Long-Term Use of Mixed-Oil Lipid Emulsion in Soybean Oil–Intolerant Home Parenteral Nutrition Patients

Background: Although home parenteral nutrition (HPN) is lifesaving for patients with chronic intestinal failure (IF), long-term use can be associated with complications such as infections, metabolic abnormalities, and IF–associated liver disease (IFALD). The key to treatment of many of these complications is prevention. Guidelines recommend avoidance of overfeeding, use of oral/enteral nutrition if possible, cyclic PN, and maintaining dose of soybean oil (SO) intravenous lipid emulsion (ILE) <1 g/kg/day as preventive strategies for IFALD. Additionally, with development of IFALD, ω-6/ω-3 polyunsaturated fatty acid ratio should be decreased in ILE. The newly available mixed-oil (MO) ILE offers such an opportunity; however, there is a paucity of long-term data available. Methods: The current study reports our long-term experience with MO ILE use in HPN patients. Results: Seventeen patients (8 female and 9 male) with an average age of 47 ± 12 years and median HPN duration of 4.6 years (1.1–32.1 years) have utilized MO ILE for >12 months after being transitioned from SO ILE because of intolerance. Use of MO ILE allowed an increase in ILE energy from 8% ± 8% to 22% ± 8% while reducing dextrose energy from 66% ± 8% to 54% ± 5%, maintaining stability in alkaline phosphatase and triglyceride levels, and achieving improvement in aspartate aminotransferase, alanine aminotransferase, total bilirubin, and α-tocopherol levels. Conclusion: In this HPN cohort with SO ILE intolerance, MO ILE was well tolerated and allowed an improvement in macronutrient composition while improving some liver parameters over a 12-month period.     

Do Herbal Agents Have a Place in the Treatment of Sleep Problems in Long-Term Care?

Sleep disruption is common in the long-term care setting. This article discusses the available literature on 2 herbal approaches to sleep problems in long-term care. The largest body of evidence exists for the use of the dietary/herbal supplements valerian and melatonin. While these agents appear to have a modest positive effect on sleep quality among older adults, most studies were small in size and included only subjective assessments of sleep quality. In addition, it is unclear whether these agents pose risks to long-term care residents because of potential drug interactions. Additional research is needed before making conclusive recommendations about the use of these interventions for sleep in the long-term care setting.     

“Out of Our Crisis”: The Lack of Long-Term Relationships in the Provision of Managed Care

During the thirty-year period between 1965 and 1995, national healthcare expenditures rose significantly to a point where it became an untenable situation for any payer class: patient, employer, or government. Although managed care was offered as a conceptual framework for providing an opportunity for improving the health of the population while limiting the growth in expenditures, significant concern remained regarding the perceived quality of care and the underlying incentive structures. The author examines current healthcare incentive structures and proposes a structural model associated with long-term contracting to allow managed care to attain its intended objectives of enhanced quality and cost containment.     

Successful Geriatric Rehabilitation: Effects on Patients’ Outcome of a National Program to Improve Quality of Care,the SINGER Study

Objective

To determine whether the implementation of a national program to improve quality of care in geriatric rehabilitation (GR) in the Netherlands improves successful GR in terms of independence in activities of daily living (ADL), discharge destination, and length of stay.

A Model-Based Economic Evaluation of Improved Primary Care Management of Patients with Type 2 Diabetes in Australia

Background

There are few studies investigating the economic value of the Australian practice nurse workforce on the management of chronic conditions. This is particularly important in Australia, where the government needs evidence to inform decisions on whether to maintain or redirect current financial incentives that encourage practices to recruit practice nurses.

Objective

The objective of this study was to estimate the lifetime costs and quality-adjusted life-years (QALYs) associated with two models of practice nurse involvement in clinical-based activities (high and low level) in the management of type 2 diabetes within the primary care setting.

Methods

A previously validated state transition model (the United Kingdom Prospective Diabetes Study Outcomes Model) was adapted, which uses baseline prognostic factors (e.g. gender, haemoglobin A1c [HbA1c]) to predict the risk of occurrence of diabetes-related complications (e.g. stroke). The model was populated by data from Australian and UK observational studies. Costs and utility values associated with complications were summed over patients’ lifetimes to estimate costs and QALY gains from the perspective of the health care system. All costs were expressed in 2011 Australian dollars (AU$). The base-case analysis assumed a 40-year time horizon with an annual discount rate of 5 %.

Results

Relative to low-level involvement of practice nurses in the provision of clinical-based activities, the high-level model was associated with lower mean lifetime costs of management of complications (?AU$8,738; 95 % confidence interval [CI] ?AU$12,522 to ?AU$4,954), and a greater average gain in QALYs (0.3; 95 % CI 0.2–0.4). A range of sensitivity analyses were performed, in which the high-level model was dominant in all cases.

Conclusion

Our results suggest that the high-level model is a dominant management strategy over the low-level model in all modelled scenarios. These findings indicate the need for effective primary care-based incentives to encourage general practices not only to employ practice nurses, but to better integrate them into the provision of clinical services.     

Should Programs of All-Inclusive Care for the Elderly Use Community-Based Primary Care Physicians?

The program of All-inclusive Care for the Elderly (PACE) is a community-based, long-term care model designed for older adults that are nursing home eligible. Bound by original design and regulations, these programs have primarily utilized a center-based ("staff") primary care physician model. However, some believe that this might hinder expansion of the PACE model. In response to this concern, three PACE programs have explored the use of "community-based" primary care physicians (CBPCPs). In an attempt to evaluate the impact of this variation in the model, we surveyed the medical director, 2 community-based primary care physicians and 6 non-physician staff members at one of these sites. Responders generally support the use of CBPCPs as a useful and productive alternative way to expand PACE services to a wider audience of eligible patients. Because some staff members perceive that CBPCPs utilize hospital and NH services at a higher rate, continued education of both CBPCPs and staff members regarding the expectations from this relationship is needed.     

Hearing the Voice of the Resident in Long-Term Care Facilities—An Internationally Based Approach to Assessing Quality of Life

Objectives

interRAI launched this study to introduce a set of standardized self-report measures through which residents of long-term care facilities (LTCFs) could describe their quality of life and services. This article reports on the international development effort, describing measures relative to privacy, food, security, comfort, autonomy, respect, staff responsiveness, relationships with staff, friendships, and activities. First, we evaluated these items individually and then combined them in summary scales. Second, we examined how the summary scales related to whether the residents did or did not say that the LTCFs in which they lived felt like home.

Experienced Quality of Post-Acute and Long-Term Care From the Care Recipient's Perspective–A Conceptual Framework

This article aims to conceptualize experienced quality of post-acute and long-term care for older people as perceived by care recipients. An iterative literature review and consultations with stakeholders led to the development of the INDividually Experienced QUAlity of Long-term care (INDEXQUAL) framework. INDEXQUAL presents the process of an individual care experience consisting of a pre (expectations), during (experiences), and post (assessment) phase. Expectations are formed prior to an experience by personal needs, past experiences, and word-of-mouth. An experience follows, which consists of interactions between the players in the caring relationships. Lastly, this experience is assessed by addressing what happened and how it happened (perceived care services), how this influenced the care recipient's health status (perceived care outcomes), and how this made the care recipient feel (satisfaction). INDEXQUAL can serve as a framework to select or develop methods to assess experienced quality of long-term care. It can provide a framework for quality monitoring, improvement, and transparency.     

Correlates of Pregnant Women’s Participation in a Substance Use Assessment and Counseling Intervention Integrated into Prenatal Care

Maternal and Child Health Journal - Screening and referral for substance use are essential components of prenatal care. However, little is known about barriers to participation in substance use...     

Physical Activity and Sarcopenia in the Geriatric Population: A Systematic Review

Introduction

Sarcopenia is an aging-related health problem in the geriatric population. Sarcopenia reduces muscle mass, muscle strength, and physical performance. Although physical activity is protective against sarcopenia for older adults, there are limited studies in this area. The purpose of this study was to integrate and analyze research on physical activity and sarcopenia in the geriatric population.

Exploratory Factor Analysis of a Patient-Centered Cancer Care Measure to Support Improved Assessment of Patients’ Experiences

ObjectiveTo increase the understanding of patient-centered care (PCC) and address the need for cross-cutting quality cancer care measures that are relevant to both patients and providers.MethodsAn exploratory factor analysis (EFA) was performed on a short version of the Patients and the Cancer Care Experience Survey, a patient-reported measure of perceived importance of social, emotional, physical, and informational aspects of care, administered to adult patients (n = 104) at a National Cancer Institute-designated comprehensive cancer center. Relationships between PCC dimensions and patient characteristics were also assessed. Principal axis factoring was applied and bivariate analyses were performed using Wilcoxon rank-sum tests.ResultsMost of our sample was over 60 years old (63.4%), female (57.4%), and white (74.2%), with either breast (41.2%) or prostate cancer (27.5%). A 5-factor model was identified: (1) quality of life (α = .91), (2) provider social support (α = .83), (3) psychosocial needs (α = .91), (4) nonprovider social support (α = .79), and (5) health information and decision-making support (α = .88). No statistically significant associations were found between these factors and patients’ characteristics.ConclusionsA preliminary factor structure for a cancer PCC measure was identified. Our findings reinforce the interrelated nature of PCC dimensions. The lessons learned from this study may be used to develop a single PCC measure that identifies patient priorities across the cancer care continuum. Data collected from such a measure can be used to support patient engagement in treatment planning and decision-making.     

Quality-of-Life–Adjusted Hazard of Death: A Formulation of the Quality-Adjusted Life-Years Model of Use in Benefit-Risk Assessment

BackgroundAlthough the quality-adjusted life-years (QALY) model is standard in health technology assessment, quantitative methods are less frequent but increasingly used for benefit-risk assessment (BRA) at earlier stages of drug development. A frequent challenge when implementing metrics for BRA is to weigh the importance of effects on a chronic condition against the risk of severe events during the trial. The lifetime component of the QALY model has a counterpart in the BRA context, namely, the risk of dying during the study.MethodsA new concept is presented, the hazard of death function that a subject is willing to accept instead of the baseline hazard to improve his or her chronic health status, which we have called the quality-of-life–adjusted hazard of death.ResultsIt has been proven that if assumptions of the linear QALY model hold, the excess mortality rate tolerated by a subject for a chronic health improvement is inversely proportional to the mean residual life.ConclusionsThis result leads to a new representation of the linear QALY model in terms of hazard rate functions and allows utilities obtained by using standard methods involving trade-offs of life duration to be translated into thresholds of tolerated mortality risk during a short period of time, thereby avoiding direct trade-offs using small probabilities of events during the study, which is known to lead to bias and variability.     

The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition

Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n?=?267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268–$423), relative to low-risk drinkers (n?=?105,023). High-risk drinking patients (n?=?5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.     

What Constitutes Preferred Long-Term Care Provided in Residential Aged Care Facilities? An Empirical Comparison of the Preferences of the General Population,Residents, and Family Members

ObjectivesRelatively few studies to date have examined the preferences of members of the general population as potential future consumers of long-term aged care services. This study aimed to use discrete choice experiment methodology to compare the preferences of 3 groups: the general population, residents, and family members of people living in long-term aged care.MethodsA total of 6 salient attributes describing the physical and psychosocial care in long-term residential aged care were drawn from qualitative research with people with a lived experience of aged care and were used to develop the discrete choice experiment questionnaire. The 6 attributes included: the level of time care staff spent with residents, homeliness of shared spaces, the homeliness of their own rooms, access to outside and gardens, frequency of meaningful activities, and flexibility with care routines. The questionnaire was administered to 1243 respondents including consumers (residents [n = 126], family member carers [n = 416]), and members of the general population (n = 701).ResultsFor both the general population and resident samples, having their own room feeling “home-like” exhibited the largest impact upon overall preferences. For the family member sample, care staff being able to spend enough time exhibited the largest impact. Tests of poolability indicated that the resident and general population samples estimates could be pooled. The null hypothesis of equal parameters between the groups was rejected for the family members, indicating significant differences in preferences relative to the resident and the general population samples.ConclusionsThis study illustrates that preferences for residential aged care delivery may vary depending upon perspective and experience.     

Where Should They Go? Undocumented Immigrants and Long-Term Care in the United States

In this paper, I consider the question of where illegal immigrants should go once their lives have been saved in hospitals and they are ready to be transferred to long-term care situations. I highlight three recent cases in which such a decision was made. In one case, the patient was kept at the hospital, in another the patient was repatriated to his home country, and in the third, the patient was discharged to his family. I consider the relevant moral values and argue that for reasons of fairness we must develop a policy that treats similar cases in similar ways. In order to best uphold patient well-being and minimize costs, the plan proposed here calls for illegal immigrants to be covered by insurance for long-term care.