of specificity was obtained at a cutoff of ≥ 5 (82.2%). For depression "in the past 24 hours," a cutoff of ≥ 1 achieved a sensitivity of 68.8% and a cutoff of ≥ 7 a specificity of 80.3%. For the categorical scale, a cutoff of "none" provided the best level of sensitivity for depression "now" (65.6%) and "in the past 24 hours" (81.3%), with an acceptable level of specificity being obtained at ≥"mild" (68.8%) and ≥"moderate" (68.8%), respectively., Conclusion: These single-item measures were not effective in screening for probable depression in chronically ill patients regardless of the time frame or the response format used, but a cutoff of ≥ 5 or "mild" or greater did achieve sufficient specificity to raise clinical suspicion., (Copyright © 2012 U.S. Cancer Pain Relief Committee. All rights reserved.)

Background: It is unknown whether health-related media stories reach diverse older adults and influence advance care planning (ACP)., Objective: To determine exposure to media coverage of Terri Schiavo (TS) and its impact on ACP., Design and Participants: Descriptive study of 117 English/Spanish-speakers, aged >or=50 years (mean 61 years) from a county hospital, interviewed six months after enrollment into an advance directive study., Measurements: We assessed whether participants had heard of TS and subject characteristics associated with exposure. We also asked whether, because of TS, subjects engaged in ACP., Main Results: Ninety-two percent reported hearing of TS. Participants with adequate literacy were more likely than those with limited literacy to report hearing of TS (100% vs. 79%, P < .001), as were participants with >or= a high school vs. < high school education (97% vs. 82%, P = .004), and English vs. Spanish-speakers (96% vs. 85%, P = .04). Because of TS, many reported clarifying their own goals of care (61%), talking to their family/friends about ACP (66%), and wanting to complete an advance directive (37%)., Conclusions: Most diverse older adults had heard of TS and reported that her story activated them to engage in ACP. Media stories may provide a powerful opportunity to engage patients in ACP and develop public health campaigns.

Quality of life is an important treatment outcome for conditions that are rarely fatal, such as cutaneous basal cell carcinoma and squamous cell carcinoma (typically called nonmelanoma skin cancer (NMSC)). The purpose of this study was to compare quality-of-life outcomes of treatments for NMSC. We performed a prospective cohort study of 633 consecutive patients with NMSC diagnosed in 1999 and 2000 and followed for 2 years after treatment at a university-based private practice or a Veterans Affairs clinic. The main outcome was tumor-related quality of life 1 to 2 years after therapy, measured with the 16-item version of Skindex, a validated measure. Skindex scores vary from 0 (best) to 100 (worst) in three domains: Symptoms, Emotions, and Function. Treatments were electrodessication and curettage (ED&C) in 21%, surgical excision in 40%, and Mohs surgery in 39%. Five hundred and eight patients (80%) responded after treatment. Patients treated with excision or Mohs surgery improved in all quality-of-life domains, but quality of life did not improve after ED&C. There was no difference in the amount of improvement after excision or Mohs surgery. For example, mean Skindex Symptom scores improved 9.7 (95% CI: 6.9, 12.5) after excision, 10.2 (7.4, 12.9) after Mohs surgery, and 3.4 (-0.9, 7.6) after ED&C. We conclude that, for NMSC, quality-of-life outcomes were similar after excision and Mohs surgery, and both therapies had better outcomes than ED&C.

Background: The use of brand rather than generic names for medications can increase health care costs. However, little is known at a national level about how often physicians refer to drugs using their brand or generic names., Objective: To evaluate how often physicians refer to drugs using brand or generic terminology., Design and Participants: We used data from the 2003 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of 25,288 community-based outpatient visits in the United States. After each visit, patient medications were recorded on a survey encounter form by the treating physician or transcribed from office notes., Measurements: Our main outcome measure was the frequency with which medications were recorded on the encounter form using their brand or generic names., Results: For 20 commonly used drugs, the median frequency of brand name use was 98% (interquartile range, 81-100%). Among 12 medications with no generic competition at the time of the survey, the median frequency of brand name use was 100% (range 92-100%). Among 8 medications with generic competition at the time of the survey ("multisource" drugs), the median frequency of brand name use was 79% (range 0-98%; P < .001 for difference between drugs with and without generic competition)., Conclusions: Physicians refer to most medications by their brand names, including drugs with generic formulations. This may lead to higher health care costs by promoting the use of brand-name products when generic alternatives are available.

Background: Sales visits by pharmaceutical representatives ("drug detailing") are common, but little is known about the content of these visits or about the impact of visit characteristics on prescribing behavior. In this study, we evaluated the content and impact of detail visits for gabapentin by analyzing market research forms completed by physicians after receiving a detail visit for this drug., Methods and Findings: Market research forms that describe detail visits for gabapentin became available through litigation that alleged that gabapentin was promoted for "off-label" uses. Forms were available for 97 physicians reporting on 116 detail visits between 1995 and 1999. Three-quarters of recorded visits (91/116) occurred in 1996. Two-thirds of visits (72/107) were 5 minutes or less in duration, 65% (73/113) were rated of high informational value, and 39% (42/107) were accompanied by the delivery or promise of samples. During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the "main message" of the visit involved at least one off-label use. After receiving the detail visit, 46% (50/108) of physicians reported the intention to increase their prescribing or recommending of gabapentin in the future. In multivariable analysis, intent to increase future use or recommendation of gabapentin was associated with receiving the detail in a small group (versus one-on-one) setting and with low or absent baseline use of the drug, but not with other factors such as visit duration, discussion of "on-label" versus "off-label" content, and the perceived informational value of the presentation., Conclusions: Detail visits for gabapentin were of high perceived informational value and often involved messages about unapproved uses. Despite their short duration, detail visits were frequently followed by physician intentions to increase their future recommending or prescribing of the drug.

Background: The financial ability to pay for food and medical care is needed to maintain health in older persons following a serious illness. Therefore, we hypothesize that the inability to pay for basic needs, which we call financial disability, predicts adverse health outcomes in older patients discharged from the hospital., Objectives: To determine the frequency of reported financial disability in older adults being discharged from a hospital, to determine patient characteristics associated with financial disability, and to examine the relationship between financial disability and functional decline and mortality., Design: Prospective cohort study., Setting/participants: Two thousand two hundred patients 70 years and older admitted to the general medicine services at two teaching hospitals in Ohio., Main Outcome Measures: Respondents were interviewed at the time of discharge to determine patients' financial ability to pay for 6 needs: groceries, general bills, medications, medical bills, a small emergency, and a major emergency. We determined functional decline in ability to perform activities of daily living from discharge to 90 days post-hospital discharge, and death 1 year after hospital discharge., Results: Financial disability was reported to be severe (unable to pay for 3-6 needs) for 21% of patients and moderate (unable to pay for 1-2 needs) for 36%. Financial disability was more common and more severe (P<.001) in persons with an annual household income less than $10,000, in persons with fewer than 12 years of formal education, in African Americans, and in women. In patients with no financial disability, moderate financial disability, and severe financial disability, functional decline 3 months after hospital discharge occurred in 15%, 20%, and 25%, respectively (P=.001), and 1-year mortality rates were 24%, 27%, and 32%, respectively (P=.002). After adjustment for potential confounders, the association of financial disability with functional decline (P=.003) and mortality (P=.02) remained significant., Conclusion: Reports of financial disability at hospital discharge identified vulnerable older adults with increased risk for functional decline and death. Interventions that alleviate financial disability may improve health outcomes in older adults discharged from hospital.

Objective: To examine the relation between two patient outcome measures that can be used to assess the quality of hospital care: changes in health status between admission and discharge, and patient satisfaction., Design: Prospective cohort study., Setting and Patients: Subjects were 445 older medical patients (aged > or =70 years) hospitalized on the medical service of a teaching hospital., Measurements and Main Results: We interviewed patients at admission and discharge to obtain two measures of health status: global health and independence in five activities of daily living (ADLs). At discharge, we also administered a 5-item patient satisfaction questionnaire. We assessed the relation between changes in health status and patient satisfaction in two sets of analyses, that controlled for either admission or discharge health status. When controlling for admission health status, changes in health status between admission and discharge were positively associated with patient satisfaction (p values ranging from .01 to .08). However, when controlling for discharge health status, changes in health status were no longer associated with patient satisfaction. For example, among patients independent in ADLs at discharge, mean satisfaction scores were similar regardless of whether patients were dependent at admission (i.e., had improved) or independent at admission (i.e., remained stable) (79.6 vs 81.2, p = .46). Among patients dependent in ADLs at discharge, mean satisfaction scores were similar regardless of whether they were dependent at admission (i.e., remained stable) or independent at admission (i.e., had worsened) (74.0 vs 75.7, p = .63). These findings were similar using the measure of global health and in multivariate analyses., Conclusions: Patients with similar discharge health status have similar satisfaction regardless of whether that discharge health status represents stable health, improvement, or a decline in health status. The previously described positive association between patient satisfaction and health status more likely represents a tendency of healthier patients to report greater satisfaction with health care, rather than a tendency of patients who improve following an interaction with the health system to report greater satisfaction. This suggests that changes in health status and patient satisfaction are measuring different domains of hospital outcomes and quality. Comprehensive efforts to measure the outcomes and quality of hospital care will need to consider both patient satisfaction and changes in health status during hospitalization.

Objective: Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients' activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses., Setting: The general medical service of a teaching hospital., Participants: Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women)., Measurements: Independence in ADL function on admission was assessed by interviewing each patient's primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent., Main Results: ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS. Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1-58.8), 1-year mortality (OR 4.4; 2.7-7.4), and 90-day nursing home use (OR 14.9; 6.0-37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both., Conclusions: ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case-mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.

This study examined surgery for colorectal cancer among Medicare beneficiaries 65 years of age or older with an initial diagnosis in 1987 (n = 81 579). Black patients were less likely than White to undergo surgical resection (68% vs 78%), even after age, comorbidity, and location and extent of tumor were controlled for. Among those who underwent resection, Black patients were more likely to die (a 2-year mortality rate of 40.0% vs 33.5% in White patients); this disparity also remained after confounders had been controlled. The disparities were similar in teaching and nonteaching hospitals and in private and public hospitals. These data may indicate racially based differences among Medicare beneficiaries in access to and quality of care for colorectal cancer.

The purpose of this study was to develop and validate the Nursing Severity Index, a new method used to measure the admission severity of illness of hospital patients using nursing diagnoses, which categorize biologic, functional, cognitive, and psychosocial abnormalities. This retrospective cohort study with independent development and testing phases was conducted at a U.S. academic medical center. In the development phase, data regarding 14,183 adult medical-surgical patients admitted to the medical center in 1985 and 1986 was used. In the testing phase, data regarding 7,302 patients admitted in 1987 and 1988 was used. Primary nurses prospectively recorded the presence or absence of 61 nursing diagnoses on admission. Demographic and clinical data were obtained from hospital data bases. In the development phase, the number of admission nursing diagnoses was highly related (P < 0.001) to in-hospital mortality. Using multiple logistic regression, 34 nursing diagnoses were identified as independent predictors of mortality; the Nursing Severity Index equals the number of these 34 diagnoses. In the testing phase of 7,302 patients, the Nursing Severity Index was related (P < 0.001) to mortality rates, which were 0.5%, 1%, 2%, 6%, 13%, 22%, and 31% in seven hierarchical strata defined by the Index. The Index was as accurate in predicting mortality as MedisGroups (receiver-operating-characteristic curve areas, 0.814 +/- 0.016 vs. 0.845 +/- 0.015, respectively, P = 0.12). Furthermore, the Nursing Severity Index and MedisGroups together (receiver operating characteristic curve area 0.880 +/- 0.014), were more accurate (P < 0.01) than either measure alone. The Nursing Severity Index assesses multiple dimensions of illness, can be easily measured during routine patient care, accurately predicts the risk of in-hospital death, and has similar prognostic accuracy as MedisGroups. Its usefulness in outcomes assessment, quality assurance, and case management merits further study.