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Accurate classification of clinical severity is important for interpreting casemix in clinical studies and for stratifying patients for clinical trials. To evaluate whether clinical judgment might be an effective method of estimating severity, all 604 patients admitted to the medical service in a one month period were rated at the time of admission by the responsible resident as to how sick they were. Within the 13 comorbid disease groups, and within the 15 basic categories of reason for admission, the physicians' severity ratings were the most significant predictor of in-hospital mortality. Death rates rose from 0% in those rated as not ill, to 2% in the mildly ill, to 6% in the moderately ill, to 23% in the severely ill, and to 58% in those rated as moribund (p less than 0.001). Sickness ratings also predicted time to death: mildly ill patients died after prolonged hospitalizations, while the moribund died shortly after admission. The patients' age, sex, race, the number of comorbid diseases or problems did not predict mortality. Patients with serious comorbidity (metastases, AIDS, or cirrhosis) had a higher mortality rate than other patients (p less than 0.001); however, the severity ratings predicted outcomes within this group (p less than 0.001) as well as among those without such serious comorbidity (p less than 0.001). Patients who were admitted with acute neurologic (p less than 0.05) or acute cardiovascular (p less than 0.01) events did have an independently worse prognosis. In conclusion, physicians' estimates or sickness provided an accurate estimate of illness severity, with mortality rates that essentially tripled from one stratum to the next. Clinical judgment may suffice to classify the clinical severity of patients at the time of enrollment in prospective trials and can provide a useful method of controlling for casemix.

To improve their overall financial position, many teaching hospitals have considered decreasing the size of their clinics. To assess the effect this would have on the inpatient service, the medical ward service of The New York Hospital was studied during the 1981 to 1982 academic year. In 50 percent of hospitalizations, patients were enrolled in the clinic system before admission. In an additional 19 percent of hospitalizations, patients had either been previously seen in the emergency room or hospitalized at this institution, but never seen in a clinic. In the remaining 31 percent of hospitalizations, the patient's admission was the first contact with the institution. This group of "new" patients simply replaced the patients who died (14 percent) or were lost to the system through transfer to chronic-care facilities (11 percent) or referral to community physicians (7 percent). Twenty percent of patients discharged to a clinic were readmitted during the study year as opposed to only 3 percent of patients who were transferred to chronic-care facilities or referred to community physicians. The clinic system is the principal source of referral into the ward service and the most effective mechanism for insuring that a patient needing rehospitalization returns to the hospital. It is concluded that major reduction of clinic size will result in severe contraction of the inpatient service.

In clinical trials measuring the short term survival of patients, prognostic stratification is important to avoid susceptibility bias. Demographic and disease specific clinical features are commonly used to established similarity, but these may not insure prognostic comparability. To identify the generic predictors of one year survival after hospitalization, a cohort of 559 patients admitted to the medical service at New York Hospital was studied. Among all of the clinical and demographic information available at the time of admission, only three were independent predictors of the time until death: functional ability, severity of illness and extent of comorbid disease. The overall one year survival rate was 66%. Six subgroups composed of patients with different combinations of the predictors of prognosis had mortality rates ranging from 97% to 14%. Illness severity was a predictor only in the less functional patients, and only severe comorbidity was associated with a decreased survival after taking into account functional ability and illness severity. Prospective estimates of severity of illness, functional ability and extent of comorbidity can be used to stratify a diverse group of patients according to their probability of one year survival after hospitalization.

Physicians have to address the question of the measures to be employed in the event that a patient's condition deteriorates after admission to the hospital. To identify the information that physicians use in making such decisions, all 604 patients admitted to the medical service during a one-month period were studied. The patient's age and residents' estimates of the patient's long-term prognosis and ability to function were the three primary factors that correlated with intervention preferences. When illness severity, the reason for admission, comorbidity, and poor function were taken into account, mortality and morbidity rates did not differ between patients for whom full vs not-full intervention was favored. Apart from differential rates of admission to critical care units, there were no important differences in the care, course, or mortality of patients for whom less than full intervention was initially favored. Suggestions that physicians should discuss resuscitation with all or most patients who may die are unrealistic. A more prudent strategy is to discuss the issue with patients whose hospital course is marked by a steady deterioration.

A number of reports have noted the trend toward home deliveries. With the aim of providing an alternative to unattended home delivery, an out-of-hospital unit for women at low medical risk was opened in New York City in October 1975. Physical care is provided by a team of nurse-midwives, obstetricians, pediatricians, and ancillary health personnel. Childbirth education is an integral part of the program. Women are carefully screened both initially and during the course of pregnancy, and transfers are made to hospital services when required. In the first 31 months of the program, 244 births were managed in the unit. No life-threatening emergencies have occurred. Experience to date indicates that a unit of this kind can safely offer care to a low-risk obstetric population.