John F. Fitzgerald

The Care of Elderly Patients with Hip Fracture

We hypothesized that the care provided to elderly patients with hip fracture in community hospitals has changed since the implementation of prospective payment systems (PPS) in 1983. We reviewed records of elderly patients admitted with hip fracture to a large community hospital from 1981 to 1986. During that period, the mean length of hospitalization decreased (from 21.9 to 12.6 days; P less than 0.0001), inpatient physical therapy decreased (from 7.6 to 6.3 sessions; P less than 0.04), and the maximal distance walked before discharge fell (from 27 to 11 m [93 to 38 ft]; P less than 0.0001). Concomitantly, the proportion of patients discharged to nursing homes rose (from 38 to 60 percent; P less than 0.0001), as did the proportion remaining in nursing homes one year after hospitalization (from 9 to 33 percent; P less than 0.0001). Neither in-hospital mortality nor one-year mortality changed significantly. As compared with beneficiaries of conventional Medicare after the implementation of PPS, HMO enrollees had shorter hospitalizations (7.3 vs. 14.0 days; P less than 0.0001), received less physical therapy (3.5 vs. 7.1 sessions; P less than 0.0001), walked shorter distances at discharge (3 vs. 13 m [11 vs. 44 ft]; P less than 0.01), and were more frequently transferred to nursing homes (83 vs. 55 percent; P less than 0.01). One year later, however, fewer HMO patients remained in nursing homes (16 vs. 35 percent; P less than 0.07). We conclude that since the implementation of PPS, hospitals have reduced the amount of care given to patients with hip fracture and have shifted much of the rehabilitation burden to nursing homes. The increase in the number of such patients remaining in nursing homes one year after the fracture suggests that the overall quality of care for these patients may have deteriorated.

Falling, health status, and the use of health services by older adults: A prospective study

In this study, data from the Longitudinal Study on Aging were used to prospectively assess the relationship between repetitive falling or falling only once in the year before baseline and changes in health status and the use of health services. Multiple and logistic regression were used to control for a variety of known covariates, in addition to the baseline values of the target outcomes. Repetitive falling was associated with decreased health status, measured by various activities of daily living and disability indices, at both 2- and 4-year follow-ups. One fall, however, was never associated with deteriorating health status. Similarly, repetitive falling was related to a decreased likelihood of visiting a physician (at the first follow-up, only), but to an increased likelihood of hospitalization, nursing home placement, and death (at both follow-ups). Falling just one time, however, was only associated with an increased likelihood of nursing home placement. Based on outcome trajectories, two subpopulations of repetitive fallers were identified. One subpopulation was consistent with the rapid deterioration hypothesized by the “spiral” response to falling, and includes about 35% of the repetitive fallers (i.e., those who die within 4 years of baseline). The other subpopulation was consistent with the initial decline and subsequent stabilization hypothesized by the “drop-stabilization” response.

Subsequent hip fracture among older adults

Subsequent hip fracture among the 368 Longitudinal Study on Aging respondents who fractured their hips from 1984 through 1991 was prospectively examined. Case-by-case review of the billing records indicated that 27 subsequent hip fractures occurred, for a rate of 1 every 33.8 person-years. Multivariable proportional hazard regression revealed that increased risks of subsequent hip fracture were associated with poor perceived health status and dizziness.

Tricompartmental knee replacement: A comparison of orthopaedic surgeons' self reported performance rates with surgical indications, contraindications, and expected outcomes

The chance of a person with osteoarthritis of the knee receiving a knee replacement is highly variable. To understand better the reasons for this variation, all practicing orthopaedists in Indiana were surveyed about their management of severe knee osteoarthritis and their perception of tricompartmental knee replacement as a therapeutic option. Their perceptions of indications and outcomes of knee replacement were compared with the self reported annual number of patients for whom they performed (or referred to other surgeons for) tricompartmental knee replacements. A completed survey was returned by 220 (79%) of the 280 orthopaedists surveyed; analyses were limited to the 188 respondents who had cared for at least one patient with osteoarthritis of the knee in the prior 2 weeks (mean = 13). These surgeons reported performing (or referring patients for) a mean of 31 knee replacements in the prior year (SD 45, median 21, range 0–480 knee replacements). There was strong agreement (>95%) among respondents for seven (21%) of 33 surgical indications and contraindications, and more general agreement (>60%) for 21 (64%). In the live factors (15%) for which there was disagreement, there was no consistent relationship between opinions and self reported knee replacement performance rate. Surgeons reporting more knee replacements had significantly higher estimates of pain relief and functional improvement following surgery, and lower esti-

Institutionalized patients with hip fractures

The authors sought to identify patient- and nursing home-specific characteristics associated with a return to community living among patients with hip fractures discharged initially to nursing homes. One hundred eighty-nine free-living elderly patients were admitted for hip fractures to a 1,120-bed community hospital during 1984–1986. At hospital discharge, 114 (60%) of these patients were institutionalized. One year later, 49/114 (43%) had returned to the community. Three factors independently correlated with patients’ return to community living: being discharged to a nursing home with a large ratio of annual admissions to number of beds (RR=2.51, 95% CI 1.65, 3.94), achieving any in-hospital ambulation (RR=4.24, 95% CI 1.77, 8.14), and receiving conventional Medicare insurance (RR = 0.37, 95% CI 0.05, 0.53). These data suggest the existence of patient and nursing home features that identify those institutionalized patients with hip fractures who are more likely to return to community dwelling.

Reliability and validity of an instrument to measure maternal health beliefs.

Noncompliance with recommended preventive pediatric care continues to be a major problem, especially in inner-city pediatric clinics. There has been little evaluation of the maternal beliefs that are associated with such noncompliance, perhaps because there are no instruments which have been assessed for reliability and validity. To evaluate the internal consistency and construct validity of a maternal health belief instrument, we interviewed 500 mothers of healthy full-term newborns postpartum. Forty-eight items measured the maternal health beliefs, according to Health Belief Model constructs (perceived susceptibility, perceived severity, perceived benefits of medical care, perceived barriers, and health motivation). Construct validity was assessed by principal components factor analysis. Eight internally consistent indices emerged, including illnesses having high and low perceived susceptibility, and low and moderate perceived benefit. Logistical access barriers and economic access barriers were also distinct. Perceived severity and health motivation formed single indices. This maternal health belief instrument was internally consistent in the study sample and showed evidence of construct validity. These indices may make important independent contributions to understanding variation in preventive well-child care utilization.

Risk factors for nonelective hospital readmissions

We previously reported a predictive model that identified potentially modifiable risk factors for nonelective readmission to a county hospital. The objectives of this study were to determine if those risk factors were generalizable to a different population. We found that the previously reported risk factors were generalizable, and other potentially modifiable risk factors were identified in this population of veterans. However, further research is needed to establish whether or not the risk factors can be modified and whether or not modification improves outcomes.

Deciphering the physician note

Objective information about legibility of physician handwriting is scant. This retrospective chart review compared handwritten general medicine clinic chart notes from internal medicine faculty and housestaff with their typed counterparts. The written counterparts took 11 seconds (46%) longer to read and 5 seconds (11%) longer to answer comprehension questions. The authors’ comprehension measure (developed specifically for ambulatory clinic notes) was only slightly higher for typed notes. The legibility of physician handwriting is not as dismal as assumed; physicians can effectively communicate on paper.

Influence of organizational components on the delivery of asthma care.

The documented growing morbidity, mortality, and disability from asthma indicate a failure in effective delivery of appropriate care. This article reviews how different components of organizational technology in hospitals, freestanding emergency centers, physician practices, prepaid groups, and schools may be linked to asthma care and asthma outcomes. A framework to address how practice patterns, risk factors, and outcomes relate to organizational characteristics, such as time orientation, uncertainty, available technology, standardization of work, specialization of work, coordination, and control strategies, is presented.

The Parent Health Belief Scales: replication in an urban clinic population.

Health locus of control (HLC) has been used to operationalize general health motivation. This study was undertaken to evaluate the internal consistency and construct validity of Tinsley and Holtgraves Parent Health Belief Scales (PHBS) as a measure of maternal HLC toward their childrens health. Five hundred mothers (71% of eligible consecutive admissions) of newborns admitted to the normal newborn nursery of a large municipal teaching hospital were interviewed 24 to 72 hours after delivery. Principal components factor analysis of the PHBS did not support the originally hypothesized three-dimensional factor structure of the PHBS. In addition, the original subscales did not have adequate internal consistency reliability. Further assessment of construct validity by comparison with maternal preventive health behaviors showed some evidence of construct validity for the scales when compared with breastfeeding behavior. When the three items written as reverse-coded Internality items are not reversed, a reliable seven-item Externality scale emerges which contains items originally thought to represent all three dimensions of HLC.