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ABSTRACT: To develop and validate the Geriatric CompleXity of Care Index (GXI), a comorbidity index of medical, geriatric, and psychosocial conditions that addresses disease severity and intensity of ambulatory care for older adults with chronic conditions.
Development phase: variable selection and rating by clinician panel. Validation phase: medical record review and secondary data analysis.
Assessing the Care of Vulnerable Elders-2 study.
Six hundred forty-four older (≥75) individuals receiving ambulatory care.
Development: 32 conditions categorized according to severity, resulting in 117 GXI variables. A panel of clinicians rated each GXI variable with respect to the added difficulty of providing primary care for an individual with that condition. Validation: Modified versions of previously validated comorbidity measures (simple count, Charlson, Medicare Hierarchical Condition Category), longitudinal clinical outcomes (functional decline, survival), intensity of ambulatory care (primary, specialty care visits, polypharmacy, number of eligible quality indicators (NQI)) over 1 year of care.
The most-morbid individuals (according to quintiles of GXI) had more visits (7.0 vs 3.7 primary care, 6.2 vs 2.4 specialist), polypharmacy (14.3% vs 0% had ≥14 medications), and greater NQI (33 vs 25) than the least-morbid individuals. Of the four comorbidity measures, the GXI was the strongest predictor of primary care visits, polypharmacy, and NQI (P < .001, controlling for age, sex, function-based vulnerability).
Older adults with complex care needs, as measured by the GXI, have healthcare needs above what previously employed comorbidity measures captured. Healthcare systems could use the GXI to identify the most complex elderly adults and appropriately reimburse primary providers caring for older adults with the most complex care needs for providing additional visits and coordination of care.
Journal of the American Geriatrics Society 04/2013; 61(4):542-50. · 3.74 Impact Factor
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ABSTRACT: The quality of care provided by primary-care physicians for patients with dementia remains poor, in part because physicians do not provide counseling and education. Local Alzheimer's Association chapters have the potential to improve the quality of care provided for dementia, but are hampered by a lack of referrals from primary-care physicians. Many physicians remain unaware of the services available through Alzheimer's Association chapters, but recognize the need to provide support to families, ensure patient safety, and manage behavioral problems. At present, systems to promote referrals and communication with local chapters are lacking. Practice redesign may facilitate linkages between practices and Alzheimer's Association chapters. However, if these linkages are to be adopted and sustained, they must demonstrate a relative advantage to physicians beyond the care they currently provide, and must be compatible with how care is currently delivered in their practices.
Alzheimer's & dementia: the journal of the Alzheimer's Association 11/2009; 5(6):498-502. · 5.90 Impact Factor
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ABSTRACT: Medication reviews are recommended annually for older patients. A medication review is a discussion of a patient's complete set of medications, but the actual content of a review is not well specified. The medical literature suggests that it is an exhaustive evaluation, but what physicians actually ask about their patients' medication regimens has been little studied.
To describe what physicians do when they review medications in the office setting.
Qualitative content analysis of audio-taped encounters between 100 patients aged 65 and older and 28 primary care physicians in two health care systems in Sacramento, California.
Physicians use a combination of non-mutually exclusive strategies when reviewing chronic medications that include: (1) efforts to obtain a complete list of patient medications (36% of visits), (2) discussion of a topic related to the management of each of a patient's chronic medications (47% of visits), and (3) sequential discussion of the majority of a patient's medications without intervening discussion (45% of visits). Of 10 medication management topics that were discussed in medication reviews, a mean of 1.5 topics (SD = 1.7, range 0-7) were mentioned for each medication, with efficacy and directions being most common. Physicians conducted a sequential discussion that included discussion of each of a patient's medications in only 32% of visits.
Comprehensive discussions about chronic medications are uncommon in routine practice. Practical conceptualization of what constitutes a physician-conducted medication review is needed.
Journal of General Internal Medicine 10/2009; 24(12):1296-302. · 2.83 Impact Factor
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ABSTRACT: To adapt the Assessing Care of Vulnerable Elders project nursing home (NH) specific quality indicators (QIs), for use with routinely collected data, and to evaluate which clinical conditions and types of care were inadequately measured using these data sources.
Retrospective cohort study.
Nursing homes.
NH residents 66 years of age and older dually enrolled in Medicare and Medicaid in 19 California counties between 1999 and 2000.
Identification of care inaccessible to measurement by Medicare and Medicaid claims linked to the Minimum Data Set (MDS). Assessment of care provided for measurable QIs by condition (eg, heart failure) and by intervention type (eg, medication use).
Only 50 of 283 QIs were captured using linked claims data. The 21,657 patients triggered 152,376 QIs (7.0 QIs/person). The overall QI pass rate (receipt of recommended care) for eligible participants was 76%. In this sample, QIs with the highest pass rates measured avoidance of adverse medications and appropriate medication use. Fewer than half of the QIs were passed for ischemic heart disease, stroke, and osteoporosis. The MDS permitted assessment of 8 QIs that focus on geriatric care. No measured QIs assessed history taking or nursing care.
The use of claims data linked to MDS to measure the quality of care process measures is feasible for NH populations, but would be more valuable if additional data elements focused on geriatric and residential care. QIs that could be applied to patients in this study suggested areas of care needing improvement.
Medical care 05/2009; 47(5):536-44. · 3.24 Impact Factor
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Journal of the American Geriatrics Society 11/2007; 55 Suppl 2:S318-26. · 3.74 Impact Factor
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ABSTRACT: The treatment of patients with musculoskeletal disease will be revolutionized during the next two decades by advances in technology. Orthopaedic surgeons are eager to incorporate new technology into their practices to improve patient outcomes and practice efficiency. However, as the orthopaedic community embraces new technology and innovative surgical procedures, there is an increased need to consider issues of patient safety and to determine the best way to incorporate technology into our practices.
Clinical Orthopaedics and Related Research 01/2005; · 2.53 Impact Factor
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ABSTRACT: Objective: Patient safety is fundamental to high-quality patient care. Critical steps toward improving the safety of the health care system include ensuring that the system is aware of its errors so that effective remedies can be applied, and enhancing the trustworthiness of the health care system for patients by disclosing errors that are meaningful to them. This study aimed to construct a conceptual model of the factors that facilitate or hinder disclosure of medical errors. Methods: We conducted 25 separate focus groups with attending physicians, nurses, residents, patients, and hospital administrators at 5 academic medical centers in a university health care system. The protocol probed the ethical perceptions of participants and the details of disclosure expectations. Audiotapes of the focus groups were transcribed and analyzed using Atlas.ti software. Codes were assigned to the text in an iterative fashion. Themes were identified and assembled into a model of disclosure. Results: All groups believed that errors should be disclosed. Important influences on whether disclosure would occur fell into four categories: provider factors, patient factors, error factors, and institutional culture. Provider issues included perceived professional responsibility, fears, and training. Patient factors included their desire for information, level of health care sophistication, and rapport with their provider. Error factors included level of harm and whether patients and others were aware of the error and the harm. Perceived tolerance for error and a supportive infrastructure were institutional factors that influenced disclosure. Conclusion: This grounded model of error disclosure delineates areas for interventions to increase disclosure as a step toward improving patient safety.
01/2005;
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Takahiro Higashi,
Ron Hays,
Julie Brown,
Caren Kamberg,
Chau Pham,
David Reuben,
Paul Shekelle,
David Solomon,
Roy Young,
Carol Roth,
John Chang,
Catherine MacLean, Neil Wenger
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ABSTRACT: Abstract
Background
While falls and urinary incontinence are prevalent among older patients, who sometimes rely on proxies to provide their health information, the validity of proxy reports of concern about falls and urinary incontinence remains unknown.
Methods
Telephone interviews with 43 consecutive patients with falls or fear of falling and/or bothersome urinary incontinence and their proxies chosen by patients as most knowledgeable about their health. The questionnaire included items derived from the Medical Outcomes Study Short Form 12 (SF-12), a scale assessing concerns about urinary incontinence (UI), and a measure of fear of falling, the Falls Efficacy Scale (FES). Scores were estimated using items asking the proxy perspective (6 items from the SF-12, 10 items from a UI scale, and all 10 FES items). Proxy and patient scores were compared using intraclass correlation coefficients (ICC, one-way model). Variables associated with absolute agreement between patients and proxies were explored.
Results
Patients had a mean age of 81 years (range 75–93) and 67% were female while proxies had a mean age of 70 (range 42–87) and 49% were female. ICCs were 0.63 for the SF-12, 0.52 for the UI scale, and 0.29 for the FES. Proxies tended to understate patients' general health and incontinence concern, but overstate patients' concern about falling. Proxies who lived with patients and those who more often see patients more closely reflected patient FES scores compared to those who lived apart or those who saw patients less often. Internal consistency reliability of proxy responses was 0.62 for the SF-12, 0.86 for the I-QOL, and 0.93 for the FES. In addition, construct validity of the proxy FES scale was supported by greater proxy-perceived fear of falling for patients who received medical care after a fall during the past 12 months (p < .05).
Conclusion
Caution should be exercised when using proxies as a source of information about older patients' health perceptions. Questions asking about proxies' views yield suboptimal agreement with patient responses. However, proxy scales of UI and fall concern are internally consistent and may provide valid independent information.
Health and Quality of Life Outcomes. 01/2005;
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ABSTRACT: To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition.
Survey of physicians and review of medical records.
Health maintenance organization in southern California.
Seven hundred twenty-nine physicians who provided care for women participating in a cohort study of memory (Women's Memory Study).
Percentage of patients with dementia or cognitive impairment (using the Telephone Interview of Cognitive Status supplemented by the Telephone Dementia Questionnaire) recognized by physicians. Relationship between physician recognition and patient characteristics and physician demographics, practice characteristics, training, knowledge, and attitudes about dementia.
Physicians (n=365) correctly identified 81% of patients with dementia and 44% of patients with cognitive impairment without definite dementia. Medical records documented cognitive impairment in 83% of patients with dementia and 26% of patients with cognitive impairment without definite dementia. In a multivariable model, physicians with geriatric credentials (defined as geriatric fellowship experience and/or the certificate of added qualifications) recognized cognitive impairment more often than did those without (risk ratio (RR)=1.56, 95% confidence interval (CI)=1.04-1.66). Physicians were more likely to recognize cognitive impairment in patients with a history of depression treatment (RR=1.3, 95% CI=1.03-1.45) or stroke (RR=1.37, 95% CI=1.04-1.45) and less likely to recognize impairment in patients with cognitive impairment without definite dementia than in those with dementia (RR=0.46, 95% CI=0.23-0.72) and in patients with a prior hospitalization for myocardial infarction (RR=0.37, 95% CI=0.09-0.88) or cancer (RR=0.49, 95% CI=0.18-0.90).
Medical record documentation reflects physician recognition of dementia, yet physicians are aware of, but have not documented, many patients with milder cognitive impairment. Physicians are unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Additional geriatrics training may promote recognition, but systems solutions are needed to improve recognition critical to provision of emerging therapies for early dementia.
Journal of the American Geriatrics Society 08/2004; 52(7):1051-9. · 3.74 Impact Factor
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ABSTRACT: The influence of payment mechanisms on physician decisions is not well understood.
The objective of this study was to test 2 null hypotheses: 1) physicians' clinical decisions would not be influenced by payment incentives; and 2) physicians would have equal concern about medical decisions made under capitation or fee-for-service (FFS) arrangements.
We conducted a physician survey in which patient insurance status (capitated or FFS) was randomly incorporated into 4 clinical scenarios using a Latin square design.
We used a nationally representative random sample of family physicians in direct patient care.
We used treatment decisions and physician "bother" scores (a measure of discomfort about decisions) in response to the clinical scenarios and adjusted for physician gender, age, board certification, income, practice location, practice mix, practice setting, geographic region, local area managed care penetration, and capitation or risk pool contracts in practice.
Seventy-two percent of sampled physicians responded. Comparing decisions made under capitation to FFS, physicians were less likely to indicate they would perform discretionary care (relative risks [RR] range, .64-.82; P<0.001), but payment had no effect on selection of life-saving care (RR, 1.02, not significant). Physicians felt significantly more "bothered" when they made clinical decisions under capitated payment (P<0.001 in all scenarios), regardless of whether a treatment was discretionary or life-saving, and whether the decision was made for or against the treatment (P<0.001).
Payment mechanism has significant effects on clinical decision-making. Reduction of resources spent for discretionary care might be achieved under capitated arrangements; however, physicians respond with greater levels of discomfort under capitation than FFS.
Medical Care 03/2004; 42(3):297-302. · 3.41 Impact Factor
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ABSTRACT: This study sought to describe the pattern of complementary/alternative medicine (CAM) use among a group of patients with advanced breast cancer, to examine the main reasons for their CAM use, to identify patient's information sources and their communication pattern with their physicians.
Face-to-face structured interviews of patients with advanced-stage breast cancer at a comprehensive oncology center.
Seventy three percent of patients used CAM; relaxation/meditative techniques and herbal medicine were the most common. The most commonly cited primary reason for CAM use was to boost the immune system, the second, to treat cancer; however these reasons varied depending on specific CAM therapy. Friends or family members and mass media were common primary information source's about CAM.
A high proportion of advanced-stage breast cancer patients used CAM. Discussion with doctors was high for ingested products. Mass media was a prominent source of patient information. Credible sources of CAM information for patients and physicians are needed.
BMC Complementary and Alternative Medicine 09/2002; 2:8. · 2.24 Impact Factor
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ABSTRACT: Cross-cultural ethical conflicts are common. However, little is known about how and to what extent acculturation changes attitudes toward end-of-life care and advance care planning. We compared attitudes toward end-of-life care among Japanese Americans and Japanese in Japan.
Self-administered questionnaire in English and Japanese.
Community-based samples of Japanese Americans in Los Angeles and Japanese in Nagoya, Japan: 539 English-speaking Japanese Americans (EJA), 340 Japanese-speaking Japanese Americans (JJA), and 304 Japanese living in Japan (JJ).
Few subjects (6% to 11%) had discussed end-of-life issues with physicians, while many (EJA, 40%; JJA, 55%; JJ, 54%) desired to do so. Most preferred group surrogate decision making (EJA, 75%; JJA, 57%; JJ, 69%). After adjustment for demographics and health status, desire for informing the patient of a terminal prognosis using words increased significantly with acculturation (EJA, odds ratio [OR] 8.85; 95% confidence interval, [95% CI] 5.4 to 14.3; JJA, OR 2.8; 95% CI 1.8 to 4.4; JJ, OR 1.0). EJA had more-positive attitudes toward forgoing care, advance care planning, and autonomous decision making.
Preference for disclosure, willingness to forgo care, and views of advance care planning shift toward western values as Japanese Americans acculturate. However, the desire for group decision making is preserved. Recognition of the variability and acculturation gradient of end-of-life attitudes among Japanese Americans may facilitate decision making and minimize conflicts. Group decision making should be an option for Japanese Americans.
Journal of General Internal Medicine 08/2002; 17(7):531-9. · 2.83 Impact Factor
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ABSTRACT: OBJECTIVE: Cross-cultural ethical conflicts are common. However, little is known about how and to what extent acculturation changes attitudes toward end-of-life care and advance care planning. We compared attitudes toward end-of-life care among Japanese Americans and Japanese in Japan.DESIGN: Self-administered questionnaire in English and Japanese.SETTING AND PARTICIPANTS: Community-based samples of Japanese Americans in Los Angeles and Japanese in Nagoya, Japan: 539 English-speaking Japanese Americans (EJA), 340 Japanese-speaking Japanese Americans (JJA), and 304 Japanese living in Japan (JJ).MEASUREMENTS AND MAIN RESULTS: Few subjects (6% to 11%) had discussed end-of-life issues with physicians, while many (EJA, 40%; JJA, 55%; JJ, 54%) desired to do so. Most preferred group surrogate decision making (EJA, 75%; JJA, 57%; JJ, 69%). After adjustment for demographics and health status, desire for informing the patient of a terminal prognosis using words increased significantly with acculturation (EJA, odds ratio [OR] 8.85; 95% confidence interval, [95% CI] 5.4 to 14.3; JJA, OR 2.8; 95% CI 1.8 to 4.4; JJ, OR 1.0). EJA had more-positive attitudes toward forgoing care, advance care planning, and autonomous decision making.CONCLUSION: Preference for disclosure, willingness to forgo care, and views of advance care planning shift toward western values as Japanese Americans acculturate. However, the desire for group decision making is preserved. Recognition of the variability and acculturation gradient of end-of-life attitudes among Japanese Americans may facilitate decision making and minimize conflicts. Group decision making should be an option for Japanese Americans.
Journal of General Internal Medicine 06/2002; 17(7):531 - 539. · 2.83 Impact Factor
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ABSTRACT: Abstract
Background
This study sought to describe the pattern of complementary/alternative medicine (CAM) use among a group of patients with advanced breast cancer, to examine the main reasons for their CAM use, to identify patient's information sources and their communication pattern with their physicians.
Methods
Face-to-face structured interviews of patients with advanced-stage breast cancer at a comprehensive oncology center.
Results
Seventy three percent of patients used CAM; relaxation/meditative techniques and herbal medicine were the most common. The most commonly cited primary reason for CAM use was to boost the immune system, the second, to treat cancer; however these reasons varied depending on specific CAM therapy. Friends or family members and mass media were common primary information source's about CAM.
Conclusions
A high proportion of advanced-stage breast cancer patients used CAM. Discussion with doctors was high for ingested products. Mass media was a prominent source of patient information. Credible sources of CAM information for patients and physicians are needed.
BMC Complementary and Alternative Medicine. 01/2002;
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JAMA The Journal of the American Medical Association 02/2001; 285(8):1015-1016. · 30.03 Impact Factor
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ABSTRACT: Objective: To introduce a brief scale for measuring the level of acculturation among Japanese Americans and to describe its development and utility. We also evaluate the relationship of demographic characteristics with acculturation in one sample of Japanese Americans.Participants and Data Collection Methods: Pilot survey of a convenience sample of 70 Japanese American adults and survey of a random sample of 1,097 members of Japanese American Community Centers in the greater Los Angeles area.Independent Variables: Demographics and Japanese generation.Dependent Variables: Brief measure of Japanese American Acculturation.Analysis Plan: T-tests and ANOVA for examining unadjusted group differences and multiple regression analysis for examining predictors of acculturation.Results: Our brief measure of acculturation had reproducible factor loadings and reliability (Cronbach's Alpha = .82} in two random samples of Japanese Americans and, in our pretest data, was highly correlated with a longer acculturation instrument commonly used (r = .71). After adjustment for demographics and recruitment site, we found that Japanese American adults under 45 years of age scored up to 9% higher on acculturation than older Japanese Americans and those with incomes above 550,000 per year scored 10% higher on acculturation then those with incomes under that amount.Conclusions: We developed and tested a brief scale for measuring acculturation among Japanese Americans. This scale demonstrates good reliability and validity in two different community samples and holds promise for explaining variation in this ethnic group including the evaluation of the impact of community programs. Such a measure may be especially suited to acculturation evaluation in long, complex survey instruments. © 2000 John Wiley & Sons, Inc.
Journal of Community Psychology 12/1999; 28(1):103 - 113. · 0.99 Impact Factor
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ABSTRACT: The assessment and management of dementia, falls and mobility disorders, malnutrition, end-of-life issues, pressure ulcers, and urinary incontinence have been identified as important quality improvement targets for vulnerable elders residing in nursing homes. This study aimed to identify valid and feasible measures of specific care processes associated with improved outcomes for these conditions.
Nine experts in nursing home (NH) care participated in a modified Delphi process to evaluate potential quality indicators (QIs) for care in NHs. Panelists met and discussed potential indicators before completing confidential ballots rating validity (process associated with improved outcomes), feasibility of measurement (with charts or interviews), feasibility of implementation (given staffing resources in average community NHs), and importance (expected benefit and prevalence in NHs). The NH panel's median votes were used to identify a final set of QIs that were subsequently reviewed by a clinical oversight committee.
Sixty-eight geriatric syndrome QIs were identified as valid and important in NH populations. Panelists assessed 12 (18%) of these QIs as having questionable feasibility to implement in average community nursing homes trying to provide quality care. Nine (13%) would not be included in systems assessing quality of care for persons with advanced dementia or poor prognosis.
Steps of care critical to the assessment and management of geriatric syndromes in NHs were identified. Feasibility is an important issue for a significant number of these, indicating that much remains to be done to design systems that efficiently and reliably implement these care processes.
Journal of the American Medical Directors Association 6(3 Suppl):S50-9. · 4.64 Impact Factor
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ABSTRACT: The purpose of this study was to develop a set of specific care processes associated with better outcomes for general medical conditions identified as quality improvement targets for institutionalized vulnerable elders.
A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures for depression, diabetes, hearing impairment, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment. Each quality indicator was written as an "if" statement, describing persons to whom the quality indicator applied followed by a "then" statement identifying the care process to be provided. A separate clinical committee reviewed the resulting set of indicators.
One hundred fourteen quality indicators were identified across the 11 medical conditions. The quality indicators capture a broad range of medical care addressing assessment, management, and follow up. Fifty-five indicators (48%) were identical to quality measures for community-dwelling vulnerable elders. A limited number were rated as questionably feasible to implement or measure (6 and 2, respectively). Thirty-eight (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis.
Explicit care processes linked to improved nursing home outcomes for general medical conditions can be identified. Most of these care processes can be measured by medical records or interview. Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia.
Journal of the American Medical Directors Association 6(3 Suppl):S36-48. · 4.64 Impact Factor
