Long-term care needs of hospitalized persons with AIDS

Objective:As the treatment for HIV infection has improved, AIDS has become a chronic disease, and the demand for long-term care has increased. The authors studied a cohort of hospitalized persons with AIDS to determine the proportion and characteristics of AIDS patients who could appropriately be cared for in long-term care facilities with skilled nursing. Design:Prospective cohort study. Setting:Medical wards of five Seattle tertiary care hospitals. Participants:120 consecutive hospitalized persons with AIDS and their primary care physicians, nurses, and social workers. Measurements and main results:Appropriateness for long-term care was determined by the patients’ physicians, nurses, and social workers. Persons with AIDS who were appropriate for long-term care constituted 32% of the cohort (38 of 120), accounting for 35% of hospital days (11 of these 38 were discharged to long-term care facilities). Four admission characteristics were independently related to appropriateness: impaired activities of daily living, diagnosis of central nervous system illness or poor cognition, living alone, and weight loss. A discriminant function correctly classified over 80% of patients for appropriateness and was developed into a predictive index for planning patient care (sensitivity =0.74, specificity =0.85). Conclusions:The authors conclude that one-third of hospitalized persons with AIDS may be appropriate for care in long-term care settings, accounting for one-third of the days AIDS patients currently spend in hospitals. These patients can be identified early in hospital stays using a simple predictive index at the bedside. Presented at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 28, 1989. Supported by the Northwest Health Services Research and Development Field Program (Seattle Veterans Affairs Medical Center) and the Seattle King County Department of Public Health, AIDS Prevention Project. The views stated herein are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Patient characteristics related to intensity of weight reduction care in a university medical clinic

Objective:To identify patient characteristics related to intensity of weight reduction care provided in a primary care practice. Design:Cross-sectional study linking data from a patient survey and data from medical records. Setting:Internal medicine housestaff clinic in an urban university hospital. Participants:321 outpatients who represented a systematic sample of all outpatients who had visited the clinic over one year. Measurements and main results:The patient population was largely black (86%) and female (65%). Most patients (54%) were overweight [body-mass index (BMI)>85th percentile for the United States by gender]. Intensity of care was defined by a composite scale: points were awarded for actions documented in the medical chart or recalled by the patient. Factors independently associated with a higher intensity of care among the 161 overweight patients were: BMI [odds ratio (OR)=1.13 per kg/m ²;95% confidence interval (95% CI)=1.04, 122; p=0.002], the patient’s self-perception of being overweight (OR=5.37; 95% CI=1.99, 14.46; p=0.001), and age of 64 years or younger (OR=2.48; 95% CI=1.12, 5.48; p=0.02). Race, gender, and presence of hypertension or hypercholesterolemia were not associated with greater intensity of care. Conclusions:Patients with hypertension and hypercholes-terolemia may be receiving suboptimal weight reduction care. Heightened awareness of being overweight may enbance the provision of weight reduction care. Prospective studies are required to confirm these findings. Received from the Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins Health Institutions, Baltimore, Maryland. Supported by the Pew Charitable Trusts and the Rockefeller Foundation Health of the Public Program. Computer analysis was supported by a grant from the National Center for Research Resources, National Institutes of Health, General Clinical Research Centers 5M01RR00035.     

Care for caregivers

Objective:To assess the types of stress experienced by health care personnel caring for AIDS patients and to develop ways to reduce that stress. Design:A multidisciplinary support group for AIDS caregivers met weekly for three months, providing a context for the meaningful expression of personal and professional concerns about AIDS-related care. Setting:A hospital-based primary care group practice at Beth Israel Hospital, Boston. Participants:Health care personnel caring for patients with AIDS. Conclusions:Those who care for people with AIDS need support systems to help them gain some mastery over the complex clinical and emotional problems raised by the illness. During the course of this support group, the members moved from feeling overwhelmed to a new sense of confidence, collegiality, and understanding of their own and others’ emotional reactions, and a renewed approach to the care of these patients. Received from Healthcare Associates and the Department of Medicine, Social Work and Psychiatry, Beth Israel Hospital; Harvard Medical School; The Center for Policy and Education; The Harvard AIDS Institute, The Harvard School of Public Health; and the Boston Institute for Psychotherapy, Boston, Massachusetts.     

Toward developing care outcome quality indicators for home care for older people: A prospective cohort study in Japan

Introduction

Care quality in Japan's long-term care (LTC) agencies, including home care, is the responsibility primarily of individual agencies, and the evaluation of service processes and outcomes is minimal.

Objectives

To describe the development of quality indicators for LTC (QIs-LTC) in Japan.

Methods

QIs-LTC were developed through literature review and expert panel discussions and then were piloted and used in a 2-year longitudinal survey. The survey (launched in September 2019) targeted older people receiving home care (n = 1450), their family members (n = 880), their professional home care providers (n = 577), and managers of home care agencies (n = 122).

Results

Across eight domains (maintaining dignity, minimizing symptoms and disease deterioration, maintaining nutritional status, maintaining bladder/bowel control, encouraging physical activities, experiencing sound sleep, maintaining serenity and contentedness, and maintaining family's well-being), 24 care quality objectives were set with 24 outcome QIs-LTC and 144 process QIs-LTC. In the survey, 84.8% of clients were using home care nursing, 26.3% were living alone, and 39.5% had dementia. In the month preceding the data collection, 13.9% of clients had a new disease or worsening of an existing disease, 8.8% were hospitalized at least once, and 47.9% did not participate in activities of interest. About 20% of clients' families were unable to spend time peacefully, and 52.8% were exhausted from the client's care.

Conclusions

The QIs-LTC developed in the current study are generic and client- and family-centered. They encompass objective and subjective information and would facilitate standardized monitoring if adopted and comparison between LTC settings, including home care. In addition, future research directives are outlined. Geriatr Gerontol Int 2023; 23: 383–394 .     

Satisfaction with ambulatory care of persons with AIDS

OBJECTIVE: To examine the relation of patient characteristics and site of care to the perception of ambulatory care quality by persons with AIDS (PWAs). DESIGN: Patient surveys and medical record review were used to determine PWAs’ perceptions of their ambulatory care, self-perceived health status, primary care relationships, sociodemographic characteristics, and severity of illness. SETTING: A public-hospital HIV clinic, an academic group practice, and a staff-model health maintenance organization (HMO) that together care for 20% of all Massachusetts PWAs. PATIENTS: All active patients as of February 12, 1990, and all new AIDS patients at each of the three sites during the subsequent 13 months. MEASUREMENTS AND MAIN BESULTS: The primary outcome measure was a six-item scale of patient-rated quality of care (PRQC), a newly developed measure that combined patients’ ratings of their physician care, nursing care, involvement in medical decisions, and overall quality of care. Multiple logistic regression was carried out with low PRQC (lowest quart He) as the dependent variable, to identify correlates of patient perceptions of poor quality. Patients who had a primary nurse were significantly less likely to have low PRQC scores (OR=0.50, 95% CI=0.26 to 0.97). Black patients and patients who used injection drugs were significantly more likely to rate their care in the lowest quartile (OR=2.22, 95% CI=1.04 to 4.78; and OR=2.43, 95% CI=1.13 to 5.23, respectively), as were those who had lower self-perceived health status, after controlling for confounders; no association was found by site or severity. CONCLUSIONS: These results show that primary nursing may be an important determinant of how PWAs rate the quality of their ambulatory care. Furthermore, PWAs who are black or who are injection drug users are less satisfied than are others with the quality of their ambulatory AIDS care. Presented in part at the annual meeting of the Society of General Internal Medicine, April 30, 1993, Arlington, Virginia. Supported by the Agency for Health Care Policy and Research, grant number HS06239.     

Surgical wound infections diagnosed after discharge from hospital: epidemiologic differences with in-hospital infections

Bacground: The purpose of this study was to study postoperative infections detected in hospital and after discharge and to identify risk factors for such infections.Methods: A prospective cohort study was used, with a follow-up of 30 days after hospital discharge, on 1483 patients admitted to the general surgery service of a tertiary care hospital. The main outcome measure was surgical wound infection (SWI). Relative risks, crude and multiple risk factors adjusted for by logistic regression analysis, and their 95% confidence intervals (CIs) were estimated.Results: During follow-up 155 patients showed evidence of nosocomial infection, 134 in hospital and 21 at home, yielding a cumulative incidence of 10.5%. According to several variables (age, American Society of Anesthesiologists score, serum albumin, the SENIC and National Nosocomial Infections Surveillance indexes of intrinsic patient risk, length of hospital stay, etc.) there were no differences between patients with postdischarge SWI and uninfected patients; however, differences were detected between postdischarge SWI and in-hospital SWI, as well as between patients with in-hospital SWI and patients without infections. The analysis of risk factors showed that most predictors for in-hospital SWI did not behave in the same manner for postdischarge SWI. Stepwise logistic regression analysis identified cancer (odds ratio = 4.5, 95% CI = 1.7 to 12.2, p = 0.003) and surgeon performing the operation (for medium risk OR = 4.4, 95% CI = 0.9 to 21.3, p = 0.059; for high risk, OR = 3.0, 95% CI = 0.7–13.3, p = 0.144) as independent risk factors for postdischarge SWI.Conclusions: There were important epidemiologic differences between in-hospital SWI and postdischarge SWI; most risk factors for in-hospital SWI are not predictors for postdischarge SWI.     

AIDS prevention in primary care clinics

To assess attitudes toward educational programs about AIDS, 540 patients and 36 of their medical providers in primary care clinics were systematically sampled to ascertain what age groups should be exposed to a pamphlet entitled “Am I at Risk for AIDS?”, as well as what was acceptable content for posters and pamphlets placed in clinic waiting rooms. Although fewer than 10% of patients and providers opposed asking both teenagers and adults to read a pamphlet listing risk groups and practices, 24% of patients and 51% of providers opposed exposing children to the pamphlets. Only 6% of patients and none of the providers opposed all posters about AIDS, but 30% of patients and 44% of providers opposed posters listing risk groups, and opposition was even greater to posters describing “safe sex.” Regarding pamphlets acceptable for clinic waiting rooms, resistance among patients and providers was common (>25%) only when sexual practices were specifically mentioned. Although 89% of patients stated they had never been asked about their sexual orientations by a doctor or nurse, 34% of providers stated that they “always” or “often” so inquire. In the primary care clinics surveyed, a wide variety of educational interventions about AIDS could be implemented with little opposition.     

Complications of care in a medical intensive care unit

Objective:To determine the frequency and nature of complications of care in the medical intensive care unit (MICU). Design:Prospective, observational study. Setting:Seven-bed MICU in a teaching and referral VA hospital. Patients:295 consecutive patients admitted to the MICU during a ten-month study period. Interventions:None. Measurements and main results:Forty-two patients (14%, 95% confidence interval 13%, 16%) experienced one or more complications during their MICU stays. Compared with other MICU patients, those experiencing complications tended to be older (mean age ± SD: 63.6±10.1 years vs 59.3±14.0 years, p<0.02) and more acutely ill (mean Acute Physiology Score ± SD: 18.3±8.0 vs 12.5±8.0, p=0.0001). These patients also had significantly longer MICU lengths of stay (mean ± SD: 12.3±14.7 days vs 3.1±4 days, p<0.0001) and higher hospital mortality rates (67% vs 27%, p<0.001). The 67% mortality rate among patients with complications significantly exceeded the expected mortality rate of 46% (calculated from the APACHE risk equation). Conclusion:Complications of care in the MICU are not rare and may independently contribute to in-hospital mortality. The potential for complications must be recognized when considering ICU care.     

The relationship of presenting physical complaints to depressive symptoms in primary care patients

Objective:To assess the relationship of specific patient chief physical complaints to underlying depressive symptoms in primary care practice. Design:A cross-sectional study that was part of a larger prevalence study of depression in primary care. Setting:A general medical primary care practice in a teaching medical center in rural New England. Patients:1,042 consecutive outpatients screened for depression with the Hopkins Symptom Checklist 49-item depression scale and for whom physicians filled out a form recording both specific chief complaints and two aspects of complaint presentation style, clarity and amplification. Interventions:None. Results:Complaints that discriminated between depressed and non-depressed patients (at the p=0.05 level) were sleep disturbance (PPV 61%), fatigue (PPV 60%), multiple (3+) complaints (PPV 56%), nonspecific musculoskeletal complaints (PPV 43%), back pain (PPV 39%), shortness of breath (PPV 39%), amplified complaints (PPV 39%), and vaguely stated complaints (PPV 37%). Conclusions:Depressed patients are common in primary care practice and important to recognize. Certain specific complaints and complaint presentation styles are associated with underlying depressive symptoms. Received from the Section of General Internal Medicine, Department of Medicine, and the Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire. Supported by NIMH Grant No. MH-3752.     

Detection of injury-prone behaviors among internal medicine patients

Objectives:1) To describe the prevalence of eight injuryprone behaviors (IPBs) and the associations of these behaviors with ten standard chronic disease and sociodemographic risk factors (CDSRFs) among internal medicine patients and 2) to identify a subset of patients with multiple IPBs who might be at particularly high risk of injury. Design:Cross-sectional survey. Setting:The University of Colorado Health Sciences Center general internal medicine clinic. Patients:Four bundred ninety-two consecutive continuity care patients were eligible. The response rate was 94.3% (464/492). Instrument:A validated, self-administered questionnaire. Main results:Thirty-four percent of patients did not wear safety belts regularly and 32% had no smoke detector in their bomes. Nearly 26% of patients had firearms at home and 6% had a loaded and unlocked gun at home. Fourteen percent of patients had seriously throught about suicide and 6% had attempted suicide. In the prior month, 10% had ridden with a drunk driver, and 4% had driven after drinking too much. Of patients aged 65 years or older, 50% had had recent falls. After adjustment for other CDSRFs, problem drinking was the CDSRF most frequently associated with IPBs. Among men, problem drinking was significantly associated with drinking and driving (OR=35.3), safety belt non-use (OR=4.3), and previous thoughts of or attempts at suicide (OR=6.2). Among women, problem drinking was significantly associated with drinking and driving (OR=8.7). Among men, being unmarried was the demographic risk factor associated with the most IPBs. Of all IPBs, safety belt non-use was most frequently associated with CDSRFs (ORs ranged from 2.8 to 4.4). Men with three or more IPBs were more likely to be problem drinkers (OR=9.6), smokers (OR=15.8), obese (OR=6.3), and unmarried (OR=67.1). Conclusions:1) Injury-prone behaviors are common among patients attending a university-based internal medicine clinic; 2) men and women have substantially different patterns of risk factor associations; 3) CDSRFs, such as problem drinking, smoking, and being unmarried, are associated with many IPBs; 4) safety belt non-use is the IPB associated with the most CDSRFs; and 5) CDSRFs appear to cluster in men with multiple IPBs, suggesting that screening for high-risk individuals may be feasible in clinical practice. Presented in abstract form at the annual meeting of the Society of General Internal Medicine, April 29 — May 1, 1991, Seattle, Washington, and received the Associates Award for Outstanding Research Presentation. Supported in part by the National Institutes of Health, Faculty Development in General Internal Medicine, grant number PE-58002-D28.     

Factors associated with death places among elderly patients receiving home-based care

The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care.This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors.The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37–7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12–25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03–0.16; P < .001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03–0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13–0.90; P = .030).Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.     

Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality

BackgroundCurrent cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population.MethodsWe analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression.ResultsThe prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all).ConclusionsIn 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.     

Providers’ HIV Prevention Discussions with HIV-Seropositive Injection Drug Users

Public health agencies have recommended incorporating HIV prevention counseling into the medical care of persons living with HIV/AIDS. Injection drug users (IDUs) especially need HIV risk-reduction counseling because of their high risk for HIV transmission through both sexual and injection behaviors. The objective of this study was to assess the prevalence of, and patient factors associated with, the delivery of HIV prevention messages to HIV-seropositive IDUs in primary care settings. A majority of participants reported having an HIV prevention discussion with their provider during their most recent primary care visit. Factors significantly associated with report of such discussion were being Hispanic or non-Hispanic Black; high school education or less; and better perception of engagement with provider. Medical providers should provide prevention messages to all HIV-seropositive IDUs, regardless of demographic factors. Effective HIV prevention interventions in primary care settings, including interventions to improve patient-provider communication, are needed for HIV-seropositive IDUs.The INSPIRE Study Group includes the following people. Baltimore: Carl Latkin, Amy Knowlton, Karin Tobin; Miami: Lisa Metsch, Eduardo Valverde, James Wilkinson, Martina DeVarona; New York: Mary, Latka, Dave Vlahov, Phillip Coffin, Marc Gourevitch, Julia Arnsten, Robert Gern; San Francisco: Cynthia Gomez, Kelly Knight, Carol Dawson Rose, Starley Shade, Sonja Mackenzie; Centers for Disease Control and Prevention: David Purcell, Yuko Mizuno, Scott Santibanez, Richard Garfein, ann O’Leary; Health Resources and Services Administration: Lois Eldred, Kathleen Handley     

What Nurses in Primary Care Practices Know About Asthma Care: Results from a National Survey

Objectives: The purpose of this study was to characterize what nurses working in primary care settings know about asthma care. Current views on the care of persons with asthma suggest the need for sound knowledge of guideline-based care and a health care team that includes both physicians, nurses, and other providers. While there are reports of physician-related asthma care practices in the United States, there are few, if any, reports of nursing knowledge, attitudes, or beliefs about asthma care.

Methods: A national, randomly selected, representative sample of nurses working in ambulatory primary care settings was interviewed by telephone using a structured interview format.

Results: Of a sample of 80 nurses, less than 10% identified inflammation of the airways as the underlying condition that causes asthma symptoms. Fifty-one percent believed the underlying condition could be treated, while 44% believed only the symptoms could be treated, and 5% didn't know. Only 35% said they were aware of the National Heart, Lung, and Blood (NHLBI) asthma guidelines.

Conclusions: Nurses working in ambulatory primary care settings may lack sufficient knowledge to effectively teach and participate in asthma care.     

The association of hospital, clinic and provider volume with HIV/AIDS care and mortality: systematic review and meta-analysis

The objective of this systematic review and meta-analysis is to examine the association between hospital, clinic and provider patient volumes on HIV/AIDS patient outcomes including mortality, antiretroviral (ARV) use and proportion of patients on indicated opportunistic infection (OI) prophylaxis. We searched MEDLINE and nine other electronic databases from 1 January 1980 through 29 May 2009. Experimental and controlled observational studies of persons with HIV/AIDS were included. Studies examined the volume or concentration of patients with HIV/AIDS in hospitals, clinics or individual providers. Outcomes included mortality, ARV use and proportion of patients on indicated OI prophylaxis. We reviewed 22,692 titles and/or abstracts. Patient characteristics, study design, volume measures, medical outcomes and study confounders were abstracted. Data were extracted independently by two reviewers. Twenty-two studies were included in the final review. High volume hospital care was associated with lower in-hospital mortality (pooled odds ratio (OR) 0.71, 95% confidence interval [CI] 0.57-0.90 p = 0.004) and lower mortality 30 days from admission (pooled OR 0.62, 95% CI 0.47-0.81 p = 0.0004). Higher volume provider care was associated with significantly higher ARV use (pooled OR 4.41, 95% CI 2.70-7.18 p<0.00001). Differences in volume definitions and controlling for confounding variables did not appreciably alter the results. Higher volume hospitals, clinics and providers were associated with significantly decreased mortality for people living with HIV/AIDS and higher volume providers and clinics had higher ARV use. Heterogeneity of volume thresholds and absence of studies from resource-limited settings are major limitations.     

Predictors of outcome in a primary care depression trial

OBJECTIVE: Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response. DESIGN: Randomized trial of a stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe (N=149) and mild to moderate depression (N=79) groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician. MEASUREMENTS AND MAIN RESULTS: Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z=−3.06, P<.002); however, this difference was not present in the more severely depressed groups (z=0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months. CONCLUSIONS: Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes. This study was supported by National Institute of Mental Health Grant MH41739.     

Post-call transfer of resident responsibility

Objective:To determine whether transferring the care of patients to another senior resident the day after admission to the bospital adversely affects the efficiency and quality of care. Design:Retrospective analysis of a natural experiment. Setting:The general medical service of the Minneapolis Veterans Affairs Medical Center, a major tertiary teaching hospital of the University of Minnesota internal medicine residency program. Patients/participants:Subjects were all the patients admitted to the medicine service from 5:00 PM to 6:00 AM over an eight-month period. Intervention:After 5:00 PM, half of the patients were admitted to the hospital by a cross-covering senior resident (CC group of patients), and their care was transferred to a different senior resident the following day. The other patients were initially evaluated by the primary senior resident (PE group of patients). Assignment to the different services was a random, sequential process. Measurements and main results:The CC group had significantly more laboratory tests performed during their hospital stay than did the PE group of patients (44 vs. 32, p=0.01), even when adjusted for length of stay. Using multiple linear regression to adjust for other clinical parameters including length of stay, DRG weight, and number of consults, the authors found that being a CC subject was a significant predictor of the number of laboratory tests obtained (p=0.01). Furthermore, the median length of stay in the CC group (n=74) was longer than that in the PE group (n=72) (eight days vs. six days); this was of borderline statistical significance, using a two-sample median test (p=0.06). Conclusion:Patients transferred to a different resident the day after admission had more laboratory tests performed and longer inpatient stays. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, D.C., April 28, 1988.     

Home visits in a rural office practice

Objective:To describe the clinical features of home visits and their role in continuity of care, costs, and benefits in a rural office practice. Design:Prospective study of all home visits performed during a 26-month period. Setting:A general medicine teaching office practice located in rural Virginia. Patients:All persons to whom home visits were made during the study period. Main results:138 home visits were made to 47 patients who had a mean age of 73.2 years. Home visits accounted for 1.4% of patient encounters in the practice, required a mean of 7.1 miles of one-way travel and a mean of 48 minutes, including travel time, to complete, and generated $36 in income per visit. Most patients (27 of 47) were not permanently homebound. Reasons for patients’ being homebound were grouped into six categories (acute illness, frail elderly, terminal illness, advanced chronic disease, neurologic problem, and miscellaneous reasons). The reasons for visits were grouped into four categories (acute self-limited illness, exacerbation of chronic disease, routine follow-up of chronic disease, and psychosocial problem). Physicians judged that 80% of home visits represented appropriate use of their services. In addition, 46% of home visits made an emergency room visit unnecessary, and 9% made a hospital admission unnecessary. At the time of 75% of home visits, physicians reported personal benefits of making the visit. Conclusions:Home visits have an important role in the care of ambulatory as well as permanently homebound patients. While physicians judged most home visits to be appropriate and personally beneficial, these visits required more time and generated less revenue than did office visits for comparable problems. Because home visits generated as well as prevented the use of medical services, their impact on the overall cost of medical care in this setting is unclear. Received from the Division of General Medicine, Department of Medicine, University of Virginia Health Sciences Center, Charlottesville, Virginia.     

Older persons’ preferences for site of treatment in acute illness

OBJECTIVE: To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care. DESIGN: Qualitative analysis of in-depth interviews using the constant comparative method. SETTING: Respondents’ homes. PARTICIPANTS: Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services. MAIN RESULTS: Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents’ views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences. CONCLUSIONS: Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, May 1997. This research was supported by the Picker/Commonwealth Scholars Program.     

Use of unpaid and paid home care services among people with HIV infection in the USA

This paper examines utilization of paid and unpaid home health care using data from a nationally representative sample of HIV-positive persons receiving medical care in early 1996 (N = 2,864). Overall, 21.0% used any home care, 12.2% used paid care and 13.6% used unpaid care. Most (70.0%) users of home care received care from only one type of provider. Substantially more hours of unpaid than paid care were used. We also found evidence of a strong association between type of service used and type of care provider: 62.4% of persons who used nursing services only received paid care only; conversely, 55.5% of persons who used personal care services only received care only from unpaid caregivers. Use of home care overall was concentrated among persons with AIDS: 39.5% of persons with AIDS received any home health care, compared to 9.5% of those at earlier disease stages. In addition to having an AIDS diagnosis, logistic regression analyses indicated that other need variables significantly increased utilization; a higher number of HIV-related symptoms, lower physical functioning, less energy, a diagnosis of CMV and a recent hospitalization each independently increased the odds of overall home care utilization. Sociodemographic variables had generally weak relationships with overall home care utilization. Among users of home care, non-need variables had more influence on use of paid than unpaid care. Both paid and unpaid home health care is a key component of community-based systems of care for people with HIV infection. The results presented in this paper are the first nationally representative estimates of home care utilization by persons with HIV/AIDS and are discussed with reference to policy and future research.