A randomized clinical trial of outpatient geriatric evaluation and management

OBJECTIVES: To measure the effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability and use of health services. DESIGN: Randomized clinical trial. SETTING: Ambulatory clinic in a community hospital. PARTICIPANTS: A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568). INTERVENTION: Comprehensive assessment followed by interdisciplinary primary care. MEASUREMENTS: Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants' group status. RESULTS: Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47-0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37-0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20-0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37-0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person. CONCLUSION: Targeted outpatient GEM slows functional decline.     

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES: To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.
DESIGN: Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.
SETTING: Eleven medical and surgical units in one 600-bed teaching hospital.
PARTICIPANTS: One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.
MEASUREMENTS: Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient–registered nurse (RN) ratio, patient–total nursing staff ratio, and skill mix.
RESULTS: Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient–RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38–2.68, P < .001; weekend day and patient–total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37–2.66, P < .001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37–2.67, P < .001).
CONCLUSION: Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.     

Partnering managed care and community-based services for frail elders: the care advocate program

OBJECTIVES: To describe a demonstration program that uses master's-level care managers (care advocates) to link Medicare managed care enrollees to home- and community-based services, testing whether referrals to noninsured services can reduce service usage and increase member satisfaction and retention. DESIGN: Using an algorithm designed to target frail, high-cost users of Medicare insured healthcare services, the program partners PacifiCare's Secure Horizons and four of its medical groups with two social service organizations. SETTING: Three care advocates located in two community-based social services agencies using telephone interviews to interact with targeted elders living in the community. PARTICIPANTS: Three hundred ninety PacifiCare members aged 69 to 96 receiving care from four PacifiCare-contracted medical groups. INTERVENTION: The 12-month intervention provides telephone assessment, links to eight types of home- and community-based services, and monthly follow-up contacts. MEASUREMENTS: Sociodemographic characteristics of intervention participants, types of service referrals, and acceptance rates. RESULTS: Lessons learned included the importance of building a shared vision among partners, building on existing relationships between members and providers, and building trust without face-to-face interactions. CONCLUSION: The program builds on current insured case management services and offers a practical bridge to community-based services.     

Cauterization Versus Fibrin Glue for Aerostasis in Precision Resections for Secondary Lung Tumors

Background: Aerostasis control in multiple resections for metastatic pulmonary diseases is a real problem. Long-term air leaks prolong postoperative hospitalization and result in an additional financial burden on the healthcare system. We focused our study on the evaluation of fibrin glue (Tissucol) as an effective means to minimize or prevent air leaks.Methods: We initiated a case-control study whereby 100 patients underwent precision resections for lung metastases. The subjects were divided into 2 groups, both with 50 patients: group 1 was treated with fibrin glue and group 2 with cauterization. Evaluation parameters consisted of the following: air leak duration, expected complications, drain time, and in-hospital stay.Results: In group 1, air-leak time was 2.68 ± 1.72 days, versus 7.80 ± 8.52 for group 2 (P < .001). In group 1, there were 2% complications, whereas in group 2 there were 28% (P < .001). Drain time was 4.54 ± 1.83 days for group 1 and 9.54 ± 8.35 for group 2 (P < .001). In-hospital stay was 6.54 ± 1.83 days for group 1 and 11.54 ± 8.35 for group 2 (P < .001).Conclusions:In the group treated with fibrin glue, we observed significant advantages. Our experience shows that the use of fibrin glue can improve aerostasis control in nonanatomical resections with high risk of air leak.Presented at the 55th Annual Cancer Symposium of the Society of Surgical Oncology, Denver, Colorado, March 14–17, 2002.     

Help seeking for emotional and behavioural problems in children and adolescents

In order to understand the discrepancy between rates of child and adolescent psychopathology and rates of mental health service use, variables influencing the help-seeking process need to be investigated. The present article aims to extend and refine previous findings by reviewing 47 recent empirical studies on parental and adolescent problem recognition and help seeking, and problem recognition by the general practitioner (GP). Several variables (child age, the presence of medical and school-related problems, informal help seeking, past treatment of parents or relatives, family size, and type of maltreatment) were discovered to influence parental/adolescent problem recognition and/or help seeking,while refinements were found for the effects of type of psychopathology, child gender, adolescent attitudes and personality, parental psychopathology, social support, and sociodemographic variables. Although recent studies uncovered several determinants of problem recognition by the GP (child gender, age, past treatment, academic problems, family composition, life events, type of visit, and acquaintance with child), this aspect of the help-seeking pathway remains relatively uncharted and, therefore, needs to be the focus of future research.     

Associated factors of rehospitalization among schizophrenic patients

The purpose of the present study was to identify the associated factors of rehospitalization in schizophrenic patients. A case-control study was conducted. The cases consisted of rehospitalized patients (n = 67) and controls selected from the outpatients who were matched by age, gender, and the period after the last discharge (n = 62). In the multiple logistic regression analysis, no clinic visits in the second month prior to entry, the number of clinic visits in the previous month, and junior high school graduation as education level were significantly (P < 0.01) associated with rehospitalization after controlling their present function as assessed by the Global Assessment of Functioning. Close monitoring of clinic visits and outreach service appear to be important in preventing rehospitalization of schizophrenic patients. These identified modifiable factors suggest further needs for development and implementation of integrated mental health services in the community.     

The identification of trends in the utilisation of mental health services by elderly: a Dutch case register study

OBJECTIVE: In view of the rapid ageing of the population any changes in the use of mental health services by the elderly became increasingly important for policy development. This study aimed at the supply of information about trends in the numbers of elderly clients, the services they used and the volume and pattern of service utilisation. METHODS: Details of elderly users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Developments in population size and age distribution in the register area were taken into account, as were the unit costs of mental health services. RESULTS: Large age specific changes were found that caused only the expenditures on the oldest elderly to increase due to a shift from outpatient clinics to prolonged psychogeriatric day treatment and inpatient care. Comparatively young elderly used fewer inpatient services and more community care. The number of new elderly clients declined progressively. In some age groups treated prevalence also decreased, but to a lesser extent, because of a prolonged use of mental health services. CONCLUSIONS: Study results seemed well in accordance with mental health policy as to deinstitutionalization and active ageing. Research on the effect of mental health care on life expectancy and the time lag between the intake of mental health providers and treated prevalence was proposed in order to improve the prediction of future service use by elderly.     

Service provision for elderly depressed persons and political and professional awareness for this subject: a comparison of six European countries

OBJECTIVE: Under-treatment of depression in late-life is a subject of rising public health concern throughout Europe. This study investigates and compares the availability of services for depressed elderly persons in Denmark, France, Germany, Sweden, Switzerland and the UK. Additionally, it explores factors that might contribute to an adequate services supply for depressed elderly people. METHOD: Review of the literature and guide supported expert interviews. Analysis of the practice of care provision for depressed elderly persons and of indicators for political and professional awareness, such as university chairs, certification processes and political programmes in gerontopsychiatry. RESULTS: Only Switzerland and the UK offer countrywide community-oriented services for depressed elderly persons. Clinical experience in treating depression in late-life is not regularly acquired in the vocational training of the concerned professionals. Indicators suggest that the 'medical society' and health politics in Switzerland and the UK regard psychiatric disease in the elderly more importantly than it is the case in the other investigated countries. CONCLUSIONS: Service provision for depressed elderly persons seems to be more elaborated and better available in countries where gerontopsychiatry is institutionalised to a greater extend in the 'medical society' and health politics.     

Adverse events in acute care: an integrative literature review

An integrative literature review was conducted to investigate studies on adverse events reported in medical, health services, and nursing literature. The review was guided by the method proposed by Jackson ( 1980 ) and Ganong (1987). Three questions shaped the review: (a) What terms are used to denote adverse events? (b) What purposes drive adverse events research? and (c) What data sources are used to study adverse events? Adverse events was the dominant term, the study of adverse events as an outcome variable was the prevailing research purpose, and monitoring or screening the patient clinical record and self‐reported incidents by health care professionals were the main data sources. Future research is recommended to conceptualize and study adverse events. © 2003 Wiley Periodicals, Inc. Res Nurs Health 26:398–408, 2003     

Information Technology in Emergency Medicine Residency–Affiliated Emergency Departments

OBJECTIVES: To describe acquisition and implementation of information technology (IT) in U.S. emergency medicine (EM) residency-affiliated emergency departments (EDs), including automatic medication error checking. METHODS: This was a survey of all U.S. EM residencies active in September 2000. Respondents specified whether specific IT tools had been "acquired" and "implemented fully." EDs were categorized according to primary versus affiliated training site, trauma level, and census. Numbers of "yes" responses were compared according to ED type (Kruskal-Wallis test, p < or = 0.05 significant). RESULTS: Of 121 residency programs, data were obtained from 93 (77%) for a total of 149 EDs. The percentages of EDs that reported full implementation for each technology are as follows: medication error checking, 7%; medication order entry, 18%; nonmedication orders, 7%; clinical documentation, 21%; old electrocardiograms, 62%; laboratory results, 84%; radiography order entry, 62%; image retrieval, 29%; radiologists' interpretations, 67%; cardiology reports, 62%; pathology reports, 70%; surgical reports/dictations, 60%; triage, 34%; tracking, 46%; electronic reference materials, 56%; registration, 84%; accounts, 72%; patient management software package, 20%; voice recognition, 7%. Trauma centers reported more IT tools than nontrauma centers (p = 0.01), and primary training sites reported fewer IT tools than affiliated EDs (p = 0.027). CONCLUSIONS: Incorporation of IT is not uniform in EDs where EM residents train. Acquisition of effective IT tools varies, and implementation lags behind acquisition. Fully implemented IT for medication error checking was reported in 7% of EDs; an additional 12% had acquired IT without implementing it fully.