Valid comparison of patient survival across ICUs requires adjustment for burden of chronic illness. The optimal measure of comorbidity in this setting remains uncertain. To examine the impact of different measures of comorbid disease on predicted mortality for ICU patients. Retrospective cohort study. Seventeen thousand eight hundred ninety-three veterans from 17 geographically diverse VA Medical Centers and 43 ICUs were studied, admitted between February 1, 1996 and July 31, 1997. ICD-9-CM codes reflecting comorbid disease from hospital stays before and including the index hospitalization from local VA computer databases were extracted, and three measures of comorbid disease were then compared: (1) an APACHE-weighted comorbidity score using comorbid diseases used in APACHE, (2) a count of conditions described by Elixhauser, and (3) Elixhauser comorbid diseases weighted independently. Univariate analyses and multivariate logistic regression models were used to determine the contribution of each measure to in-hospital mortality predictions. Models using independently weighted Elixhauser comorbidities discriminated better than models using an APACHE-weighted score or a count of Elixhauser comorbidities. Twenty-three and 14 of the Elixhauser conditions were significant univariate and multivariable predictors of in-hospital mortality, respectively. In a multivariable model including all available predictors, comorbidity accounted for less (8.4%) of the model's uniquely attributable chi statistic than laboratory values (67.7%) and diagnosis (17.7%), but more than age (4.0%) and admission source (2.1%). Excluding codes from prior hospitalizations did not adversely affect model performance. Independently weighted comorbid conditions identified through computerized discharge abstracts can contribute significantly to ICU risk adjustment models.

Traditionally, surgeons (and to a lesser extent anaesthetists) have been assisted primarily by nurses. This role has been threatened in recent years, in the UK NHS (and elsewhere), by a relatively new profession, that of the Operating Department Practitioner (ODP). The ODP profession is still in the process of establishing itself as a ‘full’ profession within UK health care. While occupational boundary disputes between professions are common in health care, it is unusual for them to become as overt as the dispute we will analyse in this paper. Drawing on fieldwork observations and interviews conducted in operating theatres, as well as documentary sources, we will show how this dispute arose, how it is manifested at both the micro and the macro level, and how both groups involved justify their positions, drawing on surprisingly similar rhetorical strategies. A further unusual feature of this dispute is the fact that, unlike many attempts by managers to substitute one type of labour for another, issues of cost are relatively unimportant, as both theatre nurses and ODPs earn similar salaries.

Background: Stigma is known to exist in mental health and is extensively researched. However, little is known about the effect of stigma on women who experience a severe postnatal illness. Aims: To consider whether or not women who are experiencing a severe postnatal illness and have been admitted to a mother and baby unit experience stigma. Method: A qualitative study consisting of six semi-structured interviews were undertaken to gain an understanding of the women's experience of stigma and the women's perceptions of themselves as mothers. Results: The findings suggested that stigma was felt both internally and externally. However the stigma did not always manifest itself in the way existing literature would suggest. Four main themes were identified as disclosure, access to services, feelings of being a bad mother, and label/diagnosis. Conclusion: An underlying stigma within the health care organization leads to groups of health professionals lacking understanding of this severe and debilitating illness. Clearer pathways of access into services are required. The women found the label and diagnosis useful and felt that a higher profile for mental illness would help to eliminate stigma. Declaration of interests: None.

Transition is a process that attends to the medical, psychosocial and educational needs of young people as they transfer to adult-orientated care. With a growing population of adolescents surviving with chronic illness well into adulthood, it is remarkable that empirical research has paid little attention to transition. This qualitative study examined the attitudes of young people with chronic illness who were facing transition, considering what young people wanted from a transition service and the ways in which provision could be improved from a service-user’s perspective. A purposive sample of seven adolescents (aged 14–17) attending a hospital youth club were interviewed. To increase the likelihood of successful transition, strategies need to be informal, flexible, highly individualized and prepare adolescents steadily for adult services.