The effect of culture-positive influenza type A on resource use and adverse events in nursing home residents

OBJECTIVES: To determine adverse clinical events and resource utilization associated with culture-positive influenza A in nursing home residents. DESIGN: A retrospective cohort study with cases and controls. SETTING: Seven hundred twenty-one-bed skilled nursing facility. PARTICIPANTS: One hundred fifty-four residents (21% of all residents) from whom influenza A was isolated during the 1997/98 season and matched controls. MEASUREMENTS: Baseline parameters, staff interventions, diagnostic tests, and adverse events were recorded from 60 days before to 60 days after specimen collection. The difference between each individual's before and after measurements determined excess utilization secondary to influenza. Controls were studied to determine time series effects. RESULTS: Baseline Minimum Data Set and nutritional parameters demonstrated significantly greater (P <.05) feeding dependency and lower serum albumin in the control group. Time series effects in the control group were negligible. Among cases, there were nine deaths within 30 days; among controls, there were four (chi2 P =.26). Within 30 days of onset, an average excess of 18 notations by nursing staff, one phone call to the physician, and one to family was noted per case. In half of cases, a nonscheduled physician visit was required. There was a 20% excess in physician orders for oxygen and bronchodilators. Chest x-rays were performed in half of the cases, and antibiotics were prescribed to half. Sixteen percent of cases had radiographic pneumonia, and 2% had congestive heart failure. The average cost for excess chest x-rays, laboratory services, antimicrobials, ambulance calls, hospital days, and emergency room and physician visits was $943.44. This does not include efforts by nursing home staff who accommodate functional decline on-site. CONCLUSION: An unexpected finding was that there were more impaired individuals who were less likely to have influenza detected or less likely to acquire influenza in the control group than in the influenza group. The morbidity, mortality, excess staff effort, and measured expenditure justify efforts to prevent influenza.     

Racial and ethnic group variations in service use in a national sample of Medicare home health care patients with type 2 diabetes mellitus

Type 2 diabetes mellitus is known to affect adults in racial and ethnic minority groups disproportionately. When diabetes mellitus-related symptoms lead to the need for skilled care in the community-dwelling Medicare population, physicians can order the Medicare home health care (HHC) benefit, and Medicare-certified home health agencies can deliver it. Little is known about the extent to which racial and ethnic disparities exist in types and patterns of HHC services delivered to Medicare beneficiaries with diabetes mellitus when they are approved for the Medicare HHC benefit. This was examined by comparing racial and ethnic groups in terms of measures of HHC service use in a nationally representative sample of Medicare HHC beneficiaries with a primary diagnosis of type 2 diabetes mellitus. Uniform clinical data from the Outcome and Assessment Information Set were linked with Medicare HHC claims for beneficiaries who received a complete episode of HHC in 2002. In the study sample (n=9,838), 62% of participants self-identified as white, 22% African American, 12% Hispanic, and 3% Asian. Nearly all (99%) participants in all racial and ethnic groups received skilled nursing services. Controlling for numerous sociodemographic and health-related covariates and geographic region of the country, African-American participants received fewer nurse visits per week and fewer visits per week from all clinical disciplines combined than whites (both P<.001), and Hispanic participants were less likely than whites to receive physical therapy (adjusted odds ratio (AOR)=0.640, 95% confidence interval (CI)=0.543-0.754, P<.001) or home health aide (AOR=0.716, 95% CI=0.582-0.880, P=.002) services. Lower use of skilled nursing and rehabilitation services by African Americans and of rehabilitation services by Hispanics warrant further clinical and research attention.     

Insulin use and increased risk of mortality in type 2 diabetes: a cohort study

Aim: To compare population‐based rates of all‐cause and cardiovascular (CV) mortality in newly treated patients with type 2 diabetes according to levels of insulin exposure. Methods: Using the administrative databases of Saskatchewan Health, 12272 new users of oral antidiabetic therapy were identified between 1991 and 1996 and grouped according to cumulative insulin exposure based on total insulin dispensations per year: no exposure (reference group); low exposure (0 to <3); moderate exposure (3 to <12) and high exposure (≥12). Time‐varying multivariable Cox proportional hazards models were used to examine the relationship between insulin exposure and all‐cause, CV‐related and non‐vascular mortality after adjustment for demographics, medications and comorbidities. Results: Average age was 65 (s.d. 13.9) years, 45% were female, and mean follow‐up was 5.1 (s.d. 2.2) years. In total, 1443 (12%) subjects started insulin, and 2681 (22%) deaths occurred. The highest mortality rates were in the high exposure group; 95 deaths/1000 person‐years compared with 40 deaths/1000 person‐years in the no exposure group [unadjusted hazard ratio (HR): 2.32; 95% confidence interval (CI): 1.96–2.73]. After adjustment, we observed a graded risk of mortality associated with increasing exposure to insulin: low exposure [adjusted HR (aHR): 1.75; 95% CI: 1.24–2.47], moderate exposure (aHR: 2.18; 1.82–2.60) and high exposure (aHR: 2.79; 2.36–3.30); p = 0.005 for trend. Analyses restricted to CV‐related (p = 0.042 for trend) and non‐vascular (p = 0.004 for trend) mortality showed virtually identical results. Conclusions: We observed a significant and graded association between mortality risk and insulin exposure level in an inception cohort of patients with type 2 diabetes that persisted despite multivariable adjustment.     

合并感染的2型糖尿病患者胰岛素泵的临床应用

目的 比较连续皮下胰岛素注射(CSII)在伴和不伴感染的2型糖尿病(T2DM)患者中的应用。 方法 CSII感染组96例、CSII非感染组95例,均进行短期胰岛素强化治疗,比较两组血糖水平、血糖达标时间、单位体重胰岛素用量、低血糖发生率等,同时对伴和不伴感染的T2DM病人CSII应用方法进行比较。 结果 CSII感染组血糖达标时间为6.81±2.64天,非感染组为5.83±2.49天,CSII感染组达标时间较长(P＜0.05),且胰岛素用量较非感染组增加了约13%;感染组的CSII应用中主要是基础率水平较高;影响血糖达标和胰岛素用量的主要因素是感染、血糖水平和体质指数。 结论 CSII在合并感染的T2DM患者中能有效控制血糖,但胰岛素需要量增加,可通过增加凌晨和白天段的基础率来达到理想的血糖控制。     

Satisfaction with end-of-life care for nursing home residents with advanced dementia

OBJECTIVES: To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia. DESIGN: Cross-sectional study. SETTING: Thirteen NHs in Boston. PARTICIPANTS: One hundred forty-eight NH residents aged 65 and older with advanced dementia and their formally designated HCPs. MASUREMENTS: The dependent variable was HCPs' score on the Satisfaction With Care at the End of Life in Dementia (SWC-EOLD) scale (range 10-40; higher scores indicate greater satisfaction). Resident characteristics analyzed as independent variables were demographic information, functional and cognitive status, comfort, tube feeding, and advance care planning. HCP characteristics were demographic information, health status, mood, advance care planning, and communication. Multivariate stepwise linear regression was used to identify factors independently associated with higher SWC-EOLD score. RESULTS: The mean ages+/-standard deviation of the 148 residents and HCPs were 85.0+/-8.1 and 59.1+/-11.7, respectively. The mean SWC-EOLD score was 31.0+/-4.2. After multivariate adjustment, variables independently associated with greater satisfaction were more than 15 minutes discussing advance directives with a care provider at the time of NH admission (parameter estimate=2.39, 95% confidence interval (CI)=1.16-3.61, P<.001), greater resident comfort (parameter estimate=0.10, 95% CI=0.02-0.17, P=.01), care in a specialized dementia unit (parameter estimate=1.48, 95% CI=0.25-2.71, P=.02), and no feeding tube (parameter estimate=2.87, 95% CI=0.46-5.25, P=.02). CONCLUSION: Better communication, greater resident comfort, no tube feeding, and care in a specialized dementia unit are modifiable factors that may improve satisfaction with care in advanced dementia.     

Mortality-related factors and 1-year survival in nursing home residents

OBJECTIVES: To identify factors associated with 1-year mortality in newly admitted and long-stay (in nursing home longer than 1 year) nursing home residents by linking Minimum Data Set (MDS) information with data from the National Death Index and use these factors to create a useful tool for estimating risk levels for 1-year mortality. DESIGN: Retrospective cohort study with development and validation cohorts. SETTING: All 643 Medicare and Medicaid certified nursing homes in New York State during the study period. PARTICIPANTS: The study included data on residents collected during full MDS assessments from June 1994 through December 1997. A total of 100,669 nursing home residents met the inclusion criteria for the newly admitted resident analysis. The newly admitted development cohort included 60,341 residents, and the newly admitted validation cohort included 40,328 residents. A total of 36,125 nursing home residents met inclusion criteria for the long-stay (residing in nursing home>1 year) cohort. The long-stay development cohort included 22,749 residents, and the long-stay validation cohort included 15,068 residents. MEASUREMENTS: The analytical approach was similar for the newly admitted and long-stay resident cohorts. Resident characteristics that were considered potential risk factors for mortality were examined individually in bivariate proportional hazards models, and factors with P <.05 were entered into a proportional hazards regression stepwise model. The strongest factors based on their chi-square values were selected for entry into a multivariate proportional hazards analysis. Hazard ratios (HRs), 95% confidence intervals, and P-values were derived from this model. A mortality risk index score was created for each resident by summing the value of each HR in the multivariate model for those who had the risk factor. A sensitivity analysis was performed to determine the effect of residents with an unknown death status. A similar analysis was performed on the validation cohort to validate the original results. RESULTS: Major factors associated with 1-year mortality were identified in both the newly admitted and long-stay cohorts. In both newly admitted and long-stay residents, a higher mortality risk index score was associated with increased 1-year mortality in both the development and validation cohorts. CONCLUSIONS: MDS data can identify major factors associated with 1-year mortality in newly admitted and long-stay nursing home residents. These factors can be used to stratify residents into risk categories for 1-year mortality. This information could be important to residents, their families, and their physicians when developing care plans, as well as to agencies interested in healthcare resource planning.