Howard B. Degenholtz

Disability among Elderly Survivors of Mechanical Ventilation

RATIONALE Studies of long-term functional outcomes of elderly survivors of mechanical ventilation (MV) are limited to local samples and biased retrospective, proxy-reported preadmission functional status. OBJECTIVES To assess the impact on disability of hospitalization with MV, compared with hospitalization without MV, accounting for prospectively assessed prior functional status. METHODS Retrospective population-based longitudinal cohort study of Medicare beneficiaries age 65 and older enrolled in the Medicare Current Beneficiary Survey, 1996-2003. MEASUREMENTS AND MAIN RESULTS Premeasures and postmeasures of disability included mobility difficulty and weighted activities of daily living disability scores ranging from 0 (not disabled) to 100 (completely disabled) based on self-reported health and functional status collected 1 year apart. Among 54,771 person-years (PY) of observation over 7 calendar years of data, 42,890 PY involved no hospitalization, 11,347 PY involved a hospitalization without MV, and 534 PY included a hospitalization with MV. Mortality at 1 year was 8.9%, 23.9%, and 72.5%, respectively. The level of disability at the postassessment was substantially higher for a prototypical patient who survived after hospitalization with MV (adjusted activities of daily living disability score [95% confidence interval] 14.9 [12.2-17.7]; adjusted mobility difficulty score [95% confidence interval] 25.4 [22.4-28.4]) compared with an otherwise identical patient who survived hospitalization without MV (11.5 [11.1-11.9] and 22.3 [21.8-22.9]) or who was not hospitalized (8.0 [7.9-8.1] and 13.4 [13.3-13.6]). CONCLUSIONS The greater marginal increase in disability among survivors of MV compared with survivors of hospitalization without MV is larger than would be predicted from prior functional status.

Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania

BackgroundJob satisfaction is important for nursing home staff and nursing home management, as it is associated with absenteeism, turnover, and quality of care. However, we know little about factors associated with job satisfaction and dissatisfaction for nursing home workers.MethodsIn this investigation, we use data from 251 caregivers (i.e., Registered Nurses, Licensed Practical Nurses, and Nurse Aides) to examine: job satisfaction scores of these caregivers and what characteristics of these caregivers are associated with job satisfaction. The data were collected from two nursing homes over a two and a half year period with five waves of data collection at six-month intervals. The Job Description Index was used to collect job satisfaction data.ResultsWe find that, overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. From exploratory factor analysis three domains represented the data, pay, management, and work. Nurse aides appear particularly sensitive to the work domain. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction on all three domains than those who do not.ConclusionThese results may be important in guiding caregiver retention initiatives in nursing homes. The finding for quality may be especially important, and indicates that nursing homes that improve their quality may have a positive impact on job satisfaction of staff, and thereby reduce their turnover rates.

Race and the intensive care unit: disparities and preferences for end-of-life care.

T here is a large and growing body of literature documenting disparities in health and health care between racial groups. Blacks are less likely than whites to receive preventive services, diagnostic testing, and a wide range of interventions (1). These disparities in health care have been linked with higher levels of mortality from cancer and heart disease. For example, blacks with obstructive coronary disease or acute myocardial infarction are less likely to undergo bypass surgery than whites (2), and they have a higher 5-yr mortality (2). Blacks with lung cancer have lower surgical resection rates and higher 5-yr mortality than whites (3). These findings have sparked a broad reassessment of how health care is delivered (4), bringing increased attention to issues of trust (5, 6), cultural competence, and communication skills (7–9) and a commitment on the part of the federal government to eliminate racial disparities by the year 2010 (10). The national discussion over health disparities is also evident in the context of intensive care. The intensive care unit (ICU) has come to symbolize the height of technical prowess available in today’s medical care system, extending the promise of life saving treatment for the most seriously ill patients. Intensive care is a very expensive intervention that consumes a significant proportion of all inpatient hospital expenditures and gross national product (11, 12). Although many ICU procedures are efficacious, mortality rates for some patient groups are high (13–16), and the cost effectiveness of the ICU depends on which patients are treated (17, 18). As with other innovations in health care, some have suggested that expenditures on new technologies do not produce improvements in the health of the population (19, 20). The purpose of this article is to examine the extent to which racial differences in use of the ICU reflects the pattern of disproportionate burden described by the Institute of Medicine (1). We first review the few studies that have addressed the impact of race on ICU care. These studies have typically found that blacks receive a lower intensity of services in the ICU; however, there is no consistent impact on mortality (21–23). Then, because the ICU is often the site of end-of-life care (In a six-state study of medical care immediately before death, approximately 22% of all deaths followed ICU admission [A. Barnato, University of Pittsburgh, personal communication].) (17), we broaden our inquiry to address the association among race, individual preferences, and use of end-of-life care. This research has shown that blacks are consistently less likely than whites to prefer limiting the use of life-extending treatments (24–27). Finally, research on cost and use of medical care reveals a mixed picture. On the one hand, cohort studies have found that seriously ill hospitalized blacks receive less intense medical care at the end of life (28). On the other hand, studies have also found that black nursing home residents receive more intense treatment (29, 30) and are more likely to die in the hospital (31, 32) and have higher expenditures (33, 34). Taking these disparate findings together, we discuss potential reasons for the apparent disconnect between preferences and what people receive, and we explore potential ways to address this issue. The article concludes with a question about the burdens of race and history. It is possible that deeply held sociocultural convictions and historical disenfranchisement of blacks have shaped the perception that limiting any intensive treatment is a form of injustice. We end with recommendations for future research and positive steps toward addressing racial and ethnic disparities in health care.

How patients feel about prolonged mechanical ventilation 1 yr later

Objectives To elicit mechanical ventilation preferences among patients who previously received prolonged (≥48 hrs) mechanical ventilation, to identify patient characteristics associated with mechanical ventilation preferences, and to assess the association between the intensive care experience and mechanical ventilation preferences. Design Prospective cohort study conducted between June of 1997 and July of 2000. Setting Four intensive care units at a tertiary care institution. Patients Former critically ill patients (n = 133; mean age ± sd, 51.8 ± 17.1 yrs; 49% women) who survived for 12 months after prolonged mechanical ventilation. Measurements Patients’ preferences toward their actual mechanical ventilation experiences, by asking patients to reflect on the decision to apply mechanical ventilation made 1 yr earlier. Preferences for hypothetical situations, by asking patients to evaluate mechanical ventilation choices, assuming that their experiences had been different in terms of pain or discomfort, familial financial burden and stress, and health status after mechanical ventilation. Results Of the 133 patients, 115 (86.5%) would have chosen mechanical ventilation, with younger and healthier patients having higher odds of choosing mechanical ventilation than older and sicker patients, respectively. One fourth of patients who initially would have chosen mechanical ventilation would have refused this therapy had their families’ financial burdens been beyond certain thresholds. A similar proportion would have refused mechanical ventilation with greater mechanical ventilation pain or discomfort. Conclusion Although most subjects would have made the same decision to receive mechanical ventilation, younger and healthier subjects were most likely to favor mechanical ventilation. Many patients indicated that factors such as the amount of pain or discomfort from mechanical ventilation and their families’ financial burden would cause them to refuse this potentially life-saving intervention.

Prevalence of Behavioral Symptoms: Comparison of the Minimum Data Set Assessments with Research Instruments

OBJECTIVE To examine the total and domain-specific prevalence of verbally and physically abusive, socially inappropriate, and care-resistive behaviors according to the Minimum Data Set (MDS) compared with research instruments in nursing home residents with severe dementia. DESIGN, SETTING, AND METHODS As part of a longitudinal observational study, MDS behavioral symptoms data were compared with corresponding items from the Ryden Aggression Scale and the Cohen-Mansfield Agitation Inventory for 15 nursing home residents with severe dementia. McNemars test was used to compare the difference in the proportion of subjects who experienced any symptoms, as well as specific symptoms in several domains, according to the MDS and the research instruments. Additionally, temporal fluctuations in behavioral symptoms were descriptively and graphically summarized. RESULTS The MDS significantly underestimated both the total proportion of subjects experiencing any behavioral symptoms (P = .016), as well as the proportion of subjects experiencing verbally abusive symptoms (P < .002), physically abusive symptoms (P = .008), or socially inappropriate behaviors (P = .016) compared with corresponding items from the research instruments. Moreover, these behaviors exhibited considerable temporal instability, suggesting that the systematic daily collection of measures of behavioral disturbances is imperative during the week in which the MDS assessment is to be completed. DISCUSSION Albeit from a small study sample, our findings call into question the validity of the MDS behavioral symptom items as they are currently recorded, and suggest that a simple intervention of twice daily completion of a behavioral symptoms checklist containing the MDS items during the week of the assessment may significantly improve the accuracy of the recorded data.

Pressure Ulcer Prevention in Black and White Nursing Home Residents: A QI Initiative of Enhanced Ability, Incentives, and Management Feedback

OBJECTIVE: To determine if educating nursing home staff about pressure ulcer prevention reduces the differential risk of pressure ulcer development in black and white nursing home residents. DESIGN: Subanalysis of a study designed to monitor the emergence of all pressure ulcers in nursing home residents during 12-week baseline and intervention periods. PARTICIPANTS: All residents and staff of a not-for-profit, 136-bed nursing home in urban western Pennsylvania. MAIN OUTCOME MEASURE: The quality improvement intervention, featuring a computer-based interactive video education program on pressure ulcer prevention and early detection, consisted of 3 components: (1) staff ability enhancement, (2) staff financial incentives, and (3) real-time management feedback. Three specific outcome measures were monitored for differential risk of pressure ulcer development in black and white nursing home residents: (1) the rate of emergent Stage I-IV pressure ulcers identified, (2) the rate of emergent Stage II-IV pressure ulcers identified, and (3) the rate of individual residents developing at least 1 pressure ulcer (Stages II-IV). RESULTS: At baseline, black residents demonstrated a higher rate of Stage II-IV pressure ulcer emergence. Black residents with any pressure ulcer were also more likely to have multiple Stage II pressure ulcers compared with white residents. During the baseline period, 31.8% of the pressure ulcers detected in white residents were Stage I, whereas no Stage I pressure ulcers were detected in black residents. During the intervention period, the rate of emergence of all pressure ulcers declined for both groups in similar trends. CONCLUSION: Black residents were more likely to have multiple Stage II-IV pressure ulcers and were less likely to have Stage I pressure ulcers identified at baseline compared with white residents. The education intervention effectively reduced the rate of pressure ulcers for all residents and eliminated the racial disparity noted during the baseline period.

Physician Follow-Up Visits After Acute Care Hospitalization for Elderly Medicare Beneficiaries Discharged to Noninstitutional Settings

The purpose of this study was to assess the effect of posthospital physician follow‐up on readmissions in older adults. Physician follow‐up visits after discharge have been promoted as a way to improve outcomes and reduce readmissions, but the evidence base for this recommendation is limited. A retrospective analysis of data from the Medicare Current Beneficiary Survey (MCBS) was conducted for 2001 to 2003. Data were extracted on elderly Medicare beneficiaries with an index hospitalization in 2002, and physician follow‐up visits and readmissions within 90 days of discharge were identified. Analysis was conducted with multivariable logistic regression modeling to assess the independent effect on 90‐day readmission of any physician follow‐up, timing of physician follow‐up, and follow‐up with only primary care physicians. A generalized linear model was used to assess the effect of physician follow‐up on total health expenditures. The analytical sample included 326 beneficiaries; 79% had a physician follow‐up visit within 90 days, and 28% were readmitted within 90 days. In multivariable modeling, physician follow‐up was negatively associated with 90‐day readmissions (odds ratio=0.23, 95% confidence interval=0.13–0.43). Follow‐up visits were protective against readmissions regardless of timing of visit and when restricted to those by primary care physicians. Having a follow‐up visit was associated with approximately

Estimating the quantity and economic value of family caregiving for community-dwelling older persons in the last year of life

10,000 lower annual health expenditures. In conclusion, physician follow‐up protects against readmission after adjusting for important covariates and is associated with significantly lower expenditures. Future efforts should ensure that patients have adequate physician follow‐up.

Long-Term Care Case Managers’ Out-of-Home Placement Decisions An Application of Hierarchical Logistic Regression

OBJECTIVES: To estimate the quantity and economic value of informal care provided to older persons during their final year of life in the community.

Biopsychosocial Characteristics of Community-Dwelling Older Adults with Limited Ability to Walk One-Quarter of a Mile

Hierarchical logistic regression was used with the results of a factorial vignette survey of a national sample of case managers for the disabled elderly in Medicaid home- and community-based services waiver programs. The effects of client, case manager, and agency factors on case managers’out-of-home placement decisions in response to hypothetical case studies were estimated. Results show that client preferences, workload, and division of labor affect the probability that a case manager will recommend an out-of-home placement, controlling for client’s physical and cognitive disability and the available resources. Significant variation among individuals was found. Implications of the findings are discussed.