OBJECTIVE: The Global Assessment of Functioning (GAF) is an integral part of the standard multiaxial psychiatric diagnostic system. The purpose of including the GAF in DSM-IV as a tool for axis V assessment is to enable clinicians to obtain information about global functioning to supplement existing data about symptoms and diagnoses and to help predict the allocation and outcomes of mental health treatment. The purpose of this study was to examine the value of the GAF as part of a systemwide program for monitoring the allocation and outcomes of mental health care services.

METHODS: Clinicians used the GAF to assess global functioning among 9,854 patients with psychiatric or substance use disorders, or both, who were already participating in an outcomes monitoring program of the Department of Veterans Affairs. A longitudinal prospective follow-up design was used.

RESULTS: Patients' clinical diagnoses and symptoms were stronger predictors of GAF ratings than was their social or occupational functioning. GAF-rated impairment was associated with the provision of inpatient or residential care and outpatient psychiatric care, but patients with greater levels of impairment did not receive more treatment. GAF ratings were only minimally associated with treatment outcomes. No robust associations were found between GAF ratings and outcomes as assessed by clinician interview or by patients' self-report at follow-up.

CONCLUSIONS: Including GAF ratings in a program for predicting the allocation and outcomes of mental health care is of questionable value. Research is needed to determine whether systematic training and ongoing validity checks would enhance the contribution of the GAF in monitoring service use and outcomes.

The contribution of bioethics to clinical care at the end of life (EOL) deserves critical scrutiny. We argue that researchers have rarely questioned the normative power of autonomy-based bioethics practices. Research on the ethical dimensions of EOL decision making has focused on an idealized discourse of patient "choice" that requires patients to embrace their dying to receive excellent palliative care.

Our critique is based on a comprehensive review of empirical research exploring bioethics practices at the EOL. In addition we will provide a brief review of our own ethnographic, longitudinal study of the decision-making experience of dying patients, their families, and their health care providers.

There is little or no empirical evidence to support the autonomy paradigm of patient "choice" in EOL decision making. What we found is that (a) prognostication at the EOL is problematic and resisted; (b) shared decision making is illusory, patients often resist advance care planning and hold other values more important than autonomy, and system characteristics are more determinative of EOL care than patient preferences; and (c) the incommensurability of medical and lay knowledge and values and the multifaceted and processual nature of patient and family decision making are at odds with the current EOL approach toward advance care planning.

It is exceedingly difficult to identify, study, and critique normative assumptions without creating them, reproducing them, or obliterating them in the process. However, a fuller account of the morally significant domains of end-of-life care is needed. Researchers and policy makers should heed what we have learned from empirical research on EOL care to develop more sensitive and supportive programs for care of the dying.

Managed care may influence technology diffusion in health care. This article empirically examines the relationship between HMO market share and the diffusion of neonatal intensive care units. Higher HMO market share is associated with slower adoption of mid-level units, but not with adoption of the most advanced high-level units. Opposite the common supposition that slowing technology growth will harm patients, results suggest that health outcomes for seriously ill newborns are better in higher-level units and that reduced availability of mid-level units may increase their chance of receiving care in a high-level center, so that slower mid-level growth could have benefitted patients.

The Institute of Medicine recently issued a landmark report on medical error. In light of this report, every aspect of health care is subject to new scrutiny regarding patient safety. Informatics technology can support patient safety by correcting problems inherent in older technology; however, new information technology can also contribute to new sources of error. We report here a categorization of possible errors that may arise in deploying a system designed to give guideline-based advice on prescribing drugs, an approach to anticipating these errors in an automated guideline system, and design features to minimize errors and thereby maximize patient safety. Our guideline implementation system, based on the EON architecture, provides a framework for a knowledge base that is sufficiently comprehensive to incorporate safety information, and that is easily reviewed and updated by clinician-experts.

Also published in the Proceedings of the American Medical Informatics Association's 2001 Symposium.

BACKGROUND: Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.

OBJECTIVES: To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.

DESIGN: Cohort study.

SETTING: All nongovernment hospitals in the United States.

PATIENTS: 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.

MEASUREMENTS: Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 micromol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 micromol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 micromol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.

RESULTS: Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, beta-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.

CONCLUSIONS: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

An extensive literature documents a high prevalence of errors in clinical diagnosis discovered at autopsy. Multiple studies have suggested no significant decrease in these errors over time. Despite these findings, autopsies have dramatically decreased in frequency in the United States and many other countries.

In 1994, the last year for which national U.S. data exist, the autopsy rate for all non-forensic deaths fell below 6 percent. The marked decline in autopsy rates from previous rates of 40-50 percent undoubtedly reflects various factors, including reimbursement issues, the attitudes of clinicians regarding the utility of autopsies in the setting of other diagnostic advances, and general unfamiliarity with the autopsy and techniques for requesting it, especially among physicians-in-training.

The autopsy is valuable for its role in undergraduate and graduate medical education, the identification and characterization of new diseases, and contributions to the understanding of disease pathogenesis. Although extensive, these benefits are difficult to quantify. This systematic review studied the more easily quantifiable benefits of the autopsy as a tool in performance measurement and improvement. Such benefits largely relate to the role of the autopsy in detecting errors in clinical diagnosis and unsuspected complications of treatment.

It is hoped that characterizing the extent to which the autopsy provides data relevant to clinical performance measurement and improvement will help inform strategies for preserving the benefits of routinely obtained autopsies and for considering its wider use as an instrument for quality improvement.

This report does not attempt to address the roles of the autopsy in medical education; furthering medical research; quality control within pathology; verification, second-opinion consultations, and legal documentation of findings; the bereavement process for surviving family members; or other benefits that are described in many of the sources listed in the bibliography (Appendix F). In addition to being difficult to quantify, these benefits apply primarily to teaching hospitals. To address the role of the autopsy as an outcome measure and tool for quality improvement, the report focuses on benefits likely to apply to all hospitals, such as the detection of important diagnostic errors and related quality problems.

Evidence from the United States suggests that technological change is a key factor in understanding both medical expenditure growth and recent dramatic improvements in the health of people with serious illnesses. Yet little international research has examined how the causes and consequences of technological change in health care differ worldwide. Seeking to illuminate these issues, this volume documents how use of high-technology treatments for heart attack changed in fifteen developed countries over the 1980s and 1990s. Drawn from the collaborative effort of seventeen research teams in fifteen countries, it provides a cross-country analysis of microdata that illuminates the relationships between public policies toward health care, technology, costs, and health outcomes.

The comparisons presented here confirm that the use of medical technology in treatment for heart attack is strongly related to incentives, and that technological change is an important cause of medical expenditure growth in all developed countries. Each participating research team reviewed the economic and regulatory incentives provided by their country's health system, and major changes in those incentives over the 1980s and 1990s, according to a commonly used framework. Such incentives include: the magnitude of out-of-pocket costs to patients, the generosity of reimbursement to physicians and hospitals, regulation of the use of new technologies or the supply of physicians, regulation of competition, and the structure of hospital ownership. Each team also reviewed how care for heart attacks has changed in their country over the past decade.

The book will be of enormous importance to health economists, medical researchers and epidemiologists, and policymakers.

Survival of patients who sustain a ventricular arrhythmia is poor but slowly improving due to in-hospital use of medications and ICDs. However, this more intensive hospital treatment has been accompanied by increased hospital expenditures, finds this study. The researchers analyzed Medicare databases from 1985 to 1995 to identify elderly patients hospitalized with ventricular arrhythmias (index admission). They created a longitudinal patient profile by linking the index hospital admission with all earlier and subsequent admissions and with death records.

During this time, about 85,000 elderly patients went to U.S. emergency departments (EDs) with ventricular arrhythmias each year. Only about 20,000 of these patients lived to be admitted to the hospital from the ED, and then about 14 percent died within the first day. From 1987 to 1995, the demographic and clinical characteristics of patients and the use of coronary angioplasty and bypass graft surgery for these patients were largely unchanged. However, the use of electrophysiology studies (EPS) grew from 3 to 22 percent and use of ICDs increased from 1 to 13 percent. A growing number of patients survived, particularly in the medium term, with 1-year survival rates increasing from 53 percent in 1987 to 58 percent in 1994, or half a percentage point each year.

At the same time, hospital expenditures rose 8 percent per year, primarily because of the increased use of EPS and ICD procedures. By 1993, Medicare was reimbursing hospitals an average of $15,627 for care for each patient during the year after admission for ventricular tachycardia/fibrillation. During the subsequent year, another $14,739 on average was spent for these patients. The increased intensity of care for these patients led to a rise in the average expenditure per patient of about $1,000 per year (in 1993 dollars) from 1987 to 1995.

The use of coronary angiography and revascularization is lower than expected among black patients. It is uncertain whether use of other cardiac procedures also varies according to race and ethnicity and whether outcomes are affected.

Methods

We analyzed discharge abstracts from all nonfederal hospitals in California of patients hospitalized for a primary diagnosis of ventricular tachycardia or ventricular fibrillation between 1992 and 1994. We compared mortality rates and use of electrophysiologic study (EPS) and implantable cardioverter-defibrillator (ICD) procedures according to the race and ethnicity of the patient.

Results

Among 8713 patients admitted with ventricular tachycardia or ventricular fibrillation, 29% (n  2508) had a subsequent EPS procedure, and 9% (n  818) had an ICD implanted. After controlling for potential confounding factors, we found that black patients were significantly less likely than white patients to undergo EPS (odds ratio 0.72, CI 0.56-0.92) or ICD implantation (odds ratio 0.39, CI 0.25-0.60). Blacks discharged alive from the initial hospital admission had higher mortality rates over the next year than white patients, even after controlling for multiple confounding risk factors (risk ratio 1.18, CI 1.03-1.36). The use of EPS and ICD procedures was also significantly affected by several other factors, most notably by on-site procedure availability but also by age, sex, and insurance status.

Conclusions

In a large population of patients hospitalized for ventricular arrhythmia, blacks had significantly lower rates of utilization for EPS and ICD procedures and higher subsequent mortality rates.