Nursing home capabilities and decisions to hospitalize: a survey of medical directors and directors of nursing

OBJECTIVES: To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents. DESIGN: Cross-sectional survey. SETTING: Four hundred forty-eight nursing homes, 76% of which were nonprofit, from 25 states. PARTICIPANTS: Medical directors and directors of nursing (DONs). MEASUREMENTS: Participants were surveyed about resource availability, determinants of hospitalization, causes of overhospitalization, and nursing home practice. RESULTS: The survey response rate was 81%, with at least one survey from 93% of the facilities. Medical directors and DONs agreed that resident preference was the most important determinant in the decision to hospitalize, followed by quality of life. Although both groups ranked on-site doctor/nurse practitioner evaluation within 4 hours as the least accessible resource, they did not rank doctors not being quickly available as an important cause of overhospitalization. Rather, medical directors perceived the lack of information and support to residents and families around end-of-life care and the lack of familiarity with residents by covering doctors as the most important causes of overhospitalization. DONs agreed but reversed the order. Medical directors and DONs expressed confidence in provider and staff ability, although DONs were significantly more positive. CONCLUSION: Medical directors and DONs agree about most factors that influence decisions to hospitalize nursing home residents. Patient-centered factors play the largest roles, and the most important causes of overhospitalization are potentially modifiable.     

Muscle endurance in elderly nursing home residents is related to fatigue perception, mobility, and circulating tumor necrosis factor-alpha, interleukin-6, and heat shock protein 70

OBJECTIVES: To explore the relationships between muscle endurance and circulating interleukin (IL)‐6, tumor necrosis factor alpha (TNF‐α), and heat shock protein (Hsp)70 in nursing home residents and to assess how muscle endurance relates to self‐perceived fatigue and mobility. DESIGN: Exploratory study. SETTING: Three nursing homes of the Foundation for Psychogeriatrics (Brussels, Belgium). PARTICIPANTS: Seventy‐seven residents (53 female and 24 male, mean age 81 ± 8). MEASUREMENTS: Participants were assessed for muscle endurance (fatigue resistance and grip work); perceived fatigue (visual analogue scale for fatigue); fatigue during daily activities (Mobility‐Tiredness Scale); effect of fatigue on quality of life (World Health Organization Quality Of Life questionnaire); mobility (Tinetti Test & Elderly Mobility Scale (EMS)); and circulating IL‐6, TNF‐α, and Hsp70. RESULTS: Residents with better fatigue resistance reported less self‐perceived tiredness (P<.05). Similar trends were observed for fatigue during daily activities and for the extent to which fatigue bothered subjects. Higher grip work was associated with less self‐perceived fatigue on all fatigue scales (P<.01). Fatigue resistance and grip work were positively related to balance and basic mobility (all P<.01; trend for relationship between fatigue resistance and EMS). Subjects with high IL‐6 and Hsp70 showed significantly worse fatigue resistance (P=.007) and muscle work (P=.045) than those with high IL‐6 and low Hsp70. In male residents, higher TNF‐α was related to worse fatigue resistance and grip work (P<.05). CONCLUSION: Elderly nursing home residents complaining of fatigue need to be taken seriously, because they show worse muscle endurance, which is related to poorer mobility. Inflammatory processes involving TNF‐α and the interaction between IL‐6 and Hsp70 are related to poorer muscle endurance in these patients.     

Evaluation of the Potential for Bloodborne Pathogen Transmission Associated with Diabetes Care Practices in Nursing Homes and Assisted Living Facilities,Pinellas County

OBJECTIVES: To evaluate and characterize routine blood glucose monitoring practices in nursing homes and assisted living facilities (ALFs). DESIGN: Cross‐sectional, self administered survey and facility site visit. SETTING: Two hundred eighty‐nine licensed long‐term care facilities in Pinellas County, Florida. PARTICIPANTS: Stratified random sample of 48 long‐term care facilities (17% overall sample). MEASUREMENTS: Data on facility characteristics, infection control policies, staff practices, and equipment used for blood glucose monitoring. Differences between facilities in each stratum were compared and evaluated using the Pearson chi‐square or Fisher exact test. RESULTS: Fifteen nursing homes and 17 small and 16 large ALFs participated; 53 declined (48% participation rate). Bloodborne pathogen training (P=.02), hepatitis B vaccination (P=.003), and blood glucose monitoring (P<.001) policies were reported less often at ALFs. Staff glove use during blood glucose monitoring was lowest (50%) at small ALFs (P=.02). Reusable fingerstick devices intended for personal use were most often in use at ALFs (P<.001); four of 18 facilities (including 1 nursing home) were inappropriately using them for multiple residents. At 22 facilities (including all nursing homes), multiple residents shared blood glucose meters; only six (27%) reported cleaning them after each use. CONCLUSION: Despite existing recommendations, practices that facilitate bloodborne pathogen transmission during blood glucose monitoring were identified at nursing homes and ALFs. Infection control practices and polices were most often lacking at ALFs. Better training and oversight of blood glucose monitoring in long‐term care is needed to prevent transmission of bloodborne pathogens.     

A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life‐Sustaining Treatment Program

OBJECTIVES: To evaluate the relationship between two methods to communicate treatment preferences (Physician Orders for Life‐Sustaining Treatment (POLST) program vs traditional practices) and documentation of life‐sustaining treatment orders, symptom assessment and management, and use of life‐sustaining treatments. DESIGN: Retrospective observational cohort study conducted between June 2006 and April 2007. SETTING: A stratified, random sample of 90 Medicaid‐eligible nursing facilities in Oregon, Wisconsin, and West Virginia. PARTICIPANTS: One thousand seven hundred eleven living and deceased nursing facility residents aged 65 and older with a minimum 60‐day stay. MEASUREMENTS: Life‐sustaining treatment orders; pain, shortness of breath, and related treatments over a 7‐day period; and use of life‐sustaining treatments over a 60‐day period. RESULTS: Residents with POLST forms were more likely to have orders about life‐sustaining treatment preferences beyond cardiopulmonary resuscitation than residents without (98.0% vs 16.1%, P<.001). There were no differences between residents with and without POLST forms in symptom assessment or management. Residents with POLST forms indicating orders for comfort measures only were less likely to receive medical interventions (e.g., hospitalization) than residents with POLST full treatment orders (P=.004), residents with traditional do‐not‐resuscitate orders (P<.001), or residents with traditional full code orders (P<.001). CONCLUSION: Residents with POLST forms were more likely to have treatment preferences documented as medical orders than those who did not, but there were no differences in symptom management or assessment. POLST orders restricting medical interventions were associated with less use of life‐sustaining treatments. Findings suggest that the POLST program offers significant advantages over traditional methods to communicate preferences about life‐sustaining treatments.     

Do Vaccination Strategies Implemented by Nursing Homes Narrow the Racial Gap in Receipt of Influenza Vaccination in the United States?

OBJECTIVES: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility‐wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING: One thousand one hundred seventy‐four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility‐level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS: Overall in the Untied States, vaccination coverage was higher for Caucasian and African‐American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations (P=.14), verbal consent allowed for vaccinations(P=.39), and routine review of facility‐wide vaccination rates (P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high (P=.009, P=.002, and P=.002, respectively). CONCLUSION: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African‐American residents, narrowing the national vaccination racial gap.     

Emergency Department Use by Nursing Home Residents

Study objective: To describe a community's experience with the use of emergency department services by nursing home residents. Methods: We performed a retrospective chart review of a population-based cohort of nursing home residents in an urban county in central Georgia with 10 nursing homes (1,300 beds) and 4 hospital-based EDs. All ED visits by nursing home residents during 1995 were analyzed. Demographic data, timing of the visit, chief complaint, tests and treatments, disposition, and financial charges were recorded. Further, we calculated the number of ED visits per 100 nursing home patient-years. Results: A total of 873 nursing home residents made 1,488 ED visits. Mean age was 76.0 years; 66.4% were female, and 55.2% were white. Of the transfers, 42.9% occurred during regular working hours. The most common chief complaints were respiratory symptoms (14.4%), altered mental status (10.1%), gastrointestinal symptoms (9.9%), and falls (8.2%); 101 patients (6.8%) were transferred for malfunction of a gastrostomy tube. The most common laboratory tests were complete blood cell count (69.5%), chest radiograph (52.0%), electrocardiogram (45.0%), urinalysis (42.7%), and determination of electrolytes (42.7%). A total of 42.4% of the ED visits led to admission to the hospital. From the 10 nursing homes, there were 110 ED visits per 100 patient-years. A 3.5-fold difference in ED use among these nursing homes could not be explained by age, gender, or other factors. The average charge per ED visit was $1,239. Conclusion: Elders living in nursing homes are frequently transferred to EDs for costly medical evaluations, and more than 40% of such visits lead to admission to the hospital. [Ackermann RJ, Kemle KA, Vogel RL, Griffin RC Jr: Emergency department use by nursing home residents. Ann Emerg Med June 1998;31:749-757.]     

Nursing home practitioner survey of diagnostic criteria for urinary tract infections

OBJECTIVES: To identify clinical and laboratory criteria used by nursing home practitioners for diagnosis and treatment of urinary tract infections (UTIs) in nursing home residents. To determine practitioner knowledge of the most commonly used consensus criteria (i.e., McGeer criteria) for UTIs. DESIGN: Self-administered survey. SETTING: Three New Haven-area nursing homes. PARTICIPANTS: Physicians (n=25), physician assistants (PAs, n=3), directors/assistant directors of nursing (n=8), charge nurses (n=37), and infection control practitioners (n=3). MEASUREMENTS: Open- and closed-ended questions. RESULTS: Nineteen physicians, three PAs, and 41 nurses completed 63 of 76 (83%) surveys. The five most commonly reported triggers for suspecting UTI in noncatheterized residents were change in mental status (57/63, 90%), fever (48/63, 76%), change in voiding pattern (44/63, 70%), dysuria (41/63, 65%), and change in character of urine (37/63, 59%). Asked to identify their first diagnostic step in the evaluation of UTIs, 48% (30/63) said urinary dipstick analysis, and 40% (25/63) said urinalysis and urine culture. Fourteen of 22 (64%) physicians and PAs versus 40 of 40 (100%) nurses were aware of the McGeer criteria for noncatheterized patients (P<.001); 12 of 22 (55%) physicians and PAs versus 38 of 39 (97%) nurses used them in clinical practice (P<.001). CONCLUSION: Although surveillance and treatment consensus criteria have been developed, there are no universally accepted diagnostic criteria. This survey demonstrated a distinction between surveillance criteria and criteria practitioners used in clinical practice. Prospective data are needed to develop evidence-based clinical and laboratory criteria of UTIs in nursing home residents that can be used to identify prospectively tested treatment and prevention strategies.     

Targeting and Managing Behavioral Symptoms in Individuals with Dementia: A Randomized Trial of a Nonpharmacological Intervention

OBJECTIVES: To test the effects of an intervention that helps families manage distressing behaviors in family members with dementia. DESIGN: Two‐group randomized trial. SETTING: In home. PARTICIPANTS: Two hundred seventy‐two caregivers and people with dementia. INTERVENTION: Up to 11 home and telephone contacts over 16 weeks by health professionals who identified potential triggers of patient behaviors, including communication and environmental factors and patient undiagnosed medical conditions (by obtaining blood and urine samples) and trained caregivers in strategies to modify triggers and reduce their upset. Between 16 and 24 weeks, three telephone contacts reinforced strategy use. MEASUREMENTS: Primary outcomes were frequency of targeted problem behavior and caregiver upset with and confidence managing it at 16 weeks. Secondary outcomes were caregiver well‐being and management skills at 16 and 24 weeks and caregiver perceived benefits. Prevalence of medical conditions for intervention patients were also examined. RESULTS: At 16 weeks, 67.5% of intervention caregivers reported improvement in targeted problem behavior, compared with 45.8% of caregivers in a no‐treatment control group (P=.002), and reduced upset with (P=.03) and enhanced confidence managing (P=.01) the behavior. Additionally, intervention caregivers reported less upset with all problem behaviors (P=.001), less negative communication (P=.02), less burden (P=.05), and better well‐being (P=.001) than controls. Fewer intervention caregivers had depressive symptoms (53.0%) than control group caregivers (67.8%, P=.02). Similar caregiver outcomes occurred at 24 weeks. Intervention caregivers perceived more study benefits (P<.05), including ability to keep family members home, than controls. Blood and urine samples of intervention patients with dementia showed that 40 (34.1%) had undiagnosed illnesses requiring physician follow‐up. CONCLUSION: Targeting behaviors upsetting to caregivers and modifying potential triggers improves symptomatology in people with dementia and caregiver well‐being and skills.     

Derivation and confirmation of scales measuring medical directors' attitudes about the hospitalization of nursing home residents

OBJECTIVE: To derive and confirm scales measuring medical director's attitudes about hospitalization of nursing home residents. METHOD: The authors surveyed nursing facility medical directors about the necessity of hospitalizing residents for eight clinical conditions and compared the ratings to those obtained from an expert panel to derive a relative hospitalization score. They also asked about factors that might influence hospitalization decisions. They performed a factor analysis to derive scales that measure attitudinal determinants of hospitalization and used the relative hospitalization score to confirm the scales. RESULTS: The survey had a 79% response rate. The relative hospitalization score demonstrated that medical directors were slightly less likely to recommend hospitalization than expert panel physicians. Factor analyses yielded 10 scales focusing on nursing home functioning, economics, resident specific considerations, and physician attitudes. Eight of the 10 scales had significant bivariable associations with the relative hospitalization score, and 6 had significant multivariable associations. DISCUSSION: Medical directors identify multiple determinants of hospitalization for nursing facility residents across several domains. Hospitalization decisions for nursing facility residents are complex and involve clinical and nonclinical factors.     

Physician Attitudes Concerning Anticoagulation Services in the Long-Term Care Setting

Objectives: There is little experience in the use of specialized anticoagulation services in the long-term care setting. Even less is known about physician attitudes regarding these services. To examine this issue, we surveyed physicians caring for nursing home residents in a sample of long-term care facilities located in Connecticut. Methods: We surveyed physicians providing care to nursing home residents of a convenience sample of 21 Connecticut nursing homes. (These facilities had participated in a quality assessment and improvement project on preventing strokes in nursing home residents with atrial fibrillation.) Physicians were requested to complete a structured questionnaire about the challenges to managing nursing home residents on warfarin therapy and preferences concerning the use of an anticoagulation service to manage warfarin therapy in this setting. Results: A total of 245 physicians were asked to participate in the survey, and 114 (47%) responded between November 5, 1999 and January 14, 2000. Of the 114 physicians who returned the survey, 91 reported that they currently cared for residents in long-term care facilities and thus completed the questionnaire. The majority of respondents agreed or strongly agreed that an anticoagulation service would reduce the workload on physicians, increase the costs of care for nursing home residents on warfarin, and increase the percent of time that nursing home residents on warfarin are maintained in the target therapeutic range. Most physicians disagreed or strongly disagreed with statements suggesting an anticoagulation service would decrease the costs of care for nursing home residents on warfarin, reduce the liability of the prescribing physician, interfere with their ability to care for patients on warfarin therapy, and reduce the risk of warfarin-related bleeding. Forty-five percent of respondents agreed with a statement that an anticoagulation service would intrude on physician decision-making. Only about half (53%) of the respondents indicated that they would or might utilize an anticoagulation service for managing their long-term care patients on warfarin. Conclusions: Use of a specialized anticoagulation service to manage warfarin therapy is a systems-level approach with the potential to improve the effectiveness and safety of this treatment. Physician skepticism regarding the usefulness of anticoagulation services will only be overcome by subjecting this approach to rigorous evaluation and by assuring physicians of their ongoing involvement in decision-making regarding warfarin therapy in their patients.     

Quality of life in nursing home residents with advanced dementia

OBJECTIVES: To examine quality of life (QOL) in nursing home (NH) residents with advanced dementia and identify correlates of QOL near the end of life. DESIGN: Cross‐sectional data derived from NH records, interviews with residents' surrogate decision‐makers, QOL ratings by NH caregivers, and assessment of residents' cognitive function. SETTING: Three NHs in Maryland. PARTICIPANTS: A cohort of NH residents with dementia (n=119) who were receiving hospice or palliative care or met hospice criteria for dementia and their surrogates. MEASUREMENTS: QOL based on the proxy‐rated Alzheimer' Disease‐Related Quality of Life (ADRQL) scale administered to NH staff and validated against a single‐item surrogate‐rated measure of QOL, the Severe Impairment Rating Scale, to measure cognitive function and dichotomous indicators of neuropsychiatric symptoms (behavior problems, mood disorders, psychosis, delusions). RESULTS: Total ADRQL scores, ranging from 12.4 to 95.1 out of 100, were normally distributed and positively correlated (P<.001) with surrogate‐rated QOL. Multiple regression analysis of ADRQL scores showed that residents with higher cognitive function (P<.001, 95% confidence interval (CI)=0.97–1.65) and those receiving pain medication (P=.006, 95% CI=3.30–19.59) had higher QOL, whereas residents with behavior problems (P=.01, 95% CI=?11.60 to ?1.30) had lower QOL. CONCLUSION: The ADRQL is a valid indicator of QOL in NH residents with advanced dementia. QOL in this population may be improved near the end of life using appropriate assessment and treatment of pain and effective management of behavior problems.     

Problems of older adults living alone after hospitalization

OBJECTIVE: To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization. DESIGN: Secondary analysis of a prospective cohort study. PARTICIPANTS: Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed. MEASUREMENTS: One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization. RESULTS: One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P=.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7.6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11.9) times more likely to be admitted to a nursing home in the month after hospitalization. CONCLUSION: Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence. This work was supported by grants from the American Physical Therapy Foundation, the Dean Foundation, and the University of Wisconsin Medical School and Graduate School. Dr. Mahoney was the recipient of a Clinical Investigator Award from the NIA (K08AG00623).     

Rural-urban differences in medical care for nursing home residents with severe dementia at the end of life

OBJECTIVES: To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes. DESIGN: Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002. SETTING: Minnesota and Texas nursing homes. PARTICIPANTS: Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01. MEASUREMENTS: Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission. RESULTS: The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization. CONCLUSION: Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.     

Trends in the Prevalence and Comorbidities of Diabetes Mellitus in Nursing Home Residents in the United States: 1995–2004

OBJECTIVES: To estimate trends in the prevalence and comorbidities of diabetes mellitus (DM) in U.S. nursing homes from 1995 to 2004. DESIGN: SAS callable SUDAAN was used to adjust for the complex sample design and assess changes in prevalence of DM and comorbidities during the study period in the National Nursing Home Surveys. Trends were assessed using weighted least squares linear regression. Multiple logistic regressions were used to calculate predictive margins. SETTING: A continuing series of two‐stage, cross‐sectional probability national sampling surveys. PARTICIPANTS: Residents aged 55 and older: 1995 (n=7,722), 1997 (n=7,717), 1999 (n=7,809), and 2004 (n=12,786). MEASUREMENTS: DM and its comorbidities identified using a standard set of diagnosis codes. RESULTS: The estimated crude prevalence of DM increased from 16.9% in 1995 to 26.4% in 2004 in male nursing home residents and from 16.1% to 22.2% in female residents (all P<.05). Male and female residents aged 85 and older and those with high functional impairment showed a significant increasing trend in DM (all P<.05). In people with DM, multivariate‐adjusted prevalence of cardiovascular disease increased from 59.6% to 75.4% for men and from 68.1% to 78.7% for women (all P<.05). Prevalence of most other comorbidities did not increase significantly. CONCLUSION: The burden of DM in residents of U.S. nursing homes has increased since 1995. This could be due to increasing DM prevalence in the general population or to changes in the population that nursing homes serve. Nursing home care practices may need to change to meet residents' changing needs.     

Nursing home resident and facility characteristics associated with pneumococcal vaccination: national nursing home survey, 1995-1999

Objectives: To assess Advisory Committee for Immunization Practices recommendations for the pneumococcal vaccine in nursing home residents using national surveys to examine factors associated with vaccination. Design: Cross‐sectional national sample surveys of nursing homes and nursing home residents with a two‐stage probability design, stratified on size and Medicare and Medicaid certification status. Setting: U.S. nursing homes during 1995, 1997, and 1999. Participants: Six current residents were randomly selected from each facility (n=approximately 8,000 each year). Measurements: Residents' pneumococcal vaccination status was obtained by asking the facility respondent for each resident: “Has [the resident] EVER had a pneumococcal vaccine, that is a pneumonia vaccination?” Vaccination status was coded as yes, no, and unknown. Results: The proportion of residents aged 65 and older that received pneumococcal vaccination increased significantly, from 23.6% in 1995 to 28.2% in 1997 to 37.4% in 1999 (P<.001). The proportion of residents in homes with pneumococcal immunization programs increased significantly, from 65.2% in 1995 to 88.9% in 1999. Conclusion: The proportion of nursing home residents aged 65 and older receiving the pneumococcal vaccine increased significantly from 1995 to 1999. Residents living in nursing homes with programs for pneumococcal immunizations were significantly more likely to be vaccinated.     

The doctor-patient relationship and HIV-infected patients’ satisfaction with primary care physicians

OBJECTIVE: To assess the extent to which perceptions of specific aspects of the doctor-patient relationship are related to overall satisfaction with primary care physicians among HIV-infected patients. DESIGN: Longitudinal, observational study of HIV-infected persons new to primary HIV care. Data were collected at enrollment and approximately 6 months later by in-person interview. SETTING: Two urban medical centers in the northeastern United States. PARTICIPANTS: Patients seeking primary HIV care for the first time. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was patient-reported satisfaction with a primary care physician measured 6 months after initiating primary HIV care. Patients who were more comfortable discussing personal issues with their physicians (P=.021), who perceived their primary care physicians as more empathetic (P=.001), and who perceived their primary care physicians as more knowledgeble with respect to HIV (P=.002) were significantly more satisfied with their primary care physicians, adjusted for characteristics of the patient and characteristics of primary care. Collectively, specific aspects of the doctor-patient relationship explained 56% of the variation in overall satisfaction with the primary care physician. CONCLUSIONS: Patients’ perceptions of their primary care physician’s HIV knowledge and empathy were highly related to their satisfaction with this physician. Satisfaction among HIV-infected patients was not associated with patients’ sociodemographic characteristics, HIV risk characteristics, alcohol and drug use, health status, quality of life, or concordant patient-physician gender and racial matching. This research was conducted in part in the General Clinical Research Center at Boston University School of Medicine, USPHS grant M01 RR00533.     

Assessment of insomnia in high level residential aged care facility residents

Insomnia is common in nursing home settings but assessment and management of sleep disturbance is often suboptimal. New assessment procedures that target potentially remediable clinical causes of insomnia were implemented and evaluated at two high level residential aged care Facilities (HLRACFs) (formerly called nursing homes), in Melbourne, Australia. Fifty‐eight of 147 residents (39%) who complained of insomnia, or were nominated by nursing staff as having disturbed sleep, and had confirmation of sleep disturbance on overnight sleep log, were provided with a structured assessment protocol. A multidisciplinary team then considered the causes of each resident's insomnia. A potentially remediable medical or psychiatric cause was identified in 66% of residents with insomnia. More than one such factor was identified in 34%. Pain was a likely factor in 39%. Depression was a likely factor in 30%. Insomnia, depression and pain were significantly correlated.     

Likelihood of Ordering Physical Restraints: Influence of Physician Characteristics

OBJECTIVES: To determine physician knowledge regarding restraint regulations and effectiveness and effect of physician characteristics on likelihood of ordering restraints. DESIGN: Cross‐sectional, factorial research survey. SETTING: Academic medical center. PARTICIPANTS: Interns in all specialties; residents in internal medicine, family practice, emergency medicine, psychiatry, and surgery; and attending faculty at an academic medical center. MEASUREMENTS: Survey of demographic, professional, and restraint knowledge items and for each of five distinct vignettes; physician ratings of probability of patient harm and likelihood of ordering restraints. For each, physicians rated probability of patient harm and likelihood of ordering restraint. RESULTS: One hundred eighty‐nine of 246 (77%) surveys were returned. More than half (58%) were men; the median age was 30 (range 25–63), median years experience was 2 (range 0–33), and 60% were U.S. medical school graduates. Mean knowledge score was 68.4% (range 27–100%). Mean likelihood of ordering restraints ranged from 0.6 (not likely) to 9 (absolutely) (overall mean 3.9 ± 2.2). Exploratory hierarchical regression on mean likelihood of ordering restraint (outcome) with independent variables of physician age and sex (Step 1), years experience and physician level (Step 2), specialization (Step 3), restraint knowledge (Step 4), and judgment of harm (Step 5) explained 31.9% of the variance (F=7.19, degrees of freedom 13,159, P<.001). Higher appraisal of harm (P<.001), less knowledge regarding restraint (P=.03), and male sex (P=.005) were unique indicators for the likelihood of ordering restraints. Psychiatry (P=.03) or internal medicine physicians (P=.05) were less likely to order restraints. CONCLUSION: Physician characteristics and lack of restraint knowledge are associated with likelihood of ordering restraints. Results will guide medical education initiatives to reduce restraint rates.     

Modification of the risk of mortality from pneumonia with oral hygiene care

OBJECTIVES: To investigate the associations between the assignment of an oral hygiene aide staff member and risk factors for mortality from pneumonia in a nursing home and to test the hypothesis that this care would affect the incidence of mortality from pneumonia. DESIGN: Electronic medical records. SETTING: Nursing home. PARTICIPANTS: One hundred forty‐three residents of a Veterans Affairs Medical Center (VAMC) nursing home. METHODS: The electronic medical records of 143 residents of a VAMC nursing home were analyzed for risk factors for pneumonia. A certified nursing assistant had been assigned to provide oral hygiene care for residents on two of four nursing home wards. Researchers performed a longitudinal analysis of resident's medical records to investigate the association between the assignment of an oral hygiene aide with the risk of mortality from pneumonia. RESULTS: Initially, the group that received oral care, an older and less functionally able group, showed approximately the same incidence of mortality from pneumonia as the group that did not receive oral care, but when the data were adjusted for the risk factors found to be significant for mortality from pneumonia, the odds of dying from pneumonia in the group that did not receive oral care was more than three times that of the group that did receive oral care (odds ratio=3.57, P=.03). Modified risk factors included age, functionality, cognitive function, and clinical concern about aspiration pneumonia. CONCLUSION: Oral hygiene nursing aide intervention may be an efficient risk factor modifier of mortality from nursing home–associated pneumonia.