A cost-utility analysis in patients receiving enteral tube feeding at home and in nursing homes

A cost-utility analysis was undertaken of enteral tube feeding (ETF) in patients with cerebrovascular accident (CVA). Mortality during ETF was established in nursing homes (n7007) or at home (n2888). Quality of life was measured (EuroQol) on a sub-sample (n25). Quality adjusted life years (QALYs) over 3 years and the cost/QALY were calculated. The cost/QALY (1 pound=1.482 euros; 30/06/05) for patients receiving ETF at home was 12,817 pounds (10,351 pounds-16,826 pounds using 95% CI for quality of life) and insensitive to the frequency of home visits (50-150% of the average frequency; 11,851 pounds-13,782 pounds), outcome of patients reverting to full oral feeding (0-100% survival; 11,023 pounds-14,440 pounds), and computed outcome of a 'control' group not given ETF (0.125-0.25 year survival; 12,991 pound-14,006 pounds). The cost/QALY in nursing homes (10,304 pounds-68,064 pounds) varied depending on the state contribution to non-medical costs and is above and below the threshold (30,000 pounds/QALY). The data suggest the cost-effectiveness of ETF in patients with CVA receiving ETF at home or in nursing homes, where the non-medical costs are paid privately, compares favourably with other interventions. The cost-effectiveness of ETF in nursing homes when the state pays all non-medical costs compares unfavourably with other treatments, raising economic, clinical, and ethical concerns.     

A pilot study of specialized nursing care for home health patients

We conducted a pilot study to assess the feasibility of remote (Web-based) consultations for leg wounds. The wounds were photographed by a home care nurse using a digital camera and the images were transmitted to a server from the nurses' office, together with patient details. The home care nurse graded the wounds and suggested a treatment plan. Subsequently, a specialist wound-care nurse also graded them and suggested a treatment plan, using the data stored on the Web server. Thirty-four patients were studied. The Web system proved simple to use and staff responses were positive. The agreement between the home care nurses and the specialist nurse in assessing wounds was good (kappa coefficients 0.41 to 0.71). Agreement over the treatment of wounds was more variable (kappa coefficients -0.75 to 0.81). The results of the pilot study are encouraging and suggest that Web-based communication can improve the quality of care for patients with leg wounds and reduce costs.     

Barriers to vision care for nursing home residents

OBJECTIVE: To describe the prevalence of periodic eye examinations by eye professionals and to examine nursing facility resident characteristics associated with lack of periodic screening. DESIGN: Retrospective chart review. SETTING: Two Midwestern nursing facilities. Participants: Between 1995 and 1997, 134 subjects aged 60 and older were recruited from two metropolitan nursing facilities. Measurements: Nursing home charts were reviewed for: demographics, length of stay, date of eye examination, eye diagnosis,visual acuity. Nursing assessments were used to obtain information about cognition, function, behavior, and the presence of Do Not Resuscitate or Do Not Hospitalize orders. The chart was reviewed for visual acuity, intraocular pressures, and the presence of eye pathology. Individuals who had not had eye examinations in the previous 2 years were screened by an ophthalmologist. This examination included external examination of the eye, fundoscopic examination, tonometry,visual acuity with correction. RESULTS: Only 62 (46%) of the subjects had been seen by an eye care professional in the previous 2 years. Visual acuity information was available for 37/64 previously examined subjects. Of those with no eye examination in the previous 2 years (n = 72), visual acuity was obtained in 32 (44%) of subjects. New eye diagnoses were made in 64% (41/64). Logistic regression models with "eye examination within the past 2 years" as the dependent variable show that residents who do not desire hospital transfer are 80% less likely to have had an eye examination than those without this designation. Sex, age, length of stay, functional status, presence of severe dementia, behavior problems, or DNR orders do not change the likelihood that a resident would have been examined. Logistic regression models with "visual acuity measured" as the dependent variable show that residents with severe dementia are 12.6 times less likely to have acuity measured than those without dementia. Those with a length of stay in the facility less than 6 months are 10% less likely to have visual acuity measured. CONCLUSIONS: This study does not confirm that barriers still exist in the provision of eye care to all nursing home residents, but the prevalence of such assessments remains low. Additional screening results in a substantial increase in the identification of treatable eye diseases. Contrary to the original hypotheses that patient characteristics that make testing difficult would provide a barrier or disincentive to vision testing, this study did not show statistical differences in the rates of vision screening for those with dementia, behavior problems, or severe functional impairment. Severe dementia does seem to affect the ability of the eye care specialist to gather subjective data such as visual acuity. It also demonstrates that vision screening does take place on nursing home residents with a broad range of cognitive and functional abilities, and this screening results in the diagnosis of many treatable eye conditions. Future efforts should be made to increase vision screening and treatment in the nursing home.     

Analysing access to nursing home care

The aim of this study is to investigate access to nursing home care in selected regions of Australia, Canada and the United States, and to examine the common ways in which nursing homes are used. Firstly, a review of methodological considerations in measuring access to nursing home care is made. Secondly, patient turnover patterns are interpreted with a view to showing differences in nursing home use among the countries studied; aggregate turnover rates, length of stay and outcomes are compared. Thirdly, groups of patients who differ in demographic and morbidity characteristics and in their use of nursing homes are discussed. Finally a number of distributive implications of these results are raised and a framework is outlined for considering redistributive consequences of changes in the use of nursing homes. It is concluded that the rate of flow of patients through nursing homes is as important a determinant of access to nursing home care as the level of bed provision and that adoption of this dynamic view of access indicates considerable scope for redistributing use of resources within the nursing home systems of all three countries.     

养老院管饲老年人膳食及营养状况调查

目的 :了解养老院管饲老年人膳食与营养状况。方法 :自行设计调查问卷,对管饲者基本资料和膳食进行调查,采用简易营养评价调查表对其进行营养评价。结果 :MNA评分中位数为13,营养不良发生率为71.1%,膳食热量摄入较低,且营养不良者、潜在营养风险者膳食热量摄入显著低于营养良好者,各营养状态下蛋白质摄入量及蛋白供能比无显著差别,膳食中维生素A、B2、C、钾、钙、镁、铁、硒、膳食纤维摄入量均不到推荐摄入量的60%,膳食维生素E及钠摄入量为推荐量的200%以上。结论 :养老院管饲者营养不良高发,膳食摄入不合理,迫切需要营养支持小组对相关人员进行健康教育,提高养老院管饲者的整体健康水平。     

Assessing quality in nursing home dementia special care units: A pilot test of the joint commission protocol

Dementia is a serious and growing public health problem in the United States. Nearly 60% of nursing home residents are estimated to be cognitively impaired. Currently about 10% of nursing homes have special care units for residents with serious dementia including Alzheimer's disease. This research evaluates a protocol developed by the Joint Commission on Accreditation of Healthcare Organizations to assess the capability of special care units to provide quality care. The protocol was pilot tested through the use of two separate evaluations of diverse special care units in metropolitan Chicago. In comparing the two separate surveys from each site, data analysis revealed a high rate of correlation between these two evaluations at three distinct levels. The standards used, their intent, and the survey process were considered sound by those who tested the protocol and by those who were evaluated by it.     

Pre-admission screening of nursing home applicants: implications for home care.

An increasing number of states are developing programs to evaluate nursing home applicants prior to admission. The purpose of these Pre-Admission Screening (PAS) programs is to assure that nursing home placement is needed and appropriate. Both the number and scope of these programs have grown considerably in the last decade as states attempt to reduce inappropriate placements and control nursing home costs and utilization. The increase in PAS can have a significant impact on community services as clients are diverted from nursing homes to home care. This article uses the results of a recently completed national survey of state-administered PAS programs to indicate the impact of PAS on community care. PAs was defined as an on-site assessment of the need or appropriateness of nursing home care conducted by a disinterested third party prior to nursing home admission. State administrators of Medicaid and/or PAS in all states and the District of Columbia were contacted by phone to determine whether or not their state conducted PAS. States with PAS were sent a comprehensive mail survey, and 25 of these (81%) returned a survey. Data is presented regarding the scope of PAS programs, the types of clients participating in PAS, the variety of services coordinated or funded in conjunction with PAS, the types of recommendations made by screening teams (institutional vs. home care), and how respondents felt that PAS was impacting community services. The article concluded with a discussion of these results.     

Infusion protocol improves delivery of enteral tube feeding in the critical care unit.

BACKGROUND: Numerous factors may impede the delivery of enteral tube feedings (ETF) in the intensive care unit (ICU). We designed a prospective study to determine whether the use of an infusion protocol could improve the delivery of ETF in the ICU. METHODS: In a prior prospective study, we monitored all patients admitted to the medical intensive care unit (MICU) or cardiac care unit (CCU) who were made nil per os and placed on ETF (control group). We found that critically ill patients received only 52% of their goal calories, primarily due to physician underordering (66% of goal), frequent cessations of ETF (22% of the time), and slow advancement (14% at goal by 72 hours). Based on these findings, we developed an ETF protocol that incorporated standardized physician ordering and nursing procedures, rapid advancement, and limited ETF interruption. After extensive educational sessions, the ETF protocol was begun. Again, all patients admitted to the MICU or CCU who were made nil per os and placed on ETF were prospectively followed (protocol group). RESULTS: Thirty-one patients in the protocol group were followed during 312 days of ETF and compared with the control group (44 patients with 339 days of ETF). Despite efforts by the nutritional support team, the infusion protocol was used in only 18 patients (58%). The main reasons for noncompliance with the protocol were physician preference and system failure (ETF order sheet not placed in chart). When used, the infusion protocol improved physician ordering (control 66% of goal volume, noncompliant 68%, compliant 82%, p < .05); delivery of calories (control 52% of goal, noncompliant 55%, compliant 68%, p < .05); and advancement of ETF (control 14% at goal by 72 hours, noncompliant 31%, compliant 56%, p < .05). Although significant reduction in ETF cessation due to nursing care was noted, it represented only a fraction of the total time ETF were stopped. Cessation due to residual volumes, patient tolerance, and procedure continued to be a frequent occurrence and was often avoidable. CONCLUSIONS: An evidence-based infusion protocol improved the delivery of ETF in the ICU, primarily because of better physician ordering and more rapid advancement. The nursing staff rapidly assimilated these changes. However, physicians' reluctance to use the protocol limited its efficacy and will need continued educational efforts.     

Foster home care for the frail elderly as an alternative to nursing home care: an experimental evaluation.

This paper describes a program (Community Care Program) in which some elderly hospital patients who were candidates for nursing home placement were placed in foster homes. Caregivers were carefully trained and supervised. A total of 112 elderly inpatients were randomly assigned to placement in a nursing home or a foster care home. Patients and caregivers were interviewed at 3, 6, 9, and 12 months after placement. Community Care Program patients were more likely to maintain or improve ADL (activities of daily living) and mental status scores. They also had better nursing outcomes and were more likely to get out of the house than were nursing home patients. Nursing home patients had higher life satisfaction, and participated in more social and recreational activities. The Community Care Program was 17 per cent less costly than nursing home care. The results suggest that foster care may be a viable alternative for a segment of the nursing home population.     

Special care units for Alzheimer's patients: their role in the nursing home market

The Special Care Unit (SCU) is a new, rapidly proliferating mode of caring for people with Alzheimer's disease (AD). Approximately 10% of nursing homes within the U.S. have SCUs with the number expected to grow substantially in coming years. SCUs are largely unregulated and not uncontroversial. This article discusses their emergence over time, their origins, growth, and the call for standardization. Subsequent sections review the range of potential benefits and costs associated with SCUs, optimally defined as well as research evidence available on this mode of care. Recent cost-setting and reform pressures in the nursing home industry are discussed in the final sections along with the likely future of AD SCUs in this environment.     

Quality of life and nutritional state in patients on home enteral tube feeding

OBJECTIVE: We assessed quality of life (QOL) in patients on home enteral tube feeding (HETF). The data should contribute to ethically justified decision making. METHODS:We used a prospective cross-sectional study (study 1) in 155 consecutive patients and a prospective longitudinal study (study 2) with a follow-up of 4 mo in 56 patients. QOL was assessed by proxy rating (Karnofsky and Spitzer indices) and self-rating (European Organization for Research and Treatment of Cancer [EORTC] QLQ C30) extended by a specific module. RESULTS: In study 1, weight losses 3 mo before HETF were 10.5 +/- 8.4% and 7.9 +/- 6.3% in competent (P < 0.05) and non-competent (P < 0,05) patients, respectively. The prevalences of severe malnutrition and weight loss were 50% and 73%, respectively. When compared with EORTC reference data for a general population, QOL was lower in HETF patients. The lowest QOL was seen in non-competent patients. Nutrition status explained up to 13% of the variance in QOL. In study 2, nutrition status stabilized or increased slightly in response to HETF. This was true for competent and non-competent patients and for patients with malignant and benign diseases. Concomitantly, physical functioning improved, whereas fatigue decreased. QOL increased in response to HETF in competent and non-competent patients, and 50% of the non-competent patients became competent CONCLUSIONS: .Measures of QOL research can be used in HETF patients. QOL is reduced in patients on HETF. Part of this effect is explained by malnutrition. HETF can prevent further weight loss and improve some aspects of QOL, thus allowing physicians to focus on patients.