Elizabeth A. Madigan

Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters.

PURPOSE An isolated focus on 1 disease at a time is insufficient to generate the scientific evidence needed to improve the health of persons living with more than 1 chronic condition. This article explores how to bring context into research efforts to improve the health of persons living with multiple chronic conditions (MCC). METHODS Forty-five experts, including persons with MCC, family and friend caregivers, researchers, policy makers, funders, and clinicians met to critically consider 4 aspects of incorporating context into research on MCC: key contextual factors, needed research, essential research methods for understanding important contextual factors, and necessary partnerships for catalyzing collaborative action in conducting and applying research. RESULTS Key contextual factors involve complementary perspectives across multiple levels: public policy, community, health care systems, family, and person, as well as the cellular and molecular levels where most research currently is focused. Needed research involves moving from a disease focus toward a person-driven, goal-directed research agenda. Relevant research methods are participatory, flexible, multilevel, quantitative and qualitative, conducive to longitudinal dynamic measurement from diverse data sources, sufficiently detailed to consider what works for whom in which situation, and generative of ongoing communities of learning, living and practice. Important partnerships for collaborative action include cooperation among members of the research enterprise, health care providers, community-based support, persons with MCC and their family and friend caregivers, policy makers, and payers, including government, public health, philanthropic organizations, and the business community. CONCLUSION Consistent attention to contextual factors is needed to enhance health research for persons with MCC. Rigorous, integrated, participatory, multimethod approaches to generate new knowledge and diverse partnerships can be used to increase the relevance of research to make health care more sustainable, safe, equitable and effective, to reduce suffering, and to improve quality of life.

Attitudes towards collaboration and servant leadership among nurses, physicians and residents

A descriptive, comparative study was conducted to examine the attitudes of nurses, physicians and residents towards collaboration and to assess their self-perception of servant leadership characteristics. The Jefferson Scale of Attitudes toward Physician-Nurse Collaboration and the Barbuto-Wheeler Servant Leadership Questionnaire were utilized for data collection. Registered nurses (RNs) (n = 2,660), physicians (n = 447) and residents (n = 171) in a Southeastern United States health system were surveyed via the intranet; there were 497 responses for analysis. The response rate should be considered and generalizations made with caution regarding the study results. RN scores were higher for both total scores and subscales as compared to physician/resident groups for collaboration and servant leadership. There was a weak positive correlation between collaboration and servant leadership in the RN group and no significant correlation between the variables in the physician/resident group. Findings from this study have implications for nursing and physician education and practice and may serve as a framework for future studies. Representative samples are needed to gain further insight and to guide future research.

Risk Factors for Hospitalization Among Medicare Home Care Patients

This study determined factors associated with an increased risk of ending Medicare home health care because of hospitalization and examined specific types of and reasons for hospitalization. Sample members (N = 922) were followed from admission to discharge as they received home care from Ohio Medicare-certified home care agencies between December 1999 and March 2002. Potential patient-level risk factors were predisposing, enabling, or need variables, and an agency-level variable denoting hospital affiliation or free-standing status was examined as a second-level risk factor. Among those hospitalized (18.3%), more than 80.0% experienced emergency hospitalizations, mostly for acute exacerbations of chronic diseases. Statistically significant risk factors for hospitalization included dyspnea severity, functional disability level, skin or wound problems, diabetes, case mix score, and guarded rehabilitation prognosis. Home care agencies might reduce hospitalizations by using clinical prognosis as a key resource for team communication and by helping patients and families anticipate potential acute exacerbations of chronic diseases and manage these events at home.

Measuring disability in Medicare home care patients: application of Rasch modeling to the outcome and assessment information set.

Background. The Outcome and Assessment Information Set (OASIS) is the universal clinical assessment tool for adult nonmaternity patients receiving skilled care at home from Medicare-certified home health agencies in the United States. Anticipating increased use of OASIS data for research purposes, this article explored the usefulness of Rasch modeling to address disability measurement challenges presented by the unique response category structure of the seven activities of daily living (ADL) and eight instrumental ADL (IADL) items in the OASIS. Objectives. To illustrate how Rasch model statistics can be used to evaluate OASIS ADL and IADL item unidimensionality and model fit; to illustrate how Rasch modeling simultaneously estimates ADL and IADL item difficulty, thresholds between item response categories, and person disability; and to compare Rasch estimates of item difficulty and person disability scores to estimates based on more conventional Likert scoring techniques. Subjects. Medicare-eligible home health care patients (n = 583) served by one of 12 home care agencies in Ohio between November 1999 and September 2000. Measures. ADL and IADL items were measured three ways: according to the original OASIS scoring (raw Likert); transformed raw Likert scores accounting for the nonuniform item structure (corrected Likert); and Rasch Partial Credit model scores. Results. The items bathing and telephone use showed evidence of unexpected response patterns; recoding of these items was necessary for good Rasch model fit. Partial Credit model results revealed that interval distances between response categories varied widely across the 15 ADL and IADL items. When ADL and IADL items were ranked by level of difficulty, results were similar between Rasch and corrected Likert measurement approaches; however, corrected Likert person scores were found to be nonlinear at highest and lowest disability levels when plotted against Rasch person scores. Conclusions. Rasch modeling can help improve the precision of disability measurement in Medicare home care patients when using ADL and IADL items from the OASIS instrument.

Additional psychometric evaluation of the Outcomes and Assessment Information Set (OASIS).

ABSTRACT The OASIS represents a rich opportunity for researchers interested in home health care outcomes. However, little psychometric information has been published. The purpose of this study was to provide additional psychometric data for selected portions of the OASIS using a sub-set of 201 subjects from a previously published study. Conceptual domains were identified-functional, affect, behavioral and clinical. Reliability was evaluated using Cronbachs alpha and the kappa coefficient for intra-rater reliability. Construct validity was evaluated by principal axis factor analysis within each domain. The functional domain had the best reliability and validity. The affect and behavioral domains had adequate kappa scores, but the alphas and the factor analyses were problematic. Two of the clinical items did not perform well with kappa scores. Recommendations and suggestions for use of the OASIS are made.

A description of adverse events in home healthcare.

Patient safety has taken on increasing importance in the American healthcare system, yet there is little information on patient safety in home healthcare. The current study aimed to describe the most frequent adverse events defined by the Centers for Medicare & Medicaid Services among the national population of patients receiving home healthcare in 2003, and to compare characteristics between patients who experience adverse events and those who do not. The findings show that 13% of all home healthcare patients had an adverse event, with 80% experiencing only 1 adverse event. More than three fourths of the adverse events were associated with discharge to the community and required continued assistance. Patients who experienced adverse events were older, had more depressive symptoms and behavioral problems, and were more functionally impaired. Women had a slightly lower relative risk of an adverse event (.98), whereas patients of minority ethnicity had a slightly higher relative risk (1.06). These findings suggest that home healthcare agencies may need to spend more time on discharge planning after home healthcare and work with existing community providers. The findings also raise questions regarding the appropriateness of these adverse events and whether there are additional adverse events that warrant monitoring and follow-up evaluation.

Rehospitalization in a National Population of Home Health Care Patients with Heart Failure

OBJECTIVE Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30-day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable. DATA SOURCES Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services. STUDY DESIGN Retrospective cohort design. DATA EXTRACTION The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File. PRINCIPAL FINDINGS The 30-day rehospitalization rate was 26 percent with 42 percent of patients having cardiac-related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable. CONCLUSIONS The persistently high rates of rehospitalization have been difficult to address. There are health care-specific actions and policy implications that are worth examining to improve rehospitalization rates.

Rehospitalization among home healthcare patients: results of a prospective study.

Reduction in rehospitalization is an outcome measure used to evaluate home care services, especially in Outcome Based Quality Management using OASIS data; however, practitioners and managers must carefully analyze the reasons patients return to the hospital. This study examines events leading to rehospitalization of patients with CHF, whether it is possible to determine upon admission which patients are at risk, and whether the readmissions were necessary and/or preventable. Among the study’s important findings are that half of the patients developed a new problem that required the rehospitalization. This and other research outcomes should be considered when analyzing adverse event reports.

Psychometric evaluation of the Chinese version of the Minnesota living with heart failure questionnaire

Background: Health-related quality of life has emerged as an important outcome in treating and managing patients with heart failure (HF). However, there is no existing instrument for use in Chinese populations. Objectives: To translate the Minnesota Living With Heart Failure Questionnaire (MLHFQ) into a Chinese version and to validate it in the clinical setting. Methods: This was a cross-sectional study. A convenience sample of 247 participants with New York Heart Association Class II to III chronic HF were recruited from a cardiovascular outpatient department in Taiwan. Results: The content validity index was 0.98. Construct validity was supported by exploratory factor analysis, which showed three factors with 20 of 21 items loading above .50, explaining 71% of the variance. Total scale and subscale scores were correlated highly with the reference instruments, indicating satisfactory concurrent and convergent validity. The mean scores of the Chinese version of the MLHFQ were significantly higher among participants with HF than those from a non-HF comparison group. The instrument demonstrated high internal consistency (Cronbachs α of .95 for the scale and .93 to .95 for the subscales). Conclusion: The psychometric properties indicate that the Chinese version of the MLHFQ is a valid and reliable instrument for future research. This instrument provides a holistic approach for measuring health-related quality of life in New York Heart Association Class II and III HF patients.

People with heart failure and home health care resource use and outcomes

AIMS AND OBJECTIVES Patients with heart failure represent a common patient population in home health care, yet little is known about their outcomes. BACKGROUND Patients with heart failure, regardless of site of care, experience substantial numbers of rehospitalisations in the United States. Home health care is a common postacute care service for patients with heart failure. DESIGN Retrospective analysis. METHODS The study employed a large administrative data base from 2003 - the Outcomes and Assessment Information Set, which is required for all US Medicare and Medicaid patients receiving home health care. PARTICIPANTS There were 145 191 patients with a primary diagnosis of heart failure represented in the data set. The outcomes of interest were the trajectory of care (point of entry and discharge from home health care), hospitalisation, length of stay and change in functional status. RESULTS Almost three-quarters (73.9%) of patients entered home health care following a hospital stay. Nearly two-thirds (64%) remained at home at discharge from home health care. Approximately 15% of patients are hospitalised during the home health care episode, most often for symptoms consistent with exacerbation of the heart failure, if a reason could be identified. The average length of stay in home health care was 44 days. There was only a small improvement in functional status: 0.50 points for activities of daily living and 0.57 points for instrumental activities of daily living. Similar small improvement occurred in depressive symptoms, 0.68. RELEVANCE TO CLINICAL PRACTICE There may be room for improvement in these outcomes with more recent evidence that suggests strategies for reducing hospitalisation and improving patient functional status abilities. Yet, the chronic progressive nature of heart failure may also provide a limiting factor in the outcomes that can be attained.