Truls Østbye

Undernutrition in community-living seniors is common and has the potential to adversely influence health outcomes. Nutritional risk screening tools can help identify seniors at risk, but few have predicted health outcomes. Seniors were recruited from 23 community service providers. The 8-item abbreviated version SCREEN (Seniors in the Community Risk Evaluation for Eating and Nutrition) was used to identify nutritional risk in 367 seniors; demographics, health, activities of daily living, and psychosocial variables were included in a baseline assessment. The seniors were followed-up by telephone for 18 months to determine the occurrence of health outcomes, including death. Cox regression was used to identify predictors of survival time. During the 18-month follow-up there were 27 deaths (approximately 7%). Using the abbreviated tool, nutritional risk was common (42.2%). This low rate of death limited the modeling to only a few key covariates, which were based on bivariate analyses. Nutritional risk was significantly associated with time to death. Gender was also associated with time to death, with men more likely to die sooner than women. Increasing age was also significantly associated with shorter survival times. Nutritional risk as measured by SCREEN was predictive of time to death. This simple tool may be useful for future epidemiological research on health outcomes of seniors. Further work should confirm these results, as the low event rate influenced the modeling strategy.

Telemedicine technology will soon be widely available in physicians' surgeries and patients' homes. In this article we discuss the broader implications of its widespread use among physicians, patients, and society as a whole, focusing on the main vehicle of communication between physician and patient; the "electronic home visit" or "electronic house call". After exploring the new relationship that is likely to develop between patients and physicians as a consequence of the use of telemedicine, we then discuss the anticipated broader social, economic and legal consequences of the widespread use of this technology.

Providing every patient with a personal primary care physician or, from the physician's perspective, establishing a stable roster or list of patients is currently being actively debated in Canada. Norway's system of primary care medicine, similar to Canada's, faces many of the same problems. In 1992 a trial rostering system with blended funding (capitation, fee-for-service and user fees) was established in 4 Norwegian municipalities. After 3 years of close monitoring, the results of system evaluations have attracted strong interest. This article reports on the benefits and problems encountered with the new rostering system in Norway. If Canada is moving in the same direction, some of the lessons learned may be helpful.

Within the next 10 years, telemedicine technology is likely to become widely available in physicians' offices and patients' homes. Rather than describing the technology of telemedicine, we discuss the implications of its widespread use among physicians, patients, and society as a whole, focusing on that mainstay of communication between physician and patient, the "electronic house call." After exploring the new relationship that is likely to develop between patients and physicians as a consequence of the use of telemedicine, we discuss the broader economic, legal, and political consequences of the widespread use of this technology.

Background and Purpose Subarachnoid hemorrhage (SAH) has a different epidemiological profile from other types of stroke and a different etiology. Although there has been a general decline in overall stroke incidence since the 1950s, secular trends for SAH have been modest. In contrast to other stroke types, changes in incidence over the last few decades have been less clear. The purpose of this study was to estimate hospitalization and case-fatality rates of SAH according to age, sex, calendar year, and season. Methods Data were obtained for each of Canada’s 10 provinces for the 10 fiscal years 1982 through 1991. All hospitalizations of persons 15 years of age or older with a primary diagnosis at discharge coded 430 according to the International Classification of Diseases, 9th Revision, were included. Rates of SAH per 100 000 population were calculated for men and women for 5-year age groups, by calendar year, and by season. Annual age- and sex-specific (hospital) case-fatality rates up to 30 days were also calculated. Additionally, hospital deaths from this study were related to national SAH mortality statistics. Results A total of 14 145 women and 8995 men were discharged with a primary diagnosis of SAH during the 10-year period. In contrast to other types of stroke, the rates of SAH were higher for women than for men at all ages. The age-standardized rates of SAH in 1991-1992 were 11.2 per 100 000 women and 8.0 per 100 000 men. For women, there was a 6% (95% confidence interval [CI], −12% to 0%) decline in hospitalization rates over that period; for men, the decline was 15% (95% CI, −21% to −8%). The peak season for SAH among women was winter; for men the peaks were in the fall and spring. For both sexes, the lowest occurrence was in the summer. Over this period, 30-day case-fatality rates declined somewhat (statistically significant only in the age group of 35 to 44 years). The number of deaths enumerated from hospital discharges was 20% to 50% lower than the number recorded on national mortality statistics, indicating that a proportion of SAH deaths occurred before (or after) the hospital stay. Conclusions Although rates of hospitalization for SAH declined over this period, SAH remains an important neurological event affecting individuals at relatively young ages. The rates were higher for women than for men at all ages. Total (in-hospital) case-fatality rate remains high.

To determine how accurately information on disability provided by a caregiver (proxy respondent) reflected the opinion of subjects themselves, and if this agreement varied by severity of dementia or relationship of the caregiver to the subject. the study was based on data from the Canadian Study of Health and Aging, a multicentre study of dementia and health of Canadians age 65 and over. Eight hundred study subjects and their caregivers were independently interviewed regarding the subjects' activities of daily living (ADL). the percentage of subjects who were independent for individual ADL items and the agreement in these reports between subjects and caregivers were investigated using three-level k statistics. index subjects with caregivers other than spouses or offspring required more assistance with ADL. The reported percentage of independence decreased with increasing severity of dementia. There was more agreement between self- and proxy-reported level of independence for physical ADL than for instrumental ADL items. Agreement decreased with increasing severity of dementia. Few statistically significant differences were noted between level of agreement and caregiver relationship. satisfactory levels of agreement on ADL between cognitively normal subjects and their caregivers indicate that proxy respondents are a reasonable source of information on ADL when data collection from the subjects themselves is not feasible. Since agreement decreases as the severity of dementia increases, caregiver reports may be preferred for elderly patients even with mild dementia in order to facilitate longitudinal assessment of ADL ratings as the dementia progresses.