David Nowels

Validation of the EQ-5D quality of life instrument in patients after myocardial infarction.

AbstractBackground: We assessed cross-sectional validity of EQ-5D after myocardial infarction (MI). Methods: We compared EQ-5D, SF-36, quality of life After MI (QLMI), and Canadian Cardiovascular Society Anginal Classification (CCSG) scores. Correlation and regression techniques were used to assess convergent validity. SF-36 and alternate Rand-36 scoring were compared. CCSG class was used to evaluate discriminative validity and clinical difference in health state scores. Results: Of 99 patients: mean age 64; median 176.5 days post-MI; 80% had one MI; 74% were CCSG I. 1/3 to 1/2 reported mobility, self-care, pain, and emotional difficulties on EQ-5D. Median health state was 0.73. EQ-5D and SF-36 (or Rand-36) strongly correlate in overall health (0.75), emotional health (0.75), pain (0.68), and activity/ functional (0.5–0.63). EQ-5D and QLMI strongly correlate in activities/ self esteem (0.56), emotional health (0.64), anxiety/depression – restriction (0.53), and overall health (0.5–0.57). EQ-5D self-care correlates weakly with all domains. Domain scores from each general instrument contributed to each other’s overall health score (adjusted R2 0.61–0.69) and to disease specific score (0.45 adjusted R2). EQ-5D discriminates among CCSG classes (p < 0.000). Physicians detected a 0.16 difference in health state scores. Conclusion: The EQ-5D provides valid general HrQOL measurement post-MI.

Outcomes and Characteristics of Patients Discharged Alive from Hospice

Objectives: To describe outcomes and characteristics of patients discharged alive from hospice.

Confirmation of the "disability paradox" among hospice patients: preservation of quality of life despite physical ailments and psychosocial concerns.

OBJECTIVE The purpose of this study was to describe quality of life (QOL) and psychosocial and spiritual issues among patients receiving hospice care. METHODS A questionnaire addressing QOL, spirituality, optimism, loss, fears about the terminal process and death anxiety was administered to 66 adults receiving care from 14 hospices. The physical components of QOL (physical symptoms and physical well-being) were rated lower than the psychosocial and spiritual aspects (support, existential well-being, psychological symptoms). RESULTS Respondents had a strong spiritual connection and a strong sense of hope. Although these individuals did not express anxiety or fear about death, there were concerns about the dying process itself. Also, although most felt at ease with their current situation, respondents were concerned about how their illness was affecting their family. Financial and legal issues did not concern most of these individuals. SIGNIFICANCE OF RESULTS There were few significant associations between patient characteristics and the QOL or other psychosocial or spiritual issues addressed. Among this older terminally ill population receiving hospice care, whose functional status was fair and for whom physical symptoms were troublesome, QOL persisted and a positive outlook prevailed.

Estimation of confusion prevalence in hospice patients.

BACKGROUND Confusion is common among ill patients and has broad consequences for their care and well-being. The prevalence of confusion in hospice patients is unknown. OBJECTIVES Describe the prevalence, severity, and manifestations of nurse-identified confusion and estimate the prevalence of delirium in hospice patients. DESIGN Cross-sectional descriptive study. SETTING Nineteen hospices in the Population-based Palliative Care Research Network (PoPCRN). PATIENTS Adult patients receiving care from participating hospices, February 15 to April 1, 2000. MEASUREMENT/ANALYSIS: Hospice nurses estimated prevalence, severity, behavioral manifestations, and consequences of confusion during the preceding week. Confused and nonconfused patients were compared using standard bivariate and stratification techniques. Logistic regression identified manifestations associated with problematic confusion. RESULTS Median age of the 299 patients was 78 years; 59% were female, 52% lived at home, and cancer was the most common diagnosis (54%). Fifty percent were confused during the preceding week, 36% of those were severely confused or disabled by confusion. Compared with nonconfused patients, confused patients were less likely to have cancer (64% vs. 43%, p < or = 0.001) and more likely to live in nursing home/assisted living (21% vs. 33%, p < or = 0.01). Disorientation to time or place, impaired short-term memory, drowsiness, and easy distractibility were common manifestations of confusion. When present, confusion caused a problem for the patient, someone else, or both 79% of the time. Inappropriate mood, cancer diagnosis, agitation, and age were the variables predicting problematic confusion. Only 14% of confused patients met criteria for delirium. CONCLUSIONS Confusion among hospice patients was common, frequently severe, and usually problematic.

Colorado Family Practice Graduates' Preparation for and Practice of Emergency Medicine

Background: Family physicians provide care in emergency departments, especially in rural areas; however, no published data describe how they perceive their preparation for emergency practice. We surveyed graduates of Colorado family practice residencies concerning their emergency medicine practice, their comfort working in emergency departments, and their perceived preparation for practicing emergency medicine. Methods: Seventy recent graduates of Colorado residencies were surveyed regarding their location, work in emergency departments, contact with emergency medical services (EMS) personnel, and perceptions about their emergency medical training. Results: Forty-five percent of respondents practiced in rural settings, 33% worked in emergency departments (56% rural, 14% urban), 60% reported contact with EMS personnel (91% rural, 32% urban), 54% believed their training adequately prepared them for working in emergency departments (82% rural vs 32% urban), 63% of rural and 22% of urban respondents indicated they wanted more major trauma experience during training, 70% reported discomfort with managing trauma, and 44% were interested in a 6-month emergency medicine fellowship. Conclusions: Most respondents believed their training in emergency medicine was adequate; however, most also reported discomfort with trauma management. Improved training for family physicians who provide emergency care could include expanded trauma care opportunities, increased work with EMS personnel, and postresidency training.

Hospice pharmaceutical cost trends.

Hospices are required to provide pharmaceuticals under the Medicare Hospice Benefit. Since there are no data describing these costs for hospice programs, this study analyzes data from a cross-sectional survey of 34 hospices concerning their pharmaceutical cost trends. Most respondents reported higher pharmaceutical-related costs between 1998 and 2002, but a significant minority reported that their costs had decreased. Pharmaceutical costs varied by patient setting, but long-acting opioids and continuous-infusion delivery systems were the two most significant contributors. A variety of mechanisms were employed to control drug costs.

New “Core Quality Measures”: Only a Beginning

A plethora of quality measures are used in health care for quality improvement, accountability (including reimbursement), and research. The Core Quality Measures Collaborative, with input from the American Academy of Family Physicians, recently released several groups of reduced core measure sets, including one for primary care. The proposed measures are less helpful for the increasing proportion patients with multiple morbidities or advancing illness. Going forward, the development of quality measures that assess multidimensional patient experiences and how closely the health care patients receive matches their goals in the face of multiple morbidities and advancing illness should be the focus.

We’re Hands On: Exploring a Supplemental Approach to Hospice Care Provision

The traditional model of hospice care provision is visit-centric and resource-intensive. Our research question emerged from a collaboration between a community-based hospice and academic researchers seeking to address real-world concerns in hospice service delivery. We sought to describe current and prior use of and hospice clinician perspectives on implementing alternatives to the face-to-face visit model to inform innovative, resource-conscious approaches to hospice care. We used mixed (qualitative and quantitative) methods, which included a Web-based survey and key informant telephone interviews. We then conducted focus groups of hospice clinicians seeking their perspectives regarding implementation of the supplemental visit approaches that were identified via the survey and key informant interviews. 81% of survey responders report using some type of supplemental visit, most commonly scheduled telephone calls. Few hospices utilize other technologies, such as video-phone, Web portals, or e-mail. Focus group participants identified the need for a significant internal “culture shift” to implement such technologies. Based on these findings, we developed a testable conceptual model for implementing supplemental hospice visits utilizing technologic innovations. A number of technologies hold promise for enhancing the efficiency, accessibility, and quality of hospice care when used to supplement face-to-face visits.