OBJECTIVE:To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes. MEASUREMENTS AND MAIN RESULTS:The MEDLARS database of the National Library of Medicine was searched. In addition, the authors' extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio T he do-not-resuscitate (DNR) order has become well accepted and widely used in American hospitals, and for the majority of patients who die in the hospital, a DNR order has been written by the time of their death. 1-3 The decision to discuss or execute a DNR order is driven by several concerns: the patient's current quality of life, the likelihood that cardiopulmonary resuscitation (CPR) will be successful, the patient's long-term prognosis following successful resuscitation, and his or her anticipated quality of life following successful resuscitation. 4,5 Although judgments about quality of life are best assessed by the patient, physicians have typically been relied on to provide biomedical information and estimates of prognosis; this is consistent with a shared approach to medical decision making. Information about prognosis can either be communicated implicitly (e.g., "I don't think CPR is likely to help you") or explicitly ("Patients with your condition have a less than 1% chance of surviving to discharge after CPR"). The explicit approach has been shown in two studies to influence patient decisions about DNR orders, 6,7 so it is important that prognostic information be as accurate as possible.[Recent work has shown, however, that physicians are not accurate in predicting the outcome of CPR. In fact, when presented with detailed vignettes of actual patient cases, physician predictions of the likelihood of immediate survival following CPR were no better than random guessing, with an area under the receiver-operating characteristic (ROC) curve not significantly different from 0.5. 8 An analysis with the physician prediction of the likelihood of survival as the outcome variable in a multivariate regression shows that physicians appear to have an underlying cognitive model. However, this model overemphasizes the imp...

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Context. Time preference (how preference for an outcome changes depending on when the outcome occurs) affects clinical decisions, but little is known about determinants of time preferences in clinical settings. Objectives. To determine whether information about mean population time preferences for specific health states can be easily assessed, whether mean time preferences are constant across different diseases, and whether under certain circumstances substantial fractions of the patient population make choices that are consistent with a negative time preference. Design. Self-administered survey. Setting. Family physician waiting rooms in four states. Patients. A convenience sample of 169 adults. Intervention. Subjects were presented five clinical vignettes. For each vignette the subject chose between interventions maximizing a present and a future health outcome. The options for individual vignettes varied among the patients so that a distribution of responses was obtained across the population of patients. Main outcome measure. Logistic regression was used to estimate the mean preference for each vignette, which was translated into an implicit discount rate for this group of patients. Results. There were marked differences in time preferences for future health outcomes based on the five vignettes, ranging from a negative to a high positive (116%) discount rate. Conclusions. The study provides empirical evidence that time preferences for future health outcomes may vary substantially among disease conditions. This is likely because the vignettes evoked different rationales for time preferences. Time preference is a critical element in patient decision making and cost-effectiveness research, and more work is necessary to improve our understanding of patient preferences for future health outcomes. Key words: time factors ; models, psychological; attitude to health; outcome assessment (health care). (Med Decis Making 2000;20:263-270)

Physician performance and peer comparison feedback can affect physician care quality and patient outcomes. This study aimed to understand family physician perspectives of the value of performance feedback in quality improvement (QI) activities. This study analyzed American Board of Family Medicine open-ended survey data collected between 2004 and 2014 from physicians who completed a QI module that provided pre- and post-QI project individual performance data and peer comparisons. Physicians made 3480 comments in response to a question about this performance feedback, which were generally positive in nature (86%). Main themes that emerged were importance of accurate feedback data, enhanced detail in the content of feedback, and ability to customize peer comparison groups to compare performance to peers with similar patient populations or practice characteristics. Meaningful and tailored performance feedback may be an important tool for physicians to improve their care quality and should be considered an integral part of QI project design.

analysis program from the Centers for Disease Control and Prevention. Text coding was performed by 2 authors (MDH, DJI). As no inferential analyses or comparisons were anticipated, the authors conducted no studies of inter-rater consistency. Results are reported as means (SD) and medians for continuous data, and as frequencies for count data.Results: Likert-scale ratings indicated generally favorable responses (predominantly 5 to 6 on a 6-point scale) to the hypertension and diabetes SAMs. In addition, over half (ie, 55% for hypertension and 54% for diabetes participants) of the respondents indicated that the experience would lead to changes in their practices. Navigation and system operation issues predominated in the free-text comments offered for the diabetes and hypertension simulations.