Evelyn Hutt

VA Eastern Colorado Health Care System, Denver, Colorado, United States

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Publications (35)114.44 Total impact

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    ABSTRACT: Veterans hospitalized for hip fracture repair may be discharged to one of several rehabilitation settings, but it is not known what factors influence postsurgical discharge setting. The purpose of the study was to examine the patient, facility, and market factors that influence the choice of postsurgical discharge setting. Using a retrospective cohort design, we linked 11,083 veterans who had hip fracture surgeries in a Department of Veterans Affairs (VA) hospital from 1998 to 2005 as assessed by the VA National Surgical Quality Improvement Program dataset with administrative data. The factors associated with five postdischarge settings were analyzed using multinomial logistic regression. We found that few veterans (0.8%) hospitalized for hip fracture were discharged with home health. Higher proportions of veterans were discharged to a nursing home (15.4%), to outpatient rehabilitation (18.8%), to inpatient rehabilitation (16.9%), or to home (48.2%). Patients were more likely to be discharged to nonhome settings for VA-provided rehabilitation if they had total function dependence, had American Society of Anesthesiologists class 4 or 5, had surgical complications prior to discharge, or lived in counties with lower nursing home bed occupancy rates. Future research should compare postsurgical and longer-term morbidity, mortality, and healthcare utilization across these rehabilitation settings.
    The Journal of Rehabilitation Research and Development 01/2014; 50(9):1267-76. · 1.69 Impact Factor
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    ABSTRACT: Background:Understanding why some patients with terminal illness are reluctant to take sufficient medication to control pain is critical to effective pain management. As a first step toward exploring the pain medication-taking behavior of palliative care patients, this pilot study tested a survey regarding pain medication adherence, medication beliefs, and quality of life (QoL).Design:Convenience sample; survey.Setting/Subjects:Six patients receiving inpatient Palliative Care consultations at an academic medical center answered questions about their outpatient pain medication-taking behavior.Measurements:Medication Adherence Report Scale (MARS), Beliefs about Medications Questionnaire (BMQ), Brief Pain Inventory (BPI), closed-response items from a pain medication adherence study in terminally ill patients, the McGill Quality of Life Questionnaire (McGill), and demographic items. The battery of questionnaires took approximately 53 minutes; five of six participants were able to complete all items. Respondents reported moderate to severe pain (mean 4.3/10 for pain on average; 7/10 for worst pain in past 24 hours), and excellent medication adherence. When asked how much relief was provided by pain therapies, respondents reported a mean 73% (range 50-100%) relief. They expressed little concern about addiction, but more concern about medication-induced nausea and constipation. Overall QoL was good (mean 6.8/10, range 5-10, higher score better), with notably high scores in existential and support domains. Inpatients receiving palliative care consultation were able to complete interviewer-administered questionnaires regarding their pain perceptions, medications, and QoL. Further studies using these instruments are feasible and could inform shared decision making about pain management.
    The American journal of hospice & palliative care 09/2013;
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    ABSTRACT: Abstract Hip fractures in the elderly have high rates of mortality and perioperative complications. Both men and COPD patients have worse mortality and complications but this may be due to more co-morbid disease. We assessed mortality and complications in a large cohort (n = 12,646) of men undergoing hip fracture surgery within the Veteran's Health Affairs (VHA) to define the association of COPD to these outcomes after adjusting for other key factors. We looked for opportunities to improve outcomes for COPD patients. Methods: Using the VA Surgical Quality Improvement Program (VASQIP), and administrative databases, we determined COPD status, types of co-morbid conditions and surgical factors, and compared these to outcomes of surgical complications, 30-day and one-year mortality for patients who underwent hip fracture repair during 1998 to 2005. Results: COPD was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the COPD was "severe: (indicated by functional disability, previous hospitalization for exacerbation, chronic drug treatment or record of FEV(1) <75% predicted), and in 2,736 (21%) cases it was considered "mild" (any previous outpatient visit or hospitalization with a coded diagnosis of COPD). Severe COPD patients had one year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD subjects. Current smoking, use of general anesthesia and delays to surgery were significant modifiable risk factors identified in adjusted models. Osteoporosis was known pre-fracture in only 3% of subjects. Conclusions: COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications. Increased use of regional anesthesia and urgent scheduling of hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.
    COPD Journal of Chronic Obstructive Pulmonary Disease 12/2012; · 2.73 Impact Factor
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    ABSTRACT: Intramedullary nails for stabilizing intertrochanteric proximal femoral fractures have been available since the early 1990s. The nails are inserted percutaneously and have theoretical mechanical advantages over plates and screws, but they have not been demonstrated to improve patient outcomes. Still, use of intramedullary nails is becoming more common. The goal of this study was to examine trends in the use and associated outcomes of intramedullary nailing compared with sliding hip screws in Veterans Affairs (VA) hospitals. Review of the VA Surgical Quality Improvement Program (VASQIP) data identified 5244 male patients in whom an intertrochanteric proximal femoral fracture had been treated in a VA hospital between 1998 and 2005. The overall sample was used to assess trends in device use, thirty-day mortality, thirty-day surgical complications, and one-year mortality. Next, propensity score matching methods were used to compare 1013 patients identified as having been treated with an intramedullary nail with 1013 patients who had a sliding-screw procedure. Multiple logistic regression models for the matched sample were used to calculate odds ratios for mortality and complications according to the choice of internal fracture fixation. Use of intramedullary nails in VA facilities increased from 1998 through 2005 and varied by geographic region. Unadjusted mortality and complication percentages were similar for the two procedures, with approximately 8% of patients dying within thirty days after surgery, 28% dying within one year, and 19% having at least one perioperative complication. While the choice of an intramedullary nail or sliding-screw procedure was related to the geographic region, year of surgery, surgeon characteristics, and several patient characteristics, it was not associated with thirty-day outcomes in either the descriptive or the multiple regression analysis. Intramedullary nail use increased from 1998 through 2005 but did not decrease perioperative mortality or comorbidity compared with standard plate-and-screw devices for patients treated for intertrochanteric proximal femoral fractures in VA facilities.
    The Journal of Bone and Joint Surgery 05/2012; 94(9):833-40. · 3.23 Impact Factor
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    ABSTRACT: The American College of Cardiology Foundation/American Heart Association (ACC/AHA) Guidelines for the Management of Heart Failure recommend palliative care in the context of Stage D HF or at the end of life. Previous studies related to heart failure (HF) palliative care provide useful information about patients' experiences, but they do not provide concrete guidance for what palliative care needs are most important and how a palliative care program should be structured. Describe HF patients' and their family caregivers' major concerns and needs. Explore whether, how, and when palliative care would be useful to them. Qualitative study using in-depth interviews of 33 adult outpatients with symptomatic HF identified using purposive sampling and 20 of their family caregivers. Approach: Interviews were transcribed verbatim and analyzed using the constant comparative method. Overall, patients and caregivers desired early support adjusting to the limitations and future course of illness, relief of a number of diverse symptoms, and the involvement of family caregivers using a team approach. A diverse group of participants desired these elements of palliative care early in illness, concurrent with their disease-specific care, coordinated by a provider who understood their heart condition and knew them well. Some diverging needs and preferences were found based on health status and age. HF patients and their family caregivers supported early integration of palliative care services, particularly psychosocial support and symptom control, using a collaborative team approach. Future research should test the feasibility and effectiveness of integrating such a program into routine HF care.
    Journal of palliative medicine 11/2011; 14(12):1317-24. · 1.84 Impact Factor
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    ABSTRACT: Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines. The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home-acquired pneumonia (NHAP) guidelines related to use of antibiotics. This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline. A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use. The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.
    The American journal of geriatric pharmacotherapy. 11/2011; 9(6):442-450.e1.
  • Cari Levy, Evelyn Hutt, Lauren Pointer
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    ABSTRACT: To determine predictors of dying in VA nursing homes, community living centers (CLCs), compared with dying in a hospital. Retrospective cohort study. VA CLCs. Included were 7408 CLC decedents from FY2005 to FY2007. Outcome: Site of death obtained from VA Vital Statistics files. Predictors of Death Site: VA-MDS variables defining patient demographics, functional status, cognitive status, major diagnostic categories, and care planning documentation. Logistic regression was used to estimate the odds ratio of death in the CLC relative to the hospital for patient and facility characteristics. Among decedents, 87% died in the CLC and 13% in a hospital. More than half of all decedents were neither enrolled in hospice nor designated as having end-stage disease. The strongest predictor of site of death in a CLC relative to a hospital was being enrolled in hospice (OR = 20.94; 95% CI: 12.38, 35.44). A designation of end-stage disease increased the odds of death in a CLC by 3.9 times (95% CI: 2.78, 5.47) compared with death in a hospital. Advance directive rates in CLCs were high (73.4%); having any advance directive increased the odds of death in a CLC by 1.57 times (95% CI: 1.35, 1.82). Recognition of end-stage disease and documentation of advance directives are powerful determinants of site of death for CLC residents. Receipt of hospice care in a CLC is a strong predictor of site of death in a CLC even in the absence of collaboration with community-based hospice and financial incentives to avoid hospitalization.
    Journal of the American Medical Directors Association 09/2011; 13(3):199-201. · 5.30 Impact Factor
  • Lauren Pointer, Evelyn Hutt
    Journal of the American Medical Directors Association 03/2011; 12(3). · 4.78 Impact Factor
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    ABSTRACT: Do demographics, clinical characteristics, care structures, mortality, and rehospitalization differ by region among a national sample of nursing home (NH) residents with heart failure (HF)? Retrospective observational study of NH residents with HF by ICD-9 CM codes or Minimum Data Set (MDS) diagnosis, using the Linked Nursing Home/Skilled Nursing Facility Stay File, containing MDS, hospitalization, and mortality data for all residents in a 10% random sample of NHs (n = 1840) during 2003-2004. Facility characteristics, demographics, functional characteristics, comorbidity, and outcomes were described by geographic region. Baseline characteristics and care structures for subjects who experienced a subsequent HF hospitalization or death were compared with those who did not, using unadjusted odds ratios and chi-square tests or Fisher's exact tests for categorical, and t tests or Wilcoxon Rank Sum tests for continuous variables. Predictive logistic regression models for mortality in all subjects and HF hospitalization in subjects with a single NH stay of fewer than 90 days were developed. Time to first HF hospitalization in longer-stay subjects was analyzed using Cox models. Mortality of NH residents with HF exceeds 45%; HF hospitalization exceeds 50% annually. Residing in a facility with 50 or fewer beds or in the rural South were both associated with lower risk of death. Older age and residing in the Midwest were associated with higher risk of HF hospitalization. Age, comorbidity, and functional impairment were not clinically different among regions of the country, but both mortality and HF hospitalization rates differed significantly by region.
    Journal of the American Medical Directors Association 10/2010; 12(8):595-601. · 5.30 Impact Factor
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    ABSTRACT: Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates. Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial. Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible. Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education. Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding. Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections. Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.
    Journal of the American Medical Directors Association 09/2010; 12(7):499-507. · 5.30 Impact Factor
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    ABSTRACT: Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home acquired pneumonia (NHAP), including influenza and pneumococcal vaccination, improves resident subject and staff vaccination rates. Quasi-experimental, mixed-methods multifaceted intervention trial conducted at 16 nursing homes (NHs) from 1 corporation (8 in metropolitan Denver, Colorado; 8 in Kansas and Missouri) during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI) and NH staff and physicians were eligible. Subjects' NH records were reviewed for vaccination. Each director of nursing (DON) completed a questionnaire assessing staffing and the number of direct care staff vaccinated against influenza. DONs and study liaison nurses were interviewed after the intervention. Bivariate analysis compared vaccination outcomes and covariates between intervention and control homes, and risk-adjusted models were fit. Qualitative interview transcripts were analyzed using content coding. No statistically significant relationship between the intervention and improved resident vaccination rates was found, so other factors associated with improved rates were explored. Estimated direct patient care staff vaccination rates were better during the baseline and improved more in the intervention NHs. Qualitative results suggested that facility-specific factors and national policy changes impacted vaccination rates. External factors influence staff and resident vaccination rates, diluting the potential impact of a comprehensive program to improve care for NHAP on vaccination.
    Journal of the American Medical Directors Association 06/2010; 11(5):365-70. · 5.30 Impact Factor
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    ABSTRACT: A lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer. We examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients. This was a cross-sectional study. Sixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer. Symptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale). Overall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction < or =30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer. Patients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.
    Journal of General Internal Medicine 04/2009; 24(5):592-8. · 3.42 Impact Factor
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    ABSTRACT: To investigate the applicability of clinical practice guidelines (CPGs) to the care of nursing home (NH) residents who experience acute myocardial infarction (AMI). Secondary examination of data from the national Cooperative Cardiovascular Project. 6684 US hospitals. A NH-dwelling (N = 8151) cohort and a community-dwelling cohort (N = 119,012). Adherence to AMI guidelines and associated mortality rates. Mortality at 30 days and 1 year respectively was 39.5% and 65.4% in the NH cohort versus 17.5% and 31.1% in the community-dwelling cohort (P < .001). Among patients who were ideally eligible to receive aspirin, 58.8% of the NH cohort and 78.9% of the community-dwelling cohort actually received aspirin (P < .001). Among patients who were ideally eligible for beta-blockers, 43.8% of the NH cohort and 61.4% of the community-dwelling cohort received beta-blockers (P < .001). The 30-day mortality for NH patients who were ideally eligible for aspirin but did not receive aspirin was significantly higher compared with NH patients who were ideally eligible but did receive aspirin (49.2% versus 26.0%, P < .001). Similarly, mortality was significantly higher for NH patients who were ideally eligible for beta-blockers but did not receive a beta-blocker (35.3% versus 18.6%, P < .001). Only half of NH patients who are ideally eligible for aspirin and beta-blockers received these medications, yet mortality was significantly lower in patients who were treated with these medications. These results demonstrate the effect of applying AMI guidelines to NH patients while also raising the question of what factors guided decisions not to provide these medications.
    Journal of the American Medical Directors Association 01/2009; 10(1):56-61. · 5.30 Impact Factor
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    ABSTRACT: Nursing home (NH)-acquired pneumonia (NHAP) causes excessive mortality, hospitalization, and functional decline, partly because many NH residents do not receive appropriate care. Care structures like nurse/resident staffing ratios can impede or abet quality care. This study examines the relationship between nurse/resident staffing ratios, turnover, and adherence to evidence-based guidelines for treating NHAP. A prospective, chart-review study was conducted among residents of 16 NHs in three states with > or = 2 signs and symptoms of NHAP during the 2004--2005 influenza season. NH medical records were reviewed concurrently for functional status, comorbidity, NHAP severity, and guideline adherence. Ratio of licensed nurse and Certified Nursing Assistant (CNA) hours per resident per day (hrpd) and ratio of newly hired nursing staff/year to current nursing staff were provided by Directors of Nursing. Associations among guideline adherence, nurse and CNA hrpd, and turnover were assessed using multiple regression to adjust for case mix, facility characteristics, and clustering of residents in facilities. Mid (1.7-2.0) and high (> 2.0) CNA hrpd were significantly associated with better pneumococcal and influenza vaccination rates. More than 1.2 licensed nurse hrpd was significantly associated with appropriate hospitalization (odds ratio [OR] 12.4; 95% confidence interval [CI], 3.5-43.8) and guideline-recommended antibiotics (OR 3.8; 95% CI, 1.7-8.7). A > 70% turnover was inversely related to timely physician notification (OR 0.4; 95% CI, 0.2-0.7) and appropriate hospitalization (OR 0.09; 95% CI, 0.05-0.26). NHAP treatment guideline adherence is associated with nurse and CNA hrpd and stability. An NH's ability to implement evidence-based care may depend on adequate staffing ratios and stability.
    The Journals of Gerontology Series A Biological Sciences and Medical Sciences 10/2008; 63(10):1105-11. · 4.98 Impact Factor
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    ABSTRACT: While palliative care is often thought of as only being applicable to dying patients, its focus on symptom alleviation, patient function, and quality of life has much to offer older adults with chronic heart failure. Heart failure worsens patients' health status through patients' symptom burden, functional limitations, and reduced health-related quality of life. Moreover, older adults with heart failure have multiple other comorbidities and polypharmacy that further contribute to poor health status. Comorbid depression is a particularly important issue. In this patient population, prognosis is limited and often uncertain. Spouses and caregivers of patients report significant distress and depression. Through symptom management, depression and psychosocial care, assistance with defining goals of care and planning for the future, and caregiver support, palliative care has the potential to improve patient health status and reduce costs and hospitalizations. This care is complementary to contemporary heart failure care and can be provided concurrently at any point during the illness based on patient and caregiver needs.
    International journal of cardiology 05/2008; 125(2):183-90. · 6.18 Impact Factor
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    ABSTRACT: Although more than 1200 hip fracture repairs are performed in United States Department of Veterans Affairs hospitals annually, little is known about the relationship between perioperative care and short-term outcomes for veterans with hip fracture. The purpose of the present study was to test whether perioperative care impacts thirty-day outcomes, with patient characteristics being taken into account. A national sample of 5683 community-dwelling male veterans with an age of sixty-five years or older who had been hospitalized for the operative treatment of a hip fracture at one of 108 Veterans Administration hospitals between 1998 and 2003 was identified from the National Surgical Quality Improvement Program data set. Operative care characteristics were assessed in relation to thirty-day outcomes (mortality, complications, and readmission to a Veterans Administration facility for inpatient care). A surgical delay of four days or more after admission was associated with a higher adjusted mortality risk (odds ratio, 1.29; 95% confidence interval, 1.02 to 1.61) but a reduced risk of readmission (odds ratio, 0.70; 95% confidence interval, 0.54 to 0.91). Compared with spinal or epidural anesthesia, general anesthesia was related to a significantly higher risk of both mortality (odds ratio, 1.27; 95% confidence interval, 1.01 to 1.55) and complications (odds ratio, 1.33; 95% confidence interval, 1.15 to 1.53). The type of procedure was not significantly associated with outcome after controlling for other variables in the model. However, a higher American Society of Anesthesiologists Physical Status Classification (ASA class) was associated with worse thirty-day outcomes. In addition to recognizing the importance of patient-related factors, we identified operative factors that were related to thirty-day surgical outcomes. It will be important to investigate whether modifying operative factors, such as reducing surgical delays to less than four days, can directly improve the outcomes of hip fracture repair.
    The Journal of Bone and Joint Surgery 02/2008; 90(1):34-42. · 3.23 Impact Factor
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    ABSTRACT: Older adults in nursing homes experience pain that is often underassessed and undertreated. Visual analog pain-intensity scales, recommended for widespread use in adults, do not work well in the older adult population. A variety of other tools are in use, including the Verbal Descriptor Scale, the Faces Pain Scale (FPS), and the Numeric Rating Scale. These tools are more acceptable to older adults, but no agreement exists about how to compare the resulting pain-intensity scores across residents. This study examined the equivalency of pain-intensity scores for 135 nursing home residents who reported their pain on the three different instruments. The results were validated with a second sample of 135 nursing home residents. The pain levels across the three tools were highly correlated, but residents were found to underrate higher pain intensity on the FPS. A modification of scoring for the FPS led to greater agreement across the three tools. The findings have implications for use of these tools for quality improvement and public reporting of pain.
    The Journal of Rehabilitation Research and Development 02/2007; 44(2):305-14. · 1.69 Impact Factor
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    ABSTRACT: Suboptimal medication use among nursing home (NH) residents is common. NH residents tend to be older, suffer from multiple conditions, and take numerous medications, increasing their risk of serious complications. This article examines pharmacotherapy in a rural, tribally owned NH. Medical records were reviewed and case studies were conducted by a team composed of a medical anthropologist, psychiatrist, and geriatrician. A rural, American Indian-owned NH in the US northern plains. 40 American Indian and 5 EuroAmerican NH residents. Minimum Data Set assessments, admission records, care plans, social histories, prescription lists, and behavioral consultation reports. Potential underuse affected almost 75% of residents; undertreatment of depressive and psychotic/agitated symptoms was especially common. Potential inappropriate use, especially of analgesics, psychotropics, and antihistamines, affected 30% of residents. A smaller, but still substantial, number of residents (21%) experienced potential overuse, much of which involved anticonvulsants, antibiotics, cardiovascular, and psychotropic agents. The prescription of 10 or more medications was significantly associated with potential drug interactions, as well as underuse, inappropriate medication use, and overuse. Psychotropic medications were the most potentially problematic medication category, and were strongly implicated in potential underuse, inappropriate use, and overuse. Fewer medications; the discontinuation of drugs known to be potentially problematic for NH residents; modification of psychotropic medication regimens; use of cognitive-enhancing medications where appropriate; implementation of an electronic medical record system; and greater use of nonpharmacological behavioral interventions may have substantially improved residents' treatment regimens.
    Journal of the American Medical Directors Association 02/2007; 8(1):1-7. · 4.78 Impact Factor
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    ABSTRACT: The assessment and treatment of pain in persons with cognitive impairments pose unique challenges. Disorders affecting cognition include neurodegenerative, vascular, toxic, anoxic, and infectious processes. Persons with memory, language, and speech deficits and consciousness alterations are often unable to communicate clearly about their pain and discomfort. Past research has documented that persons with cognitive impairments, particularly dementia, are less likely to ask for and receive analgesics. This article provides an overview of the assessment, treatment, and management of pain in adults with cognitive impairments. We review types of cognitive impairment; recent work specific to best practices for pain management in patients with dementia, including assessment-tool development and pharmacological treatment; challenges in patients with delirium and in medical intensive care and palliative care settings; and directions for future research.
    The Journal of Rehabilitation Research and Development 02/2007; 44(2):315-30. · 1.69 Impact Factor
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    ABSTRACT: To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home-acquired pneumonia (NHAP) into practice using a small intervention trial. Pre-posttest with untreated control group. Two Colorado State Veterans Homes (SVHs) during two influenza seasons. Eighty-six residents with two or more signs of lower respiratory tract infection. Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing. Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test. At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year. Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents.
    Journal of the American Geriatrics Society 12/2006; 54(11):1694-700. · 4.22 Impact Factor

Publication Stats

534 Citations
114.44 Total Impact Points


  • 2009–2013
    • VA Eastern Colorado Health Care System
      Denver, Colorado, United States
  • 2011
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States
  • 2002–2011
    • University of Colorado
      • Division of Health Care Policy and Research
      Denver, Colorado, United States
  • 2006
    • Simon Fraser University
      Burnaby, British Columbia, Canada
  • 2004–2006
    • Yale University
      • School of Nursing (YSN)
      New Haven, Connecticut, United States