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ABSTRACT: OBJECTIVE: We examined the (a) influence of nursing facility characteristics on resident quality of life and (b) the impact of cognitive impairment and residence on a dementia special care unit(SCU) on QOL after controlling for resident and facility characteristics. METHOD: Multilevel models (resident and facility) were estimated for residents with and without cognitive impairment on conventional units and dementia SCU. Data came from the 2007 Minnesota Nursing Home Resident Quality of Life and Consumer Satisfaction Survey (N = 13,983). RESULTS: Level of resident CI was negatively related to QOL, although residing on a dementia SCU was positively related to QOL. Certified Nursing Assistant and activity personnel hours per resident day had a positive relationship with resident QOL. DISCUSSION: Our results highlight the need to ensure adequate levels of paraprofessional direct care staff and the availability of dementia-focused (SCU)s despite current constraints on long-term care funding.
Journal of Aging and Health 03/2013; · 1.56 Impact Factor
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ABSTRACT: OBJECTIVES: Prevention and public reporting of falls have suffered due to inadequate attention given to the association of falls and cognitive impairment (CI) among nursing home (NH) residents. This study examines the relationship between CI, residence on dementia special care units (SCUs) and other resident characteristics and likelihood of residents experiencing new falls in NHs. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A total of 21,587 residents from 381 Minnesota NHs. MEASUREMENTS: The NH Minimum Data Set (MDS) for 21,587 residents from 381 Minnesota NHs in the first calendar quarter of 2008 were analyzed. New falls, (fall noted on a current MDS assessment but not on a prior assessment); cognitive status, (as defined by Cognitive Performance Scale); residence on an SCU, and health and functional status covariates were recorded. A random effects logistic regression model was used to examine relationships between new falls and the resident's cognitive status, type of unit, and covariates. RESULTS: The likelihood of a new fall had a nonlinear association with CI. Compared with residents with normal or mild CI, the likelihood of a new fall was significantly higher among residents with moderate CI (OR = 1.43). The risk decreased slightly (OR = 1.34) for residents with more advanced CI, whereas the presence of severe CI was not significantly associated with new falls. Overall the likelihood of new falls was significantly higher for residents on SCUs compared with those on conventional units (OR = 1.27). CONCLUSIONS: Severity of CI and residence on SCU impact fall incidence and should be accounted for in future fall- prevention interventions and quality-reporting indicators and measures.
Journal of the American Medical Directors Association 09/2012; · 4.64 Impact Factor
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ABSTRACT: We investigated the relationship between cognitive status and quality of life (QOL) of Minnesota nursing home (NH) residents and the relationship between conventional or Alzheimer's special care unit (SCU) placement and QOL. The study may inform development of dementia-specific quality measures.
Data for analyses came from face-to-face interviews with a representative sample of 13,130 Minnesota NH residents collected through the 2007 Minnesota NH Resident Quality of Life and Consumer Satisfaction survey. We examined 7 QOL domains: comfort, meaningful activities, privacy, environment, individuality, autonomy, relationships, and a positive mood scale. We applied multilevel models (resident and facility) to examine the relationship between the resident's score on each QOL domain and the resident's cognitive impairment (CI) level and SCU placement after controlling for covariates, such as activities of daily living dependency, pain, depression or psychiatric diagnosis, and length of stay.
Residents with more severe CI reported higher QOL in the domains of comfort and environment and lower QOL in activities, individuality, privacy and meaningful relationships, and the mood scale. Residents on SCU reported higher QOL in the meaningful activities, comfort, environment, and autonomy domains but had lower mood scores.
Our findings point to QOL domains that show significant variation by CI and thus may be of greatest interest to consumers, providers, advocacy groups, and other stakeholders committed to improving dementia care. Findings are particularly applicable to the development of NH quality indicators that more accurately represent the QOL of NH residents with CI.
The Gerontologist 01/2012; 52(5):632-40. · 2.48 Impact Factor
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ABSTRACT: To describe the association between anticholinergic medications and incident delirium in hospitalized older adults with cognitive impairment and to test the hypothesis that anticholinergic medications would increase the risk of incident delirium.
Observational cohort study.
Urban public hospital in Indianapolis, Indiana.
One hundred forty-seven participants aged 65 and older with cognitive impairment who screened negative for delirium at the time of admission to a general medical ward.
Cognitive function at the time of admission was assessed using the Short Portable Mental Status Questionnaire (SPMSQ). Anticholinergic medication orders between the time of admission and the final delirium assessment were evaluated. Anticholinergic medication orders were identified using the Anticholinergic Cognitive Burden Scale. Delirium was assessed using the Confusion Assessment Method.
Fifty-seven percent of the cohort received at least one order for possible anticholinergic medications, and 28% received at least one order for definite anticholinergic medications. The incident rate for delirium was 22% of the entire cohort. After adjusting for age, sex, race, baseline SPMSQ score, and Charlson Comorbidity Index, the odds ratio (OR) for developing delirium in those with orders for possible anticholinergic medications was 0.33 (95% confidence interval (CI) = 0.10-1.03). The OR for developing delirium among those with orders for definite anticholinergic medications was 0.43 (95% CI = 0.11-1.63).
The results did not support the hypothesis that prescription of anticholinergic medications increases the risk of incident delirium in hospitalized older adults with cognitive impairment. This relationship needs to be established using prospective study designs with medication dispensing data to improve the performance of predictive models of delirium.
Journal of the American Geriatrics Society 11/2011; 59 Suppl 2:S277-81. · 3.74 Impact Factor
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ABSTRACT: Community health centers have the potential to lessen obesity. We conducted a retrospective evaluation of a quality improvement program that included electronic body mass index (BMI) screening with provider referral to an in-clinic lifestyle behavior change counselor with weekly nutrition and exercise classes. There were 26,661 adult patients seen across five community health centers operating the weight management program. There were 23,593 (88%) adult patients screened, and 12,487 (53%) of these patients were overweight or obese (BMI >or=25). Forty percent received a provider referral, 15.6% had program contact, and 2.1% had more than 10 program contacts. A mean weight loss of seven pounds was observed among those patients with more than 10 program contacts. No significant weight change was observed in patients with less contact. Achieving public health impact from guideline recommended approaches to CHC-based weight management will require considerable improvement in patient and provider participation.
Journal of Health Care for the Poor and Underserved 01/2010; 21(2):617-28. · 1.10 Impact Factor
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ABSTRACT: Few healthcare economic evaluations, and none in cardiac rehabilitation, report results based on both community and patient preferences for health outcomes. We published the results of a randomized trial of cardiac rehabilitation after myocardial infarction in 1994 in which preferences were measured using both perspectives but only patient preferences were reported. This secondary analysis uses both types of preference measurements.
We collected community Quality of Well-Being (QWB) and patient Time Trade-off (TTO) preference scores from 188 patients (rehabilitation, n=93; usual care, n=95) on entry into the trial, at 2 months (end of the intervention) and again at 4, 8, and 12 months. Mean preference scores over the 12-month follow-up study period, estimates of quality-adjusted life years (QALYs) gained per patient, incremental cost-effectiveness ratios [costs inflated to 2006 US dollars] and probabilities of the cost-effectiveness of rehabilitation for costs per QALY up to USD100,000 are reported.
Mean QWB preference scores were lower (P<0.01) than the corresponding mean TTO preference scores at each assessment point. The 12-month changes in mean QWB and TTO preference scores were large and positive (P<0.001) with rehabilitation patients gaining a mean of 0.011 (95% confidence interval, -0.030 to +0.052) more QWB-derived QALYs, and 0.040 (-0.026, 0.107) more TTO-derived QALYs, per patient than usual care patients. The incremental cost-effectiveness ratio for QWB-derived QALYs was estimated at $60 270/QALY (about euro50 600/QALY) and at $16 580/QALY (about euro13 900/QALY) with TTO-derived QALYs. With a willingness to spend $100 000/QALY, the probability of rehabilitation being cost-effective is 0.58 for QWB-derived QALYs and 0.83 for TTO-derived QALYs.
This secondary analysis of data from a randomized trial indicates that cardiac rehabilitation is cost-effective from a community perspective and highly cost-effective from the perspective of patients.
European Journal of Cardiovascular Prevention and Rehabilitation 10/2008; 15(5):608-15. · 2.63 Impact Factor
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ABSTRACT: Caring for an individual with Alzheimer's dementia (AD) is stressful, and studies show that this stress has an impact on both the physical and mental health of the caregiver. However, many questions remain about the characteristics of AD patients and their caregivers that contribute to this stress and how it impacts caregivers' use of healthcare resources.
To study the impact of stress on the physical and mental health of the caregiver.
Patients underwent extensive testing to allow description of their degree of cognitive impairment, behavioral and psychological symptoms, medical comorbidities, and functional abilities. Caregivers were assessed for depressive symptoms and also for emergency department (ED) use and hospitalizations in the previous six months. Multivariate logistic regression was used to evaluate impact of patients' dementia symptoms on caregivers' acute care utilization.
One hundred and fifty-three AD patients and their caregivers attending two large, urban, university-affiliated primary care practices were enrolled in a cross-sectional study to examine the facets of dementia caregiving that impact caregiver acute health care utilization.
Twenty-four percent of the caregivers had at least one ED visit or hospitalization in the six months prior to enrollment. After adjusting for caregiver age, gender, and education, our logistic regression model found that the caregivers' acute care utilization was associated with their depression as measured by the PHQ-9 (OR 1.09, 95% CI 1.00-1.18), the patients' behavioral and psychological symptoms as measured by the NPI (OR 1.04, 95% CI 1.01-1.08), and the patients' functional status as measured by the ADCS-ADL (OR 1.05, 95% CI 1.01-1.09).
To improve the health of AD caregivers, a primary care system needs to reallocate resources to manage the functional, behavioral, and psychological symptoms related to the care-recipients suffering from AD.
Journal of General Internal Medicine 09/2008; 23(11):1736-40. · 2.83 Impact Factor
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ABSTRACT: There is a growing awareness among providers of the symptom burden experienced by cancer patients. Systematic symptom screening is difficult. Our plan was to evaluate a technology-based symptom screening process using touch-tone telephone and Internet in our rural outreach cancer program in Indiana. Would rural patients have adequate access to technologies for home-based symptom reporting?
1) To determine access to touch-tone telephone service and Internet for patients in urban and rural clinics; 2) to determine barriers to access; 3) to determine willingness to use technology for home-based symptom reporting.
Patients from representative clinics (seven rural and three urban) in our network were surveyed. Inclusion criteria were age greater than 18, able to read, and diagnosis of malignancy.
The response rate was 97%. Of 416 patients completing the survey (230 rural, 186 urban), 95% had access to touch-tone telephone service, while 46% had Internet access (56% of urban patients, 38% of rural patients). Higher rates of Internet access were related to younger patient age, current employment, and higher education and income. The primary barrier to Internet access was lack of interest. Use of the Internet for health related activities was less than 50%. The preferred means of symptom reporting in patients with internet access were the touch-tone telephone (70%), compared to reporting by the Internet (28%).
Access to communication technologies appears adequate for home-based symptom reporting. The use of touch-tone telephone and Internet reporting, based upon patient preference, has the potential of enhancing symptom detection among cancer patients that is not dependent solely upon clinic visits and clinician inquiry.
BMC Cancer 03/2005; 5:18. · 3.01 Impact Factor
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ABSTRACT: Clinicians, patients, and health policy-makers must judge whether healthcare interventions are worth the side effects, inconvenience, and costs. The number needed to treat (NNT) provides an estimate of the number of patients who need to be treated to attain an additional favorable outcome, or to prevent an additional adverse outcome, and is the reciprocal of the absolute risk reduction. The closer the NNT is to 1.0-meaning that every patient who is treated achieves a benefit-the more effective the treatment. Traditionally, mortality has been considered a primary outcome measure of the effectiveness of cardiac rehabilitation and, if the event rates in two groups (ie, rehabilitation and usual care) are known, the absolute risk reduction can be calculated and the NNT estimated. Mortality data were derived from three meta-analyses of cardiac rehabilitation trials: one published in 1988 (n = 3614), one in 1989 (n = 4247), and one in 2001 (n = 7683). The respective estimated NNT for mortality in the meta-analyses were 32, 46, and 72 (95% confidence intervals [95% CI] 19, 1403). Improved exercise tolerance and patient-perceived health-related quality of life (HRQL) are also considered important and attainable outcomes of cardiac rehabilitation but are continuous, not dichotomous, variables. If the minimal important difference for a continuous outcome is known, then the proportions of patients who improve, remain the same, or deteriorate can be determined and the NNT estimated. Exercise tolerance and HRQL data from two randomized controlled trials of 8 weeks of rehabilitation after myocardial infarction, the Cardiac Rehabilitation in Advanced Age trial (CR-AGE; n = 270) and the McMaster Early Rehabilitation Study (MERS; n = 201) were used to estimate the NNT. In CR-AGE, the improvement in exercise tolerance was significantly greater in the rehabilitation than usual care group and the estimated NNT was 5 (95% CI 3, 13). The generic global HRQL score increased significantly in CR-AGE with rehabilitation with an estimated NNT of 12 (95% CI 5, 26) but, as the subscale group differences were not significant, the NNT was not estimated. The NNT for exercise tolerance was not estimated in MERS, as the group difference was not significant. On the other hand, specific HRQL scores in MERS increased significantly with rehabilitation giving an estimated NNT for global HRQL of 6 (95% CI 3, 21) and 6 to 10 for the HRQL sub-scales. The data and the estimated NNT from the meta-analyses of cardiac rehabilitation in large numbers of patients suggest a limited mortality effect, probably reflecting current cardiology practice. The estimated NNT from the two trials with relatively small numbers of patients suggest inconsistent exercise tolerance effects and a relatively short duration for improved HRQL. Along with the classic reporting scales, information about clinical and laboratory variables, and patient preferences, the NNT is a useful additional measure of effectiveness that provides both clinicians and patients with information about the impact of cardiac rehabilitation as secondary prevention therapy.
Journal of Cardiopulmonary Rehabilitation 22(1):22-30.
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Journal of Health Care for the Poor and Underserved 21(2):617-628. · 1.10 Impact Factor
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Journal of Health Care for the Poor and Underserved 21(2):617-628. · 1.10 Impact Factor
