Andrew M. Kramer

Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention

Objectives: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates.

Indwelling Urinary Catheter Use in the Postoperative Period: Analysis of the National Surgical Infection Prevention Project Data

OBJECTIVES To describe the frequency and duration of perioperative catheter use and to determine the relationship between catheter use and postoperative outcomes. DESIGN Retrospective cohort study. SETTING Two thousand nine hundred sixty-five acute care US hospitals. PATIENTS Medicare inpatients (N = 35 904) undergoing major surgery (coronary artery bypass and other open-chest cardiac operations; vascular surgery; general abdominal colorectal surgery; or hip or knee total joint arthroplasty) in 2001. Main Outcome Measure Postoperative urinary tract infection. RESULTS Eighty-six percent of patients undergoing major operations had perioperative indwelling urinary catheters. Of these, 50% had catheters for longer than 2 days postoperatively. These patients were twice as likely to develop urinary tract infections than patients with catheterization of 2 days or less. In multivariate analyses, a postoperative catheterization longer than 2 days was associated with an increased likelihood of in-hospital urinary tract infection (hazard ratio, 1.21; 95% confidence interval [CI], 1.04-1.41) and 30-day mortality (parameter estimate, 0.54; 95% CI, 0.37-0.72) as well as a decreased likelihood of discharge to home (parameter estimate, - 0.57; 95% CI, - 0.64 to - 1.51). CONCLUSIONS Indwelling urinary catheters are routinely in place longer than 2 days postoperatively and may result in excess nosocomial infections. The association with adverse outcomes makes postoperative catheter duration a reasonable target of infection control and surgical quality-improvement initiatives.

Nonpayment for Harms Resulting From Medical Care: Catheter-Associated Urinary Tract Infections

FIRST, DO NO HARM” IS ONE OF THE ENDURING PRINciples of the health care professions. In a painful irony, however, the current reimbursement system not only fails to penalize hospitals for largely preventable harms due to medical care, but it often rewards them in the form of additional reimbursement. That paradigm will change, however, in response to a modification to the Inpatient Prospective Payment System (IPPS), which the Centers for Medicare & Medicaid Services (CMS) instituted on August 1, 2007. Following a congressional mandate, the CMS has reshaped the reimbursement system to hold hospitals accountable for failing to avert 8 largely preventable harms (BOX) resulting from medical care.

Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic.

Objectives: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care.

The Care Transitions Intervention: A Patient-Centered Approach to Ensuring Effective Transfers Between Sites of Geriatric Care

ABSTRACT During an episode of illness, older patients may receive care in multiple settings; often resulting in fragmented care and poorly-executed care transitions. The negative consequences of fragmented care include duplication of services; inappropriate or conflicting care recommendations, medication errors, patient/caregiver distress, and higher costs of care. Despite the critical need to reduce fragmented care in this population, few interventions have been developed to assist older patients and their family members in making smooth transitions. This article introduces a patient-centered interdisciplinary team intervention designed to improve transitions across sites of geriatric care.

Excess Body Weight Is Not Independently Associated with Outcome in Mechanically Ventilated Patients with Acute Lung Injury

Context Although obesity poses many health risks, clinicians have been uncertain whether excess body weight adversely affects the outcomes of severe illnesses such as acute lung injury requiring mechanical ventilation. Contribution Among patients in a trial of mechanical ventilation strategies, obese patients and lean patients had similar mortality and ventilation outcomes. Implications Physicians should not assume that intubated obese patients fare worse than those who are of normal weight. Whether excess body weight puts patients at risk for poor outcomes in other types of critical illness is a subject for future study. The Editors Sixty-four percent of U.S. adults are overweight or obese, and this trend is accelerating (1, 2). Despite the well-described chronic health consequences of excess weight (3), we know little about the effect of obesity on outcomes from acute illnesses, particularly those requiring admission to the intensive care unit. Obese patients have a greater prevalence of comorbid conditions that may affect outcome (3), and they experience physiologic changes (4, 5) that may impair their ability to compensate for the stresses of critical illness. Because of these findings, conventional wisdom holds that obesity increases mortality and morbidity for patients in the intensive care unit. However, an independent effect of obesity on outcome from critical illness has never been conclusively demonstrated. If, in fact, obese persons are at risk, investigators should determine the mechanism of this increased risk and target interventions to this group. Acute lung injury is an inflammatory pulmonary condition associated with a variety of initiating insults. Acute lung injury is a frequent cause of respiratory failure requiring mechanical ventilation and a common indication for admission to the intensive care unit. The reported mortality rate is 40% to 60% (6). We performed a secondary analysis of a randomized trial of ventilator management in patients with acute lung injury (7) to better describe the influence of excess body weight on the outcome of critical illness. In that trial, patients randomly assigned to low tidal volume had better outcomes than patients assigned to high tidal volume. The experimental protocols for this trial required measurement of height to determine assigned tidal volume. This measurement also allowed calculation of body mass index (BMI) for each patient, a variable not often recorded for critically ill patients. Some argue that larger tidal volumes are beneficial for obese patients requiring mechanical ventilation (8). This raises concern that patients with different BMIs may require different ventilator strategies. By evaluating the interaction between the assigned ventilator protocol and BMI, we were able to determine whether the beneficial effect of lower tidal volume extends to obese patients with acute lung injury. Methods Setting and Sample We examined data on patients who participated in the National Heart, Lung, and Blood Institutes multicenter, randomized trials of the Acute Respiratory Distress Syndrome Network (7, 9, 10). Of the 902 patients in these studies, the first 861 participated in a randomized trial of mechanical ventilation that compared lower tidal volume with higher tidal volume (6 mL/kg of predicted body weight vs. 12 mL/kg, respectively). In a factorial design, 2 other trials evaluated ketoconazole versus placebo (234 patients) or lisofylline versus placebo (194 patients). After the ventilator trial ended because it showed a significant benefit associated with lower tidal volumes, an additional 41 patients received lisofylline or placebo plus the lower tidal volume strategy. Neither lisofylline (9) nor ketoconazole (10) affected outcomes of acute lung injury. Details of these studies and inclusion and exclusion criteria are described elsewhere (7, 9, 10). In brief, patients were eligible if they required mechanical ventilation and met diagnostic criteria for acute lung injury. Patients with a weight-to-height ratio (kilograms divided by centimeters) of 1.0 or greater were excluded. Analysis was done on an intention-to-treat basis. Measures of Excess Body Weight We used BMI as a measure of the degree of excess body weight. We calculated BMI from data in enrollment documents by dividing the patients body weight in kilograms by the square of his or her height in meters. Ventilator and Weaning Protocols The protocol for mechanical ventilator management is described elsewhere (7). The major difference between the two study groups was the selected tidal volume. Investigators calculated predicted body weight from the patients height and sex and used this predicted weight to determine the initial tidal volume for each patient. In the group assigned to higher tidal volumes, the initial tidal volume was 12 mL/kg of predicted body weight. In the group treated with lower tidal volumes, the initial tidal volume was 6 mL/kg. Investigators performed a daily weaning screen on every patient in an attempt to standardize the process of liberation from mechanical ventilation. Outcome Measures The primary outcome measure was survival to 28 days after study enrollment. Secondary dependent variables included achievement of unassisted ventilation by day 28, survival to discharge to home or to 180 days (the duration of follow-up in the primary studies), and the number of ventilator-free days. Unassisted ventilation was defined as liberation from mechanical ventilation for 48 or more consecutive hours. The number of ventilator-free days is the number of days of unassisted ventilation from day 1 to day 28. Statistical Analysis We performed unadjusted analyses by comparing values for patients across the 3 BMI categories (normal vs. overweight vs. obese) for outcome variables of interest and for other predictors. Unadjusted associations between other predictors and the outcomes were also explored. We used a 2-sided Fisher exact test for dichotomous variables; a 2-sided likelihood ratio chi-square test for nondichotomous categorical variables; and a KruskalWallis test, analysis of variance, or Wilcoxon rank-sum test for continuous variables, as appropriate. We constructed correlation matrices to guide regression estimation. We used logistic regression for the dichotomous outcome variables and linear regression for the continuous outcome variables. To estimate the base regressions, we selected variables for inclusion on the basis of several considerations, including significant differences in unadjusted analyses and clinical relevance. Among variables with a correlation greater than 0.50, only 1 was considered for inclusion to minimize multicollinearity. Variables that were thought to be strongly clinically relevant to the outcome and those found to have a statistically significant unadjusted effect (P < 0.05) were ultimately included in the base model. Variables in addition to those in Table 1 that were evaluated for inclusion were study site, ethnicity, diagnosis of diabetes, peak glucose level within 24 hours of enrollment, nonpulmonary organ failures, use of vasopressors, fluid balance in the 24 hours before study entry, and pneumonia as primary cause of lung injury. Unless otherwise stated, variables reflected the patients clinical state at the time of study enrollment. Table 1. Characteristics of the Sample After estimation of the base regressions, we forced the indicators of excess body weight into the model and determined their predictive values. We performed analyses in several different ways. We used the National Heart, Lung, and Blood Institute divisions of BMI to categorize patients as normal weight (BMI of 18.5 to 24.9 kg/m2), overweight (BMI of 25.0 to 29.9 kg/m2), or obese (BMI 30 kg/m2). To test any effect across BMI category, we used a categorical variable with 2 degrees of freedom in the regression. Because of concern that we would not be able to detect an effect that was nonincremental, we compared the overweight BMI group with the normal BMI group and the obese BMI group with the normal BMI group. To examine whether the efficacy of lower tidal volume ventilation varied by degree of excess body weight, we estimated the interaction effects between BMI group and assignment to the higher tidal volume protocol. Because the interaction effects between BMI category and treatment assignment were not significant (as tested by using a likelihood ratio test with 2 degrees of freedom), a main effects model was fit. This likelihood-ratio test was also used to test the significance of the 3-category BMI variable. To examine the patients with extreme excess body weight, patients were divided into 4 BMI categories (normal, overweight, obese [BMI of 30 to 39.9 kg/m2], and severely obese [BMI 40 kg/m2]). This categorical variable with 3 degrees of freedom was also tested in the regression. In addition to these analyses, we also used BMI as a continuous variable. Because critically ill patients often receive fluid resuscitation or diuresis, we recalculated BMI as adjusted for the net fluid balance for each patient over the 24 hours before study entry (fluid-adjusted BMI). Negative fluid balances were added to the patients body weight and positive fluid balances were subtracted from his or her weight to calculate BMI. We substituted the median fluid balance for the patients study site if the individual fluid balance was unavailable (51 records). We used a MantelHaenszel chi-square test for the ordinally categorical variables and a Wilcoxon rank-sum test for continuous variables. Pearson chi-square test produced results similar (P > 0.2) to those of the MantelHaenszel test. We used SAS software, version 8.02 (SAS Institute, Inc., Cary, North Carolina), for all analyses. A P value less than 0.05 was considered statistically significant. Protection of Human Subjects The institutional review boards of each participating center approved the primary studies. Patients or their sur

The Increased Needs of Patients in Nursing Homes and Patients Receiving Home Health Care

To evaluate the effects of Medicares prospective payment system and Medicaids preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states. For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care. We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicares prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaids policy of de-institutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality.

Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement

OBJECTIVES: To evaluate effects on patient outcomes of Outcome‐Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC).

Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke.

OBJECTIVE: Older persons with general medical and surgical conditions increasingly receive posthospital rehabilitation care in nursing homes and rehabilitation hospitals. This study describes the characteristics of such patients, contrasted with patients with traditional rehabilitation diagnoses of hip fracture and stroke.

Precipitants of Emergency Room Visits and Acute Hospitalization in Short-Stay Medicare Nursing Home Residents

OBJECTIVES To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission. DESIGN NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred. SETTING Sixty skilled nursing facilities in five states during 1994. PARTICIPANTS Six hundred thirty-six residents who became acutely ill with urinary tract infection (UTI), pneumonia, or congestive heart failure (CHF) during the first 90 days of their nursing home admission were identified from 2,414 random NH Medicare admissions, excluding those with orders not to be hospitalized. MEASUREMENTS Diagnosis, age, gender, advance care directives, nursing shift during which problem occurred, comorbidity, symptoms, and signs of acutely ill NH residents transferred to the hospital or emergency department were compared with those not transferred. RESULTS Rates of hospitalization varied markedly by acute illness: 11 of residents with UTI, 46 with pneumonia, and 58 with an exacerbation of CHF (P< .001). In stratified multivariate analysis, older age decreased the odds of rehospitalization only for CHF. Male gender increased odds of hospitalization for pneumonia (odds ratio (OR) = 2.94) and decreased odds of hospitalization for CHF (OR = 0.28). Do not resuscitate orders were negatively associated with hospitalization only for pneumonia (OR = 0.23), whereas weekend and evening/night shifts increased odds of hospitalization for UTI. Each illness had its own set of symptoms, signs, and comorbidities associated with hospitalization. CONCLUSIONS Whether an acutely ill NH Medicare patient was rehospitalized depended primarily on the particular illness. The relative importance of age, gender, shift, advance care directives, symptom severity, signs, and comorbid illnesses varied by diagnosis.