Richard J. Schuster

Healthcare Providers’ Perceptions and Self-Reported Fall Prevention Practices: Findings from a Large New York Health System

Among older adults, falls are the leading cause of injury-related deaths and emergency department visits, and the incidence of falls in the United States is rising as the number of older Americans increases. Research has shown that falls can be reduced by modifying fall-risk factors using multifactorial interventions implemented in clinical settings. However, the literature indicates that many providers feel that they do not know how to conduct fall-risk assessments or do not have adequate knowledge about fall prevention. To help healthcare providers incorporate older adult fall prevention (i.e., falls risk assessment and treatment) into their clinical practice, the Centers for Disease Control and Prevention’s (CDC) Injury Center has developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool kit. This study was conducted to identify the practice characteristics and providers’ beliefs, knowledge, and fall-related activities before they received training on how to use the STEADI tool kit. Data were collected as part of a larger State Fall Prevention Project funded by CDC’s Injury Center. Completed questionnaires were returned by 38 medical providers from 11 healthcare practices within a large New York health system. Healthcare providers ranked falls as the lowest priority of five conditions, after diabetes, cardiovascular disease, mental health, and musculoskeletal conditions. Less than 40% of the providers asked most or all of their older patients if they had fallen during the past 12 months. Less than a quarter referred their older patients to physical therapists for balance or gait training, and <20% referred older patients to community-based fall prevention programs. Less than 16% reported they conducted standardized functional assessments with their older patients at least once a year. These results suggest that implementing the STEADI tool kit in clinical settings could address knowledge gaps and provide the necessary tools to help providers incorporate fall-risk assessment and treatment into clinical practice.

Physician Cardiovascular Disease Risk Factor Management: Practices in France vs the United States

Cardiovascular risk factor management by French vs US primary care physicians was studied. A survey was conducted that found that French physicians spend >20 minutes while US physicians spend five to 10 minutes (P<.001) addressing cardiovascular risk with patients. Fifty‐three percent of French (vs 33% of US) physicians focus more on lifestyle modification and less on medication management (P<.0001). Sixty‐nine percent of French physicians spend 0% to 20% of their time on administration while 65% of US physicians spend 10% to 30% (P=.0028). Fifty‐one percent of French physicians see patients in one to three months for follow‐up, while 51% of US physicians see patients in three to six months (P<.0001). Eighty‐seven percent of French (vs 39% of US) physicians have guidelines available in the examination room either frequently or very frequently. US physicians report disparities in care more frequently than do French physicians (P<.0001). Forty‐nine percent of French (vs 10% of US) physicians believe that they have relative freedom to practice medicine (P<.001). US physicians report greater administrative efforts, frustration, and disparities in their practice. French physicians focus more of their efforts on lifestyle management and see their patients more frequently and for a longer visit time. J Clin Hypertens (Greenwich). 2011;13:10–18. ©2010 Wiley Periodicals, Inc.

The Clinician Engagement and Education Session Modernizing “Academic Detailing”

In industrial processes, Deming demonstrated that “quality” required the active application of a measured systems approach to production. Eisenberg effectively began the wide dissemination of promoting the “quality” process in health care, with his disciples recognizing that research discovery does not automatically lead to practice. It has been clearly shown that systems innovations in health care, including changing physician practice behavior, can improve quality and reduce cost. Central to the implementation of quality in the health care system are the social and professional processes that influence clinician behavior. Traditionally, “academic detailing” has been used widely as a way to engage physicians to influence clinical practice. Modeled from the approach taken by the pharmaceutical industry, academic detailing focuses on establishing credibility, assessing baseline knowledge, and identifying physician opinion leaders for follow-up interaction. Many others have studied and further developed this approach, with Grol providing a highly effective summary of available tools to initiate change in physician practice behavior (eg, rewards, penalties, audit, feedback, decision support) that can result in improvement of outcomes by between 4% and 22%. It has been predicted that clinical outcomes could be improved by as much as 75% with a focus on changing clinician systems of care.

Prevalence of Risk Factors for the Metabolic Syndrome in the Middle Income Caribbean Nation of St. Lucia

The objective of this research was to measure the presence of metabolic syndrome risk factors in a sample population in the middle income Caribbean nation of St. Lucia and to identify the demographic and behavioral factors of metabolic syndrome among the study participants. Interviews and anthropometric measures were conducted with 499 St. Lucians of ages 18–99. Descriptive statistics were used for the analysis. Fifty-six percent of females and 18 percent of males had a waist size equal to or above the indicator for the metabolic syndrome. Behavioral risk factors such as sedentary lifestyle, smoking, and alcohol consumption varied by gender. Thirty-six percent of women and 22% of men reported a sedentary lifestyle and 43% of women and 65% of men reported any alcohol consumption. More research should be done to determine the cultural norms and gender differences associated with modifiable risk behaviors in St. Lucia.

A Cross-Cultural Analysis of Physician Management of Obesity. Comparing the US, France, Israel and Japan: Little Interest and Little Success

Background: Obesity is a global health problem. Physicians are frequently engaged with overweight and obese patients. Obesity guidelines have been successfully implemented on a small scale, but generally physicians struggle to manage obesity effectively. Methods: In a web-based survey, primary care physicians in the United States (US), France, Israel and Japan, were asked how they manage cardiovascular risk factors. They were specifically asked how frequently they saw patients in follow-up for hypertension, hyperlipidemia and obesity. Results: Respondents (956) included 656 French, 198 Israeli, 45 Japanese, and 53 US physicians. Follow-up for obesity no sooner than 3 months was recommended, by 73% (US) and 79% (Israeli) physicians, whereas 67% of French and 66% of Japanese physicians recommended more frequent follow-up (3 months or less). Hypertension and hyperlipidemia was managed more aggressively, especially the US, Israel and Japan. Discussion: Obesity is an international concern, with rates increasing everywhere. The prevalence of obesity is high in the US and Israel and much lower in France and Japan. Chronic disease management is most effective with frequent follow-up. US obesity guidelines recommend frequent (often monthly) follow-up visits. US and Israeli physicians do not appear to be aggressive in managing obesity, whereas French and Japanese physicians report more effort to manage obesity. In the US, obesity management is not considered effective and physicians are uncomfortable attempting to manage obesity with their patients. In France especially, physicians have a more social relationship with their patients and seem oriented toward chronic disease management, including greater attention to lifestyle change. Conclusion: Obesity has been medicalized and is a profound problem internationally. The medical care system must address obesity management more effectively. Further studies are needed to understand how physicians manage obesity and new approaches should be promoted to improve the outcomes of obesity management.

Humanitarian healthcare: treating Syrian patients in Israeli hospitals

Purpose The purpose of this paper is to present the findings on interpersonal relational processes of Israeli healthcare providers (HCPs) and Syrian patients and caregivers using data collected in two Israeli hospitals. Design/methodology/approach Using a parallel mixed-methods design, data were integrated from observations, interviews, and surveys. In total, 20 HCPs and three Syrian patient caregivers provided interview data. Quantitative data were collected from 204 HCPs using surveys. The qualitative component included the phenomenological coding. The quantitative analysis included factor analysis procedures. Throughout parallel analysis, data were mixed dialogically to form warranted assertions. Findings Results from mixed analyses support a three-factor model representing the HCPs’ experiences treating Syrian patients. Factors were predicted by religious and occupational differences and included professional baseline, humanitarian insecurity, and medical humanitarianism. Research limitations/implications Limitations of this study included issues of power, language differences, and a small Syrian caregiver sample. Practical implications As the fearful, injured, and sick continue to flee violence and cross geopolitical borders, the healthcare community will be called upon to treat migrants and refugees according to ethical healthcare principles. Originality/value The value of this research is in its critical examination of the HCPs’ interactions with patients, a relationship that propels humanitarian healthcare in the face of a global migrant crisis.

The Second Lebanon War Experience at Western Galilee Hospital.

The summer of 2006 in northern Israel served as the battleground for the second war against Hezbollah based along Israels border with southern Lebanon. Western Galilee Hospital (WGH), which is located only 6 miles from the Lebanese border, served as a major medical center in the vicinity of the fighting. The hospital was directly impacted by Hezbollah with a Katyusha rocket, which struck the ophthalmology department on the 4th floor. WGH was able to utilize a 450-bed underground facility that maintained full hospital functionality throughout the conflict. In a major feat of rapid evacuation, the entire hospital population was relocated under the cover of darkness to these bunkers in just over 1 hour, thus emptying the building prior to the missile impact. Over half of the patients presenting during the conflict did not incur physical injury but qualified as acute stress disorder patients. The particulars of this evacuation remain unique owing to the extraordinary circumstances, but many of the principles employed in this maneuver may serve as a template for other hospitals requiring emergency evacuation. Hospital functionality drastically changed to accommodate the operational reality of war, and many of these tactics warrant closer investigation for possible implementation in other conflict zones.

Disagreement between emergency department admission diagnosis and hospital discharge diagnosis: mortality and morbidity

Abstract Background: Previous studies have shown that changes in diagnoses from admission to discharge are associated with poorer outcomes. The aim of this study was to investigate how diagnostic discordance affects patient outcomes. Methods: The first three digits of ICD-9-CM codes at admission and discharge were compared for concordance. The study involved 6281 patients admitted to the Western Galilee Medical Center, Naharyia, Israel from the emergency department (ED) between 01 November 2012 and 21 January 2013. Concordant and discordant diagnoses were compared in terms of, length of stay, number of transfers, intensive care unit (ICU) admission, readmission, and mortality. Results: Discordant diagnoses was associated with increases in patient mortality rate (5.1% vs. 1.5%; RR 3.35, 95% CI 2.43, 4.62; p<0.001), the number of ICU admissions (6.7% vs. 2.7%; RR 2.58, 95% CI 2.07, 3.32; p<0.001), hospital length of stay (3.8 vs. 2.5 days; difference 1.3 days, 95% CI 1.2, 1.4; p<0.001), ICU length of stay (5.2 vs. 3.8 days; difference 1.4 days, 95% CI 1.0, 1.9; p<0.001), and 30 days readmission (14.11% vs. 12.38%; RR 1.14, 95% CI 1.00, 1.30; p=0.0418). ED length of stay was also greater for the discordant group (3.0 vs. 2.9 h; difference 8.8 min; 95% CI 0.1, 0.2; p<0.001). Conclusion: These findings indicate discordant admission and discharge diagnoses are associated with increases in morbidity and mortality. Further research should identify modifiable causes of discordance.