Hospital Elder Life Program in the Real World: The Many Uses of the Hospital Elder Life Program Website

The Hospital Elder Life Program (HELP) can prevent delirium, a common condition in older hospitalized adults associated with substantial morbidity, mortality, and healthcare costs. In 2011, HELP transitioned to a web‐based dissemination model to provide accessible resources, including implementation materials; information for healthcare professionals, patients, and families; and a searchable reference database. It was hypothesized that, although intended to assist sites to establish HELP, the resources that the HELP website offer might have broader applications. An e‐mail was sent to all HELP website registrants from September 10, 2012, to March 15, 2013, requesting participation in an online survey to examine uses of the resources on the website and to evaluate knowledge diffusion related to these resources. Of 102 responding sites, 73 (72%) completed the survey. Thirty‐nine (53%) had implemented and maintained an active HELP model. Twenty‐six (35%) sites had used the HELP website resources to plan for implementation of the HELP model and 35 (50%) sites to implement and support the program during and after launch. Sites also used the resources for the development of non‐HELP delirium prevention programs and guidelines. Forty‐five sites (61%) used the website resources for educational purposes, targeting healthcare professionals, patients, families, or volunteers. The results demonstrated that HELP resources were used for implementation of HELP and other delirium prevention programs and were also disseminated broadly in innovative educational efforts across the professional and lay communities.     

Improving Access to Noninstitutional Long‐Term Care for American Indian Veterans

Home‐based primary care (HBPC) is an effective model of noninstitutional long‐term care developed in the Department of Veterans Affairs (VA) to provide ongoing care to homebound persons. Significant rural populations of American Indians have limited access to services designed for frail older adults. Fourteen Veterans Affairs Medical Centers (VAMCs) initiated efforts to expand access to HBPC in concert with local tribes and Indian Health Service (IHS) facilities. This study characterizes the resulting emerging models of HBPC and co‐management. Using an observational design, key respondent telephone interviews (n = 37) were conducted with stakeholders representing the 14 VAMCs to describe these HBPC programs, and HBPC models were evaluated in relation to VAMC organizational culture as revealed on the annual VA All Employee Survey. Twelve VAMCs independently developed HBPC expansion programs for American Indian veterans, and six different program models were implemented. Two models were unique to collaborations between VAMCs and tribes; in these collaborations, the tribes retained primary care responsibilities. VAMC used the other four models for delivery of care in remote rural areas to all veteran populations, American Indians and non‐Indians alike. Strategies to improve access by reducing geographic barriers occur in all models. Comparing mean VAMC organizational culture ratings, as defined in the Competing Values Framework, revealed significant group differences for one of these six models. Findings from this study illustrate the flexibility of the HBPC program and opportunities for co‐management and expansion of healthcare access for American Indians and non‐Indians, particularly in rural areas.     

Preliminary Data from Community Aging in Place,Advancing Better Living for Elders,a Patient‐Directed,Team‐Based Intervention to Improve Physical Function and Decrease Nursing Home Utilization: The First 100 Individuals to Complete a Centers for Medicare and Medicaid Services Innovation Project

Current medical models frequently overlook functional limitations and the home environment even though they partially determine healthcare usage and quality of life. The Centers for Medicare and Medicaid Services (CMS) Innovation Center funds projects that have potential to affect the “triple aim,” a framework for decreasing costs while improving health and quality of life. This article presents preliminary data from Community Aging in Place, Advancing Better Living for Elders (CAPABLE), a model funded by the CMS Innovation Center and designed to overcome the functional and home environmental barriers of older adults. CAPABLE is a patient‐directed, team‐based intervention comprising an occupational therapist, a registered nurse, and a handyman to decrease hospitalization and nursing home usage of community‐dwelling older adults with functional limitations who are dually eligible for Medicare and Medicaid. Activity of daily living limitations improved in 79% of the first 100 people who completed the intervention. Preliminary findings of this novel intervention may have implications for other older adults with functional limitations.     

Targeting oncogenic interleukin‐7 receptor signalling with N‐acetylcysteine in T cell acute lymphoblastic leukaemia

Activating mutations of the interleukin‐7 receptor (IL7R) occur in approximately 10% of patients with T cell acute lymphoblastic leukaemia (T‐ALL). Most mutations generate a cysteine at the transmembrane domain leading to receptor homodimerization through disulfide bond formation and ligand‐independent activation of STAT5. We hypothesized that the reducing agent N‐acetylcysteine (NAC), a well‐tolerated drug used widely in clinical practice to treat acetaminophen overdose, would reduce disulfide bond formation, and inhibit mutant IL7R‐mediated oncogenic signalling. We found that treatment with NAC disrupted IL7R homodimerization in IL7R‐mutant DND‐41 cells as assessed by non‐reducing Western blot, as well as in a luciferase complementation assay. NAC led to STAT5 dephosphorylation and cell apoptosis at clinically achievable concentrations in DND‐41 cells, and Ba/F3 cells transformed by an IL7R‐mutant construct containing a cysteine insertion. The apoptotic effects of NAC could be rescued in part by a constitutively active allele of STAT5. Despite using doses lower than those tolerated in humans, NAC treatment significantly inhibited the progression of human DND‐41 cells engrafted in immunodeficient mice. Thus, targeting leukaemogenic IL7R homodimerization with NAC offers a potentially effective and feasible therapeutic strategy that warrants testing in patients with T‐ALL.     

Risk Adjustment and the Assessment of Disparities in Dialysis Mortality Outcomes

Standardized mortality ratios (SMRs) reported by Medicare compare mortality at individual dialysis facilities with the national average, and are currently adjusted for race. However, whether the adjustment for race obscures or clarifies disparities in quality of care for minority groups is unknown. Cox model-based SMRs were computed with and without adjustment for patient race for 5920 facilities in the United States during 2010. The study population included virtually all patients treated with dialysis during this period. Without race adjustment, facilities with higher proportions of black patients had better survival outcomes; facilities with the highest percentage of black patients (top 10%) had overall mortality rates approximately 7% lower than expected. After adjusting for within-facility racial differences, facilities with higher proportions of black patients had poorer survival outcomes among black and non-black patients; facilities with the highest percentage of black patients (top 10%) had mortality rates approximately 6% worse than expected. In conclusion, accounting for within-facility racial differences in the computation of SMR helps to clarify disparities in quality of health care among patients with ESRD. The adjustment that accommodates within-facility comparisons is key, because it could also clarify relationships between patient characteristics and health care provider outcomes in other settings.     

The Connecticut Experiments Second Year: Ultrasound in the Screening of Women with Dense Breasts

To determine if the addition of screening breast ultrasound in women with mammographically normal but dense breasts improves breast cancer detection. The study utilized a retrospective chart review. Data collected included: (a) total number of screening mammograms; (b) total number of dense breast screening ultrasounds; (c) screening ultrasound Breast Imaging Reporting Data System (BI‐RADS) code results; (d) biopsy results; and (e) demographic data on women with malignant biopsies. Data were obtained from sites throughout Connecticut from November 1, 2010 to October 31, 2011. Data from 5 Connecticut radiology practices covering 10 sites were collected. Sites conducted a total of 57,417 screening mammograms and 10,282 dense breast screening ultrasounds. Of the screening ultrasounds, 87% (8,972/10,282) were BI‐RADS 1 or 2, 9% (875/10,282) were BI‐RADS 3, 4% (435/10,282) were BI‐RADS 4 or 5, and 39 were found to have a cancer or high‐risk lesion on biopsy. This correlates to 3.8 cancers or high‐risk lesions per 1,000 women screened. If high‐risk lesions are excluded, there are 24 cases of biopsy proven malignancy corresponding to 2.3 cancers per 1,000 women screened. In this study, screening breast ultrasound in women with mammographically normal but dense breasts demonstrated a positive predictive value of 9% (39/435) and specificity of 96% (8,972/9,368). Based on the data collected from sites throughout Connecticut, screening breast ultrasound in women with dense breast parenchyma detects mammographically occult malignancy and high‐risk lesions. The results are especially significant given recent studies suggesting that breast density is an independent risk factor for breast cancer and that mammography is less effective in detecting cancer in dense breasts. The improved specificity and sensitivity between the 1st and 2nd years’ suggests there is a learning curve that may continue to improve the results.     

Feasibility and Safety of Outpatient Total Laparoscopic Hysterectomy

Methods:We report a prospective, consecutive case series of 128 outpatient TLHs performed for benign gynecologic conditions in a tertiary care center.Results:Of the 295 women scheduled for a TLH, 151 (51%) were attempted as an outpatient procedure. A total of 128 women (85%) were actually discharged home the day of their surgery. The most common reasons for admission the same day were urinary retention (19%) and nausea (15%). Indications for hysterectomy were mainly leiomyomas (62%), menorrhagia (24%), and pelvic pain (9%). Endometriosis and adhesions were found in 23% and 25% of the cases, respectively. Mean estimated blood loss was 56 mL and mean uterus weight was 215 g, with the heaviest uterus weighing 841 g. Unplanned consultation and readmission were infrequent, occurring in 3.1% and 0.8% of cases, respectively, in the first 72 hours. At 3 months, unplanned consultation, complication, and readmission had occurred in a similar proportion of inpatient and outpatient TLHs (17.2%, 12.5%, and 4.7% versus 18.1%, 12.7%, and 5.4%, respectively). In a logistic regression model, uterus weight, presence of adhesions or endometriosis, and duration of the operation were not associated with adverse outcomes.Conclusion:Same-day discharge is a feasible and safe option for carefully selected patients who undergo an uncomplicated TLH, even in the presence of leiomyomas, severe adhesions, or endometriosis.