Evelyn Hutt

Symptom Burden, Depression, and Spiritual Well-Being: A Comparison of Heart Failure and Advanced Cancer Patients

ABSTRACTBACKGROUNDA lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer.OBJECTIVEWe examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients.DESIGNThis was a cross-sectional study.PARTICIPANTSSixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer.MEASUREMENTSSymptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being scale).MAIN RESULTSOverall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction ≤30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer.CONCLUSIONSPatients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.

Patient Risk Factors, Operative Care, and Outcomes Among Older Community-Dwelling Male Veterans with Hip Fracture

BACKGROUND Although more than 1200 hip fracture repairs are performed in United States Department of Veterans Affairs hospitals annually, little is known about the relationship between perioperative care and short-term outcomes for veterans with hip fracture. The purpose of the present study was to test whether perioperative care impacts thirty-day outcomes, with patient characteristics being taken into account. METHODS A national sample of 5683 community-dwelling male veterans with an age of sixty-five years or older who had been hospitalized for the operative treatment of a hip fracture at one of 108 Veterans Administration hospitals between 1998 and 2003 was identified from the National Surgical Quality Improvement Program data set. Operative care characteristics were assessed in relation to thirty-day outcomes (mortality, complications, and readmission to a Veterans Administration facility for inpatient care). RESULTS A surgical delay of four days or more after admission was associated with a higher adjusted mortality risk (odds ratio, 1.29; 95% confidence interval, 1.02 to 1.61) but a reduced risk of readmission (odds ratio, 0.70; 95% confidence interval, 0.54 to 0.91). Compared with spinal or epidural anesthesia, general anesthesia was related to a significantly higher risk of both mortality (odds ratio, 1.27; 95% confidence interval, 1.01 to 1.55) and complications (odds ratio, 1.33; 95% confidence interval, 1.15 to 1.53). The type of procedure was not significantly associated with outcome after controlling for other variables in the model. However, a higher American Society of Anesthesiologists Physical Status Classification (ASA class) was associated with worse thirty-day outcomes. CONCLUSIONS In addition to recognizing the importance of patient-related factors, we identified operative factors that were related to thirty-day surgical outcomes. It will be important to investigate whether modifying operative factors, such as reducing surgical delays to less than four days, can directly improve the outcomes of hip fracture repair.

Determining mild, moderate, and severe pain equivalency across pain-intensity tools in nursing home residents

Older adults in nursing homes experience pain that is often underassessed and undertreated. Visual analog pain-intensity scales, recommended for widespread use in adults, do not work well in the older adult population. A variety of other tools are in use, including the Verbal Descriptor Scale, the Faces Pain Scale (FPS), and the Numeric Rating Scale. These tools are more acceptable to older adults, but no agreement exists about how to compare the resulting pain-intensity scores across residents. This study examined the equivalency of pain-intensity scores for 135 nursing home residents who reported their pain on the three different instruments. The results were validated with a second sample of 135 nursing home residents. The pain levels across the three tools were highly correlated, but residents were found to underrate higher pain intensity on the FPS. A modification of scoring for the FPS led to greater agreement across the three tools. The findings have implications for use of these tools for quality improvement and public reporting of pain.

Cognitive impairment and pain management: review of issues and challenges.

The assessment and treatment of pain in persons with cognitive impairments pose unique challenges. Disorders affecting cognition include neurodegenerative, vascular, toxic, anoxic, and infectious processes. Persons with memory, language, and speech deficits and consciousness alterations are often unable to communicate clearly about their pain and discomfort. Past research has documented that persons with cognitive impairments, particularly dementia, are less likely to ask for and receive analgesics. This article provides an overview of the assessment, treatment, and management of pain in adults with cognitive impairments. We review types of cognitive impairment; recent work specific to best practices for pain management in patients with dementia, including assessment-tool development and pharmacological treatment; challenges in patients with delirium and in medical intensive care and palliative care settings; and directions for future research.

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.

Assessing the appropriateness of pain medication prescribing practices in nursing homes

OBJECTIVES: To test a tool for screening the quality of nursing home (NH) pain medication prescribing.

Associations Among Processes and Outcomes of Care for Medicare Nursing Home Residents with Acute Heart Failure

OBJECTIVE To characterize Medicare skilled nursing facility (SNF) residents who become acutely ill with heart failure (HF) and assess the association between the outcomes of rehospitalization and mortality, and severity of the acute exacerbation, comorbidity, and processes of care. DESIGN SNF medical record review of Medicare patients who developed an acute exacerbation of heart failure (HF) during the 90 days following nursing home admission. SETTING A total of 58 SNFs in 5 states during 1994 and 1997. PARTICIPANTS Patients with 156 episodes of acute HF among 4693 random Medicare nursing home admissions. MEASUREMENTS Demographic variables, symptoms, signs, comorbidity, nursing home characteristics, nurse staffing ratios, and processes of care were compared between acute HF subjects transferred to hospital and those not transferred; and between subjects who died within 30 days of an acute exacerbation and those who survived. RESULTS After adjusting for age, disease severity, and comorbidity, residents whose change in condition was evaluated during the night shift were more likely to be hospitalized (OR 4.20, 95%CI 1.01-17.50). Residents who were prescribed an angiotensin-converting enzyme inhibitor or who received an order for skilled nursing observation more often than once a shift were 1/3 as likely to die as those who did not (OR 0.303, 95%CI 0.11-0.82), after adjusting for hypotension, delirium, do not resuscitate orders, and prior hospital length of stay. CONCLUSION For residents who develop an acute exacerbation of HF during a SNF stay, there is an association between attributes of nursing home care and the outcomes of rehospitalization and mortality.

A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home–Acquired Pneumonia in a State Veterans Home

OBJECTIVES: To assess the feasibility of a multifaceted strategy to translate evidence‐based guidelines for treating nursing home–acquired pneumonia (NHAP) into practice using a small intervention trial.

Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study.

BACKGROUND Intramedullary nails for stabilizing intertrochanteric proximal femoral fractures have been available since the early 1990s. The nails are inserted percutaneously and have theoretical mechanical advantages over plates and screws, but they have not been demonstrated to improve patient outcomes. Still, use of intramedullary nails is becoming more common. The goal of this study was to examine trends in the use and associated outcomes of intramedullary nailing compared with sliding hip screws in Veterans Affairs (VA) hospitals. METHODS Review of the VA Surgical Quality Improvement Program (VASQIP) data identified 5244 male patients in whom an intertrochanteric proximal femoral fracture had been treated in a VA hospital between 1998 and 2005. The overall sample was used to assess trends in device use, thirty-day mortality, thirty-day surgical complications, and one-year mortality. Next, propensity score matching methods were used to compare 1013 patients identified as having been treated with an intramedullary nail with 1013 patients who had a sliding-screw procedure. Multiple logistic regression models for the matched sample were used to calculate odds ratios for mortality and complications according to the choice of internal fracture fixation. RESULTS Use of intramedullary nails in VA facilities increased from 1998 through 2005 and varied by geographic region. Unadjusted mortality and complication percentages were similar for the two procedures, with approximately 8% of patients dying within thirty days after surgery, 28% dying within one year, and 19% having at least one perioperative complication. While the choice of an intramedullary nail or sliding-screw procedure was related to the geographic region, year of surgery, surgeon characteristics, and several patient characteristics, it was not associated with thirty-day outcomes in either the descriptive or the multiple regression analysis. CONCLUSIONS Intramedullary nail use increased from 1998 through 2005 but did not decrease perioperative mortality or comorbidity compared with standard plate-and-screw devices for patients treated for intertrochanteric proximal femoral fractures in VA facilities.

Improving Hip Fractures Outcomes for COPD Patients

Abstract Hip fractures in the elderly have high rates of mortality and perioperative complications. Both men and COPD patients have worse mortality and complications but this may be due to more co-morbid disease. We assessed mortality and complications in a large cohort (n = 12,646) of men undergoing hip fracture surgery within the Veterans Health Affairs (VHA) to define the association of COPD to these outcomes after adjusting for other key factors. We looked for opportunities to improve outcomes for COPD patients. Methods: Using the VA Surgical Quality Improvement Program (VASQIP), and administrative databases, we determined COPD status, types of co-morbid conditions and surgical factors, and compared these to outcomes of surgical complications, 30-day and one-year mortality for patients who underwent hip fracture repair during 1998 to 2005. Results: COPD was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the COPD was “severe: (indicated by functional disability, previous hospitalization for exacerbation, chronic drug treatment or record of FEV1 <75% predicted), and in 2,736 (21%) cases it was considered “mild” (any previous outpatient visit or hospitalization with a coded diagnosis of COPD). Severe COPD patients had one year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD subjects. Current smoking, use of general anesthesia and delays to surgery were significant modifiable risk factors identified in adjusted models. Osteoporosis was known pre-fracture in only 3% of subjects. Conclusions: COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications. Increased use of regional anesthesia and urgent scheduling of hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.