Edward Alan Miller

Predicting Elderly People’s Risk for Nursing Home Placement, Hospitalization, Functional Impairment, and Mortality: A Synthesis:

Long-term care resources would be allocated more cost-effectively if care planning and medical/functional eligibility decisions were grounded more firmly in extant evidence regarding the risk of nursing home placement, hospitalization, functional impairment, and mortality. This article synthesizes the studies that longitudinally assess the predictors of each of these outcomes for the 65 and older population in the United States. A database was assembled containing 167 multivariate analyses abstracted from 78 journal articles published between 1985 and 1998. Findings show that 22 risk factors consistently predict two or more outcomes, including three that predict all four: worse performance on physical function measures not based on activities of daily living, greater illness severity, and prior hospital use. Findings should help prioritize variable selection choices of those setting eligibility criteria, allocating care resources, and doing descriptive studies. Gaps are shown to exist in the understanding of outcome effects of facility, market, policy, and other system attributes.

Telemedicine and doctor-patient communication: an analytical survey of the literature.

The literature about the effect of telemedicine on doctor-patient communication was reviewed. A total of 38 studies were identified: six were surveys of provider and community attitudes; 21 were post-encounter surveys of participants in a medical consultation; and 11 were qualitative analyses of behaviour in a medical encounter. Twenty-one of the 38 investigations originated in the USA, six in the UK, four in Australia, three in Norway, two in Canada, one in Finland and one in Sweden. All were relatively recent. The findings from each study were coded according to 23 categories developed from the literature and a positive or negative rating was assigned to each of the 213 communication results. Approximately 80% of abstracted findings favoured telemedicine, with all but two of the 23 categories analysed (non-verbal behaviour and lack of touch) reporting more positive than negative results. Verbal content analysis is important for the development of interventions aimed at facilitating doctor-patient telecommunication. However, further research is necessary if the nature and content of the communication process are to be fully understood.

The technical and interpersonal aspects of telemedicine: effects on doctor-patient communication.

The influence of telemedicine on the nature and content of doctor–patient communication stems from both its technical and its interpersonal aspects. While the technical aspects are concerned with the communication technologies used and the clinical processes enabled by those technologies, the interpersonal aspects are concerned with relationships between system personnel, providers and patients, and the way in which those relationships are organized. On the one hand, this paper posits that the influence of the technical environment stems from depersonalization of the doctor–patient relationship, participatory enhancements and impediments, and sensory and non-verbal limitations. On the other hand, it posits that the influence of the interpersonal environment stems from third-party participation, social and professional distancing, and underdeveloped norms and standards. A combined positivist and interpretivist evaluation strategy would enable researchers to make better-informed connections between telemedicine, medical encounter behaviour and health outcomes.

Reforming Long-Term Care in the United States: Findings From a National Survey of Specialists

PURPOSE Theories of the policy process recognize that policy proposals are typically generated, debated, redrafted, and accepted for consideration through the gradual accumulation of knowledge within communities of specialists. Thus, to inform long-term care (LTC) reform efforts, we conducted a Web-based survey of 1,147 LTC specialists nationwide. DESIGN AND METHODS Survey respondents included consumer advocates, provider representatives, public officials, policy experts, and others with experience in LTC. Administration took place between September 2007 and March 2008 and addressed prevailing challenges and options for reform. RESULTS Although differences could be discerned, constituency group views converged in several areas. There was general agreement that LTC financing needed to be socialized more and that impediments to organizational change needed to be overcome. Respondents also felt that LTC needed to be rebalanced toward home- and community-based settings, though few supported doing so by limiting nursing home (NH) bed supply. Although virtually all felt that the federal government was doing a poor job regulating LTC providers, most believed that the approaches used to oversee NHs should also be applied to assisted living. Payment incentives were highlighted as the most effective strategy for improving quality even though it suffers from the same informational deficits compromising consumer reporting. IMPLICATIONS By giving voice to those who know LTC very well, and identifying areas of agreement and disagreement, this study should prove useful in promoting LTC reform where it might otherwise remain politically intransigent.

Nursing Home Organizational Change: The “Culture Change” Movement as Viewed by Long-Term Care Specialists

A decade-long grassroots movement aims to deinstitutionalize nursing home (NH) environments and individualize care. Coined “NH Culture Change” the movement is often described by its resident-centered/directed care focus. While empirical data of “culture change’s” costs and benefits are limited, it is broadly viewed as beneficial and widely promoted. Still, debate abounds regarding barriers to its adoption. We used data from a Web-based survey of 1,147 long-term care specialists (including NH and other providers, consumers/advocates, state and federal government officials, university/academic, researchers/consultants, and others) to better understand factors associated with perceived barriers. Long-term care specialists view the number-one barrier to adoption differently depending on their employment, familiarity with culture change, and their underlying policy views. To promote adoption, research and broad-based educational efforts are needed to influence views and perceptions. Fundamental changes in the regulatory process together with targeted regulatory changes and payment incentives may also be needed.

Where's the Revolution? Digital Technology and Health Care in the Internet Age

Despite the growing use of online resources, it is unclear how many Americans are using the World Wide Web for different health-related purposes and whether factors promoting use of the Internet in health care correspond with those affecting more traditional in-person and telemedicine encounters. This research uses a national public opinion survey to examine the degree to which health care consumers communicate through conventional, face-to-face consultation, telemedicine, or digital technology, and the relationship between these means of communication and respondent characteristics. Results indicate that few people are using digital technology to get information, communicate with health personnel, or make online medical purchases. Furthermore, less well educated, lower-income individuals living in rural areas tend to use the health care Internet less than others. Several policy measures need to be undertaken in order to accelerate the appropriate use of digital technology by health care consumers of all kinds. These include improving education and technological literacy and providing access to low-cost digital technology. Without a consumer complement to prevailing efforts to spur health information technology development and implementation on the part of providers, the promise of the digital revolution will continue to be limited to certain better-connected segments of the population.

Telemedicine and doctor–patient communication: a theoretical framework for evaluation

The literature on doctor-patient communication demonstrates that patient, provider and contextual characteristics influence behaviour within medical encounters, which in turn is an important determinant of health outcomes. This paper introduces a conceptual model which posits that telemedicine affects health outcomes through changes in the way doctors and patients communicate with one another. It also proposes that this process depends on the medium through which the consultation takes place, whether in person, over the telephone, via fax or email, or through two-way interactive video. Since participants in two-way interactive video-consultations rarely meet in person, it is particularly important that the effect of substituting video for face-to-face consultations be delineated.

Incidence of new-onset diabetes mellitus among patients receiving atypical neuroleptics in the treatment of mental illness: evidence from a privately insured population.

The purpose of this study is to determine sociodemographic, clinical, and pharmacotherapeutic characteristics, especially use of atypical antipsychotics, associated with incident diabetes mellitus in a population of privately insured patients with mental health diagnoses. Patients with a mental health diagnosis stably medicated for a 3-month period during January 1999 through October 2000 and having no diabetes were followed through December 2000. Cox proportional hazards models were developed to identify antipsychotic medications associated with newly diagnosed diabetes. Of the 7381 patients identified, 339 developed diabetes, representing an annual incidence rate of 4.7%. Diabetes risk among the entire sample was lowest for risperidone (hazard ratio [HR] = 0.69; p < 0.05), while quetiapine (HR = 0.74), olanzapine (HR = 0.95), and clozapine (HR = 1.22) were not significantly different from first-generation antipsychotics. Diabetes risk was significantly lower among males receiving risperidone (HR = 0.49; p < 0.01) or quetiapine (HR = 0.50; p < 0.10), while diabetes risk among females did not differ significantly from first-generation antipsychotics for any atypical examined. These findings are substantially different from other reports.

Characteristics associated with use of public and private web sites as sources of health care information : Results from a national survey

Objective:We sought to determine the frequency with which Americans access health information from governmental (public sector) and nongovernmental (private sector) web sites and to identify similarities and differences in the characteristics associated with use of each type. Methods:Data derive from 928 individuals who responded to a November 2005 national survey. In addition to forms of health communication, we asked about age, gender, race, income, education, insurance, lifestyle, residence, satisfaction, literacy, and health. We report the extent of web site use stratified by sponsorship type—public and private. We also use χ2 tests to examine bivariate associations. Logistic regression and multiple imputation of missing data were used to examine the correlates of use in a multivariate context. Results:More than twice as many respondents visited private web sites (29.6%) than public web sites (13.2%). However, just 23.6% and 18.9% of private and public web site visitors, respectively, reported doing so once a month or more. Both public and private web site visitors were more likely to be better-educated respondents (odds ratio [OR] = 0.83, OR = 1.57) reporting greater concerns about health care access (OR = 1.28, OR = 1.20) than nonvisitors. Younger individuals (OR = 0.83) living in urban areas (OR = 1.59) with stronger health literacy (OR = 1.24) and reporting greater concerns about health care affordability (OR = 1.59) were more likely to visit privately sponsored web sites but nonpublicly sponsored ones. Conclusion:Relatively low utilization levels necessitate a concerted effort to improve the quality, accessibility, and relevance of Internet health information. Efforts to close the digital divide must recognize differences in user characteristics across governmental and nongovernmental web site providers.

Health information Websites: characteristics of US users by race and ethnicity

We conducted a national public opinion survey of adults aged 18 years or older in the continental US to determine their use of health Websites. Of the 928 individuals contacted, 868 (94%) reported their race/ethnicity. More non-Hispanic Whites reported using the Internet (34%) than African Americans (31%) and Hispanics (20%). We used logistic regression to estimate adjusted odds ratios describing the relationship between Website usage and covariates across the racial/ethnic subgroups. Whereas better perceived health was associated with greater Website use among Hispanics and Whites, stronger health literacy was associated with greater use among Hispanics. No African American or Hispanic respondent aged 65 years or older reported going online. The relationship between education and use was more than twice as strong for African Americans and Hispanics than other groups. That some minority groups are less likely to use the World Wide Web for health information may further compound existing disparities. One place where this problem may be addressed is in the nations schools.