Study objective-Although national variation in short-term prognosis (that is, 30 day mortality) after a patient's first hospitalisation for heart failure may depend on individual diVerences between patients, dissimilarities in hospital practices may also influence prognosis. This study, therefore, sought to disentangle patient determinants from institutional factors that might explain such variation. Design-A multilevel logistic regression modelling was performed with patients (1st level) nested in hospitals (2nd level). Institutional eVects (that is, 2nd level variance and intra-hospital correlation) were calculated unadjusted and adjusted for specific patient (that is, age and previous diseases) and institutional (that is, size of hospital) characteristics. Patients were followed up until death or 30 days from hospital admission.
Setting-Hospitals in Sweden.Patients-The study identified all the 20 420 men and 17 923 women (ages 65 to 85) admitted to the 90 acute care hospitals in Sweden during the period 1992-1995 for their first hospitalisation attributable to heart failure. Main results-Patient age and previous diseases (particularly senile dementia) were major determinants of impaired prognosis. Institutional factors explained only 1.6% and 2.3% of the total variation in 30 day mortality in men and women, respectively. These modest institutional eVects remained after adjusting for patient age and previous diseases, but were in part explained by hospital size. Conclusions-National variation in shortterm prognosis after an initial hospitalisation for heart failure was mainly explained by diVerences between patients, with hospital factors playing a minor part. Of the latter, hospital size seemed to emerge as one determinant (that is, the greater the number of patients, the better the individual prognosis). (J Epidemiol Community Health 2001;55:323-329)
integrated specialist teams can deliver high quality care to these vulnerable patients. We would like to thank Mental Health Foundation and Research Into Ageing, who funded studies from which some of the data were acquired. Contributors: All authors helped to formulate the study design, coordinate the collection of data, and write the paper. CB undertook the data evaluation and will act as guarantor. Funding: None. Competing interests: None declared. 1 Kitwood T, Bredin K. Evaluating dementia care: the DCM method. 7th ed. Bradford: Bradford Dementia Research Group, 1997. 2 Brooker D. Looking at them looking at me. A review of observational studies into the quality of institutional care for elderly people with dementia.
Background: Many procedures for patient education are introduced in clinical practice without proper evaluation in randomised trials. Aims: To compare systematic nurse and pharmacist led education including an interactive Kodak Photo-CD Portfolio technique with conventional information regarding heart failure patients' knowledge. Methods: One hundred and thirty heart failure patients discharged from hospital were randomised to receive either conventional information or additional structured education with a follow-up of 6 months. Difference in knowledge was tested by questionnaire after 6 Ž . months. Results: At the end of the study there was a significant difference in the intervention group n s 50 compared to the Ž . control group n s 58 regarding knowledge as tested by a questionnaire. Of maximal 28 points the intervention group Ž . Ž . attained 17.2 points mean and the control group 14.3 points mean , 95% confidence interval for difference 1.0᎐4.7 points Ž . P s 0.0051 . Conclusions: Two to 3 hours of systematic education improved heart failure patients' knowledge on essential issues. High age does not preclude the introduction of a new technique for patient education. ᮊ
Background: Disease-management programmes including patient education have promoted improvement in outcome for patients with heart failure. However, there is sparse evidence concerning which component is essential for success, and very little is known regarding the validity of methods or material used for the education.
Milrinone, a new, nonglycosidic inotropic agent with peripheral vasodilating properties, was given as a single oral 5 mg dose to 7 healthy subjects, 7 patients with moderate renal impairment (CRI I, creatinine clearance 30-63 ml/min) and 7 patients with severe renal impairment had hypertension. The mean urinary recovery of milrinone was 82% in healthy subjects, the renal clearance was 288 ml/min and the plasma half-life (t1/2) was 0.94 h. In CRI the mean plasma t1/2 was prolonged (CRI I 1.78 h, CRI II 3.24 h). There was a significant linear relationship between creatinine clearance and the elimination rate constant, and between creatinine clearance and the renal clearance of milrinone. During the study day there was a tendency to a decrease in supine BP from 1 to 6-8 h after dosing, with the maximal decrease at 2-3 h (healthy subjects 118/71----107/56, CRI 159/95----136/79 mmHg). The same degree of change was seen in standing BP. A slight rise in standing HR was seen from 2-6 h after dosing. Changes in BP and HR are difficult to evaluate since the study was not placebo-controlled. The plasma elimination rate of milrinone was decreased in CRI and dose adjustment may be necessary. Placebo-controlled studies of milrinone in hypertensive patients would be required to validate its possible antihypertensive effect.
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