Ashley K. Sherman

Comprehensive Primary Care for Children With Special Health Care Needs in Rural Areas

Objective. Most research on comprehensive primary care interventions for children with chronic health conditions has been conducted in large urban areas, where child health and related services are readily available. The purpose of this study was to evaluate the feasibility and impact of a medical home demonstration project in a more rural part of the country. Methods. Fifty-one parents of children with special health care needs participated in a pre-/posttreatment assessment of a program designed to enhance comprehensive and coordinated care. Participants were recruited from 3 primary care practices in a central Midwest state and remained in the program for ∼12 months. Results. Parents reported significant increases in satisfaction with care coordination and access to mental health services after the intervention. They also noted decreases in family needs, caregiver strain, parents’ missed work days, children’s school absences, and utilization of ambulatory services. Satisfaction with primary care declined slightly but remained in the “very good” range. Families of children with more complex conditions were more likely to report a decrease in needs after intervention, but other factors, such as geographic location or socioeconomic status, were not related to key outcome variables. Conclusions. Comprehensive care has a positive effect on children with chronic health conditions and their families, including those who live in more rural areas. Additional study is needed to learn more about rural service delivery strategies that promote implementation of this approach in general practice.

Rural versus urban social support seeking as a moderating variable in traumatic brain injury outcome.

Objective:To investigate personal beliefs about seeking social support following traumatic brain injury (TBI) and the relationship of these appraisals to demographic and injury variables, social integration, and quality of life ratings. Setting:The central region of a Midwest state. Participants:Fifty-six adults with TBI who were more than 6 months postinjury and living in the community. Main outcome measures:The Hesitation Scale, a 20-item survey that assesses reasons that people might hesitate to reach out to others in the community, and portions of the Living Life After Traumatic Brain Injury Scale. Results:Negative attitudes and beliefs about seeking social support were significantly related to lower perceptions of social support, lower ratings of quality of life, longer time since injury, being divorced or separated, and living in an urban area. Predictors of higher quality of life ratings included more positive appraisals about seeking social support, living in a rural area, and the ability to engage in productive activity. Conclusions:Positive outcomes after TBI appear to be moderated by living in a rural area, which is associated with more openness to seeking social supports and contributes to better quality of life.

Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation.

Schopp LH, Clark M, Mazurek MO, Hagglund KJ, Acuff ME, Sherman AK, Childers MK: Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation. Am J Phys Med Rehabil 2006;85:678–684. Objective:Although previous research has shown an association between spinal cord injury (SCI) and testosterone production, these studies have yielded inconsistent results. The present study documented the prevalence of low testosterone among men with SCI. Design:Participants were 92 men with SCI participating in inpatient rehabilitation. Data included total serum testosterone level, demographic and injury information, neurologic level and degree of incomplete function, American Spinal Injury Association Impairment Scale grade, and additional laboratory values, including prealbumin, albumin, hematocrit, and aspartate aminotransferase. Results:The median testosterone level for men who sustained injuries <4 mos earlier was 160 ng/dl. Testosterone categories were significantly associated with age, time since injury, hematocrit, albumin level, and aspartate aminotransferase in the univariate analyses. Age, time since injury, and hematocrit levels were significant predictors of low testosterone in the multivariate analysis. Conclusion:The prevalence of low testosterone among men with acute SCI seems to be high. The results suggest the need for routine screening for low testosterone among men with SCI and consideration given to testosterone replacement therapy. Future research is needed to investigate the etiology, pathogenesis, and potential avenues for treatment of low testosterone among men with SCI.

A comparison of consumer-directed and agency-directed personal assistance services programmes

Purpose: To compare a consumer-directed personal assistance services (PAS) programme with an agency-directed PAS programme. Method: A convenience sample was used for this cross-sectional study with one data collection point. Outcomes were compared for consumer-directed and agency-directed PAS. Hierarchical regressions were also used to determine the predictors of outcomes across PAS programmes. In-home interviews were conducted by a trained data collector from April 2000 to December 2001. Results: Participants in the consumer-directed programme reported more choices over PAS and satisfaction with PAS. Self-reported outcomes were primarily predicted by the following variables: service arrangement, type of provider, importance of directing PAS, health status, number of personal assistants used in past 12 months, sufficient PAS hours received, and social support. Conclusions: Consumer-directed PAS enhances outcomes for many persons with disabilities. Self-reported outcomes are affected by many factors that could be addressed in PAS programme development.

Antibiotic Treatment and Survival of Nursing Home Patients With Lower Respiratory Tract Infection: A Cross-National Analysis

PURPOSE Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different. METHODS We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity. RESULTS Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94–1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality. CONCLUSION Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment.

Predictors of Death in Patients on Peritoneal Dialysis: The Missouri Peritoneal Dialysis Study

Background: The study was designed to identify predictors of death in subjects on peritoneal dialysis (PD). Methods: The population consisted of patients initiated on PD at the University of Missouri-Columbia and Dialysis Clinic Incorporated from January 1, 1990, through December 31, 1999. Baseline variables included demographics, clinical data, initial measures of nutritional status, adequacy, and transport characteristics. Co-morbidities were scored using a modified version of the Index of Coexistent Disease. Ongoing (during the course of PD) variables consisted of clinical characteristics and weighted time average of a number of laboratory, adequacy, and nutritional variables. The variables were screened using a univariate procedure, and then analyzed using stepwise logistic regression to evaluate their independent relation to death. Results: There were 105 men and 86 women – 180 Caucasians, 10 African-American, 1 Asian, mean age 61 ± 13 (SD) years, and mean duration of follow-up 21 ± 18 months. Eighty-two patients suffered the outcome of death. Lean body mass (LBM) at the initiation of PD was negatively associated with the risk of death (p < 0.01). In addition, the need for a partner to perform PD, total morbidity count, and the summated severity score of all co-morbidities were associated with an increased risk of death. The analysis of ongoing variables revealed that serum phosphate (negative association, p = 0.02) and number of hospitalization days per month on PD (p = 0.0006) were associated with an increased risk of death. Conclusion: Phosphate levels and LBM are strong negative predictors of death in PD subjects. Further, patients who need the assistance of a partner to perform PD have decreased survival.

Testosterone replacement therapy and motor function in men with spinal cord injury: a retrospective analysis.

Clark MJ, Petroski GF, Mazurek MO, Hagglund KJ, Sherman AK, Lammy AB, Childers MK, Acuff ME: Testosterone replacement therapy and motor function in men with spinal cord injury: a retrospective analysis. Am J Phys Med Rehabil 2008;87:281–284. Objective:To evaluate motor function in men with spinal cord injury (SCI) given testosterone replacement therapy (TRT). Design:American Spinal Injury Association (ASIA) rehabilitation discharge motor index scores were compared between men with SCI given TRT (testosterone cypionate, 200 mg, monthly; n = 50) and a comparison group (n = 480) in a retrospective study. Covariates included admission motor and FIM scores, level of injury (paraplegia/tetraplegia), days since injury, and age. Results:ASIA discharge motor scores for ASIA impairment scale grades C and D were significantly different (P < 0.05) in men with incomplete SCI given TRT, relative to the comparison group. The covariate-adjusted mean discharge score for the TRT group was higher than for the comparison group. There were no significant differences in discharge FIM scores (P = 0.34) for men with incomplete injuries and no differences in the adjusted discharge ASIA motor scores (P = 0.92) or adjusted discharge FIM scores (P = 0.16) for men with complete injuries. Conclusion:The data support a relationship between TRT and strength gains in men with residual motor function after SCI. Prospective studies are necessary to validate these findings.

A longitudinal comparison of consumer-directed and agency-directed personal assistance service programmes among persons with physical disabilities

Purpose. To compare outcomes for persons who were enrolled in an agency-directed personal assistance services (PAS) programme and then changed to a consumer-directed PAS programme. Method. A convenience sample was used for this longitudinal study. In-home interviews were conducted by a trained data collector from April 2000 to December 2001. Results. Participants reported more satisfaction and safety with personal assistance, and fewer unmet needs after receiving consumer-directed services than after receiving agency-directed services. Other variables related to outcomes included race and ethnicity, employment, functional status, unmet needs, and the level of confidence in obtaining help if assistance is unavailable. Participants (74%) also reported high rates of unmet needs in the past month. Conclusions. Consumer-directed PAS enhances outcomes for many persons with disabilities. Self-reported outcomes are affected by many factors that could be addressed in PAS program development.

Consumer-Assistant Education to Reduce the Occurrence of Urinary Tract Infections Among Persons with Spinal Cord Injury

Urinary tract infections (UTIs) have been identified as one of the most common secondary conditions among individuals with spinal cord injury (SCI). This article describes the outcomes of an educational intervention to reduce UTI incidence. Persons with SCI who attended an in-person educational workshop reported a decrease in the occurrence of UTIs over a 6-month period, compared to persons not attending the workshop (p .02). Future studies should include oversampling for those persons at greatest risk, including minorities and those with poor health status, with few social supports, and with high cervical level injuries who rely more extensively on personal assistant services.

Predictors of Hospitalization in Patients on Peritoneal Dialysis: The Missouri Experience

Background: We analyzed a large number of demographic and biochemical variables to identify predictors of hospitalization in subjects on peritoneal dialysis (PD). Methods: All patients initiated on PD at our center from January 1990 through December 1999 were included. The following variables at the initiation of PD were included: demographics, clinical data, nutritional and adequacy parameters, transport characteristics, and various co-morbidities. Co-morbidities were graded for severity using a modified version of the Index of Coexistent Disease. Variables included during the course of PD consisted of weighted time average of a number of laboratory, adequacy, and nutritional parameters along with the number of peritonitis episodes per year. Stepwise linear regression was used following a univariate screening procedure to identify independent predictors of the outcome of hospitalization days per month on PD. Results: The subject population consisted of 191 subjects (105 men, 86 women; 180 Caucasians, 10 African-American, 1 Asian). The mean age was 61 ± 13 (SD) years and mean duration of follow-up was 21 ± 18 months. The baseline variable analysis revealed that the presence of partner to perform PD predicted increased hospitalization (p < 0.0001). Additionally, the presence and severity of peripheral vascular disease and residual renal Kt/V at baseline (negative association) predicted increased hospitalization. In the analyses of ongoing variables, stepwise linear regression solely identified weighted time average albumin as a strong negative predictor of hospitalization (p < 0.0001). Conclusion: A comprehensive analysis of a large number of variables revealed that serum albumin during the course of PD (negative association) and the need for partner to perform PD strongly predicted increased hospitalization in PD subjects.