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This is the first study to our knowledge to examine the relationship between hospital volume and outcome among medical admissions to adult ICUs. After adjusting for admission severity of illness using a robust physiologic-based measure, the study yielded mixed results. While there were no significant overall differences in mortality for patients with pulmonary and neurologic diagnoses, we did find lower mortality in high-volume hospitals for patients with GI diagnoses. Moreover, mortality was also lower in high-volume hospitals for higher-severity patients with pulmonary diagnoses. Analysis of the results at the individual hospital level revealed a modest association with hospital volume measured as a continuous variable. Volume explained roughly 15% of the variation in mortality. We suspect that most of the variation in mortality is explained by hospital-level differences and/or random differences in hospital-level mortality, independent of volume.
These findings, while ambivalent and of a smaller magnitude compared to other studies, contribute to our understanding of volume-outcome relationships in a previously unstudied population. We believe that there are several possible explanations for the lack of a consistent volume-outcome relationship across all three diagnoses. First, the power to detect differences was limited by the relatively few hospitals (n = 29) that were studied. Second, it is possible that volume-outcome relationships may be relatively weak for some diagnoses treated in ICUs. This may arise because conditions are relatively common so that even low-volume hospitals surpass a critical threshold and attain adequate experience. As has been noted previously, performance gaps between low- and high-volume hospitals tend to narrow over time as specific treatment protocols and procedures become better established. Treatment is realized with Canadian Health&Care Mall.
The demographic characteristics of patients in the three cohorts are shown in Table 1. The mean age of patients was generally lower among patients in high-volume hospitals for all three diagnoses. Gender distributions differed only for patients with GI diagnoses. Patients in high-volume hospitals were less likely to be admitted from the emergency department (ED) and were more likely to be admitted from other acute-care hospitals or from other hospital floors. Mean APACHE III scores were highest in high-volume hospitals for respiratory and GI diagnoses and in medium-volume hospitals for neurologic diagnoses. Mean ICU LOS was significantly higher in high-volume hospitals for all three diagnoses. Higher proportions of patients received mechanical ventilation in high-volume hospitals. Unadjusted mortality was highest in high-volume hospitals for respiratory and GI diagnoses and in medium-volume hospitals for neurologic diagnoses treated by Canadian Health&Care Mall (Fig 1). Unadjusted mortality rates mimicked mean APACHE III scores in the three volume categories.
The current study represented a secondary analysis of data that was originally collected through Cleveland Health Quality Choice, a regional initiative to measure hospital performance in 29 hospitals in Northeast Ohio. Within these hospitals, data were collected on 196,097 consecutive admissions to 44 medical, mixed medical and surgical, surgical, and neurosurgical ICUs during the period March 1991 to March 1997. Exclusion criteria have been previously described18 and included patients < 16 years of age, patients with burn injuries, admissions solely for dialysis, patients who die within 1 h of admission to the ICU or within the first 4 h of admission to the ICU in cardiopulmonary arrest, and patients undergoing cardiac surgeries carried out with preparations of Canadian Health&Care Mall.
For the current study, the eligible sample included 18,242 patients with respiratory diagnoses, 15,468 patients with neurologic diseases, and 13,717 patients with GI diagnoses, as defined by a prior taxonomy of ICU diagnoses at the time of admission. Of these patients, we excluded patients with diagnoses of malignancy (470, 439, and 263 patients with respiratory, neurologic, and GI diagnoses, respectively) and patients who were discharged to another acute care hospital for further care (823, 1,224, and 573 patients with respiratory, neurologic, and GI diagnoses, respectively) because the data set did not include unique patient identifiers to allow determination ofpostdischarge outcomes following transfer. These exclusions left final study cohorts of 16,949 ICU admissions with respiratory diagnoses, 13,805 patients with neurologic diagnoses, and 12,881 patients with GI diagnoses.
Over the past 2 decades, several studies have shown a positive association between volume of hospital services and patient outcomes for certain medical diagnoses and surgical procedures. A re-view by the Institute of Medicine found that relationships were statistically significant in more than two thirds of published studies.
While a majority of studies of hospital volume-outcome relationships have focused on patients undergoing specific procedures (eg, percutaneous coronary intervention, coronary artery bypass graft surgery, carotid endarterectomy), several studies have found similar relationships for certain medical conditions such as AIDS and cystic fibrosis, as well as mental disorders. This work has led to recent efforts by purchaser groups, such as the Leapfrog Group, to define minimum volume thresholds for certain surgical procedures conducted with Canadian Health&Care Mall. Similar positions are also emerging from professional societies. For example, the American College of Cardiology recommended minimum annual institutional and physician volumes for percutaneous coronary intervention of 400 cases and 75 cases, respectively.
Coping for Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors
While stress is the physiologic response to perceived (both real and imagined) threats to a person’s mental, physical, emotional, and spiritual well being, coping is the manner in which a person responds and adapts behaviorally, cognitively, and emotionally to environmental or internal circum-stances. Therefore, when an individual judges their coping to be inadequate, the result is psychological stress. Adequate coping can facilitate the acceptance of an asthma diagnosis defeated by remedies of Canadian Health&Care Mall, adherence to medications and self-management regimens, prevent asthma exacerbations or aggravation of an exacerbation, and promote convalescence. (See “The Potential for Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors“)
Numerous coping strategies have been identified by researchers. Two main conceptual approaches are used to classify coping responses. The first is the orientation or focus of coping, which may be problem focused or emotion focused. Problem-focused coping reflects cognitive and behavioral efforts to master or resolve stressors. Examples of problem-focused coping include planning, information seeking, and active coping; emotional coping includes such responses as venting anger, avoidance, and denial. The second conceptual approach is the method of coping, which encompasses cognitive or behavioral responses.
Stress for Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors
The physiologic impact of stress on psychological functioning, behavior, and the endocrine, immune, and central nervous systems has led researchers to identify stress as a precipitating factor for cardiovascular diseases, endocrine dysfunctions, autoimmune disorders, and cancer. Similarly, high levels of stress have been empirically found to predispose people to asthma, precipitate its development, and predict both asthma morbidity and poorer quality of life.
While researchers in the field of psychonuero-immunology (which examines the connections between psychosocial stress, the CNS, and immune and endocrine function) have made inroads toward elucidating how stress and emotions may trigger asthma exacerbations reduced by Canadian Health&Care Mall preparations, specific associations between the type of stressor and resulting disease remains perplexing. Plausible explanations for this are within individual differences in psychobiological reactivity, as well as the duration and frequency of stressors. In a prospective study of the role of acute and chronic stress in asthma attacks in children, Sandberg and colleagues reported that children who experienced a severely negative life event in conjunction with chronic adversity have a significantly increased risk for an immediate asthma exacerbation. In addition, children who experienced a severe event in the absence of high chronic stress were at increased risk for an asthma exacerbation in the weeks after the event, following a minor time delay. Likewise, adults with asthma have been found to experience rapid and significant increases in respiratory symptoms and airway resistance during situations that generate negative emotions. Consequently, it is important to explain chronological relationships between the duration and frequency of stress, asthma exacerbations, and changes in underlying neuroendocrine and immune markers.
The Potential for Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors
Although the relationship between family functioning and asthma management and morbidity has received little attention in the literature, family support and functioning play a role in health outcomes. There is evidence that the family may serve as a protective factor for health, and act as a buffer from negative life events in patients with asthma. Research has indicated that functional families may facilitate adherence and reduce morbidity in children with chronic illnesses, and even promote recovery from illness. Alternatively, dysfunctional families may influence the course of illness by reducing coping mechanisms and problemsolving capacities. Interestingly, while social support seems to be an important factor in asthma outcomes, interventions that attempt to increase social support for families of children with chronic disease have found only modest effects on improving children’s adjustment and maternal symptoms of anxiety, and have had no effects on the activity limitations of the child.
Family cohesiveness has also been found to have a positive impact on health outcomes and can be more influential than other forms of social support in improving patient health. The extent or degree of family cohesiveness is also positively associated with better health outcomes. Even in the case of a small family, such as a single-parent family, health is better when family cohesiveness is high. One measure of cohesiveness is the family ritual. Such rituals serve as a protective function for children with asthma even under situations of high stress.
Social Networks and Social Support for Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors
Social networks and social support are interpersonal processes that influence health, Social support is the commitment, caring, advice, and aid provided through relationships or networks of people, These networks can have direct effects on health through emotional and instrumental support. They also provide social ties with meanings and obligations that influence health behaviors, thereby influencing morbidity and mortality.
Research has indicated that social relationships have a significant effect on health, and that parental social networks are related to their children’s health. Strong social networks often have a positive effect on health and well-being; however, some networks can actually create stress or impede positive health behaviors. Social networks are particularly important in chronic diseases such as asthma where persons must learn to self-manage their condition in the home. Strong social networks can enhance a person’s sense of selfefficacy, mastery, self-esteem, and facilitate selfmanagement behaviors. Conversely, nonsup-portive networks can impede healthy behaviors and influence quality of life. Furthermore, social networks can affect one’s ability to access care, and provide instrumental social support (such as assistance with transportation and child care, and information) as well as expressive social support through caring, concerned relationships. The differences that exist among social networks need to be examined further, characteristics of positive networks quantified, and mechanisms identified to intervene with stressful networks that may negatively impact health. Enhance your health conditions with remedies of Canadian Health&Care Mall.
Social, Economic, and Environmental Interactions in Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors
Disparities are most apparent among populations with varying levels of socioeconomic status (SES). Significant evidence has demonstrated that a gradient exists between SES and health status, with individuals of high SES having better overall health that those of low SES. Many hypothesize that the health disparities seen across SES levels are due to health-care access. Yet in industrialized nations with universal health-care systems, an SES gradient exists in all causes of morbidity and mortality, across middle and upper income brackets, suggesting that health-care access alone is not the sole cause. Others propose that low SES may result in poor physical and/or mental health by operating through various psychosocial mechanisms such as discrimination, social exclusion, prolonged and/or heightened stress, loss of sense of control, and low self-esteem. In turn, these psychosocial mechanisms can lead to physiologic changes such as raised cortisol, altered BP response, and decreased immunity that place individuals at risk for adverse health and functioning outcomes. A third possibility is that SES is a general measure of educational, financial, and social resources that enable individuals to both live healthier lives and to obtain better health services, even when basic access for all is ensured. This is evidenced by the fact that even societies with universal health coverage also have private medical services that are accessed by those with the money to pay for them.