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Asinger RW, Henry TD, Herzog CA, Paulsen PR, Kane RL. Clinical outcomes of PTCA in chronic renal failure: a case-control study for comorbid features and evaluation of dialysis dependence. THE JOURNAL OF INVASIVE CARDIOLOGY 2001; 13:21-8. [PMID: 11146683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
We compared clinical outcomes following percutaneous transluminal coronary angioplasty (PTCA) for 77 chronic renal failure (CRF) (dialysis and nondialysis) patients and a control group matched for history of myocardial revascularization, specific revascularization procedure, gender, age, diabetes, number of native vessels diseased, number of vessels dilated, and the specific vessel(s) dilated. CRF patients had a higher incidence of peripheral vascular disease, hypertension, and more complex PTCA target lesion types than controls: 5% vs. 16% Type A, 12% vs. 28% Type B1, 44% vs. 41% Type B2, 39% vs. 15% Type C (p < 0.001). The primary success rate for PTCA in CRF patients and controls was 89% and 97% (p < 0.05). Survival analysis 24 months following PTCA showed a lower composite cardiac event-free survival (angiographic restenosis, myocardial infarction, coronary artery bypass surgery, and cardiac death) for those with CRF than controls, 54% vs. 69% (p = 0.002). Over the study period, 26 CRF patients died (11 from cardiac causes) compared to only 3 control patients (one from a cardiac cause); p < 0.001 for all cause and p < 0.003 for cardiac mortality. We also compared PTCA results between two categories of CRF patients. The first consisted of 49 end-stage renal disease (ESRD) patients on dialysis and the second included 28 patients not on dialysis (13 with creatinine > 2. 0 mg/dL and 15 with ESRD post-renal transplant). Both subgroups had similar coronary anatomy, including PTCA, target lesion type, and acute and long-term outcomes. In conclusion, we observed acceptable primary success and complication rates for PTCA in CRF patients compared with controls matched for comorbid features despite more complex target lesion morphology. Poorer long-term outcomes, however, were apparent for those with CRF regardless of dialysis dependence and likely relate to more extensive atherosclerosis and complex target coronary lesions at index PTCA as well as other features related to CRF.
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Boult C, Kane RL, Brown R. Managed care of chronically ill older people: the US experience. BMJ (CLINICAL RESEARCH ED.) 2000; 321:1011-4. [PMID: 11039975 PMCID: PMC1118779 DOI: 10.1136/bmj.321.7267.1011] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kane RL, Saleh KJ. Ethics in practice: residency training. J Bone Joint Surg Am 2000; 82:1510-1; author reply 1511. [PMID: 11057484 DOI: 10.2106/00004623-200010000-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
This study uses 4 years of data from the Medicare Current Beneficiary Survey to compare the use of Medicare covered services for persons who report having a diagnosis of dementia or Alzheimer disease with those who do not, adjusting for the prevalence of comorbidities and functional limitations. Although overall rates of Medicare spending are higher for demented persons, when other factors such as functional status are included in the predictive model, there is no consistent relation between the presence of dementia and higher Medicare spending. In some years, dementia was associated with higher adjusted expenditures for community living persons, whereas nursing home residents with Alzheimer disease have lower Medicare expenditures.
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Pacala JT, Kane RL, Atherly AJ, Smith MA. Using structured implicit review to assess quality of care in the Program of All-Inclusive Care for the Elderly (PACE). J Am Geriatr Soc 2000; 48:903-10. [PMID: 10968293 DOI: 10.1111/j.1532-5415.2000.tb06886.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a quality assessment tool for care rendered to enrollees in the Program for All-inclusive Care of the Elderly (PACE) that can discriminate care quality ratings across PACE sites. DESIGN Structured implicit review (SIR) of medical records by trained geriatricians and geriatric nurse practitioners. SETTING Eight PACE sites. PARTICIPANTS Older adults enrolled in a PACE program for at least 6 months (n = 313). MEASUREMENTS Process and outcome measures for both overall care and 14 specific conditions (tracers) managed up to 1 year. RESULTS Overall care quality was judged to be above a community standard in 56% and below standard in 8% of cases. Process of care was rated as very good or good in 70% of the cases. Outcomes depended on how questions were phrased: only 19% of cases improved, whereas 28% were judged to have fared better than expected given their condition at baseline. The SIR method produced ratings demonstrating considerable variability across the sites; three of the sites consistently showed poorer quality ratings than the other five. CONCLUSIONS PACE care was generally assessed to be of good quality, but with room for improvement. Despite significant limitations of poor interrater reliability for process of care measures, excessive time involved for the reviews, and lack of a control group, the SIR method was able to consistently discriminate quality ratings among PACE sites. A modified version of the assessment instrument could prove useful in a quality improvement program for PACE care.
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Bleiberg J, Kane RL, Reeves DL, Garmoe WS, Halpern E. Factor analysis of computerized and traditional tests used in mild brain injury research. Clin Neuropsychol 2000; 14:287-94. [PMID: 11262703 DOI: 10.1076/1385-4046(200008)14:3;1-p;ft287] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The present study examines the relation between a set of computerized neuropsychological measures, Automated Neuropsychological Assessment Metrics (ANAM), and a set of traditional clinical neuropsychological tests. Both sets of tests have been employed in recent studies of mild brain injury. Factor analysis and stepwise regression indicate that both sets of tests measure similar underlying constructs of cognitive processing speed, resistance to interference, and working memory. The present findings indicate strong concordance between computerized and traditional neuropsychological measures and support the construct validity of ANAM and similar procedures.
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Kane RL, Chen Q, Finch M, Blewett L, Burns R, Moskowitz M. The optimal outcomes of post-hospital care under medicare. Health Serv Res 2000; 35:615-61. [PMID: 10966088 PMCID: PMC1089140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE To estimate the differences in functional outcomes attributable to discharge to one of four different venues for post-hospital care for each of five different types of illness associated with post-hospital care: stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fracture, and to estimate the costs and benefits associated with discharge to the type of care that was estimated to produce the greatest improvement. STUDY SETTING/DATA SOURCES Consecutive patients with any of the target diagnoses were enrolled from 52 hospitals in three cities. Data sources included interviews with patients or their proxies, medical record reviews, and the Medicare Automated Data Retrieval System. ANALYSIS A two-stage regression model looked first at the factors associated with discharge to each type of post-hospital care and then at the outcomes associated with each location. An instrumental variables technique was used to adjust for selection bias. A predictive model was created for each patient to estimate how that person would have fared had she or he been discharged to each type of care. The optimal discharge location was determined as that which produced the greatest improvement in function after adjusting for patients' baseline characteristics. The costs of discharge to the optimal type of care was based on the differences in mean costs for each location. DATA COLLECTION/EXTRACTION METHODS Data were collected from patients or their proxies at discharge from hospital and at three post-discharge follow-up times: six weeks, six months, and one year. In addition, the medical records for each participant were abstracted by trained abstractors, using a modification of the Medisgroups method, and Medicare data were summarized for the years before and after the hospitalization. PRINCIPAL FINDINGS In general, patients discharged to nursing homes fared worst and those sent home with home health care or to rehabilitation did best. Because the cost of rehabilitation is high, greater use of home care could result in improved outcomes at modest or no additional cost. CONCLUSIONS Better decisions about where to discharge patients could improve the course of many patients. It is possible to save money by making wiser discharge planning decisions. Nursing homes are generally associated with poorer outcomes and higher costs than the other post-hospital care modalities.
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Weinert CR, Arnett D, Jacobs D, Kane RL. Relationship between persistence of abdominal symptoms and successful outcome after cholecystectomy. ARCHIVES OF INTERNAL MEDICINE 2000; 160:989-95. [PMID: 10761964 DOI: 10.1001/archinte.160.7.989] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients frequently have persistent abdominal symptoms after undergoing cholecystectomy. The relationship between abdominal symptoms and biliary dysfunction is often unclear. OBJECTIVES To describe the persistence rate of abdominal symptoms in a large cohort of patients after elective cholecystectomy, to identify predictors of symptom persistence and operative success, to understand which symptoms improve after cholecystectomy, and to describe the important determinants of an unsuccessful operation. METHODS Secondary analysis of a prospective, multisite cohort study of 2481 patients undergoing elective cholecystectomy. RESULTS The mean +/- SD number of abdominal symptoms per patient decreased from 3.1 +/- 2.0 to 1.1 +/- 1.3; 27% of patients who identified a symptom as most bothersome before surgery still had the symptom 6 months after surgery. Symptom persistence rates ranged from 5.6% (vomiting) to 40.2% (gas/flatulence). A balance score that quantified the abdominal symptom mix between dyspeptic and biliary symptoms shifted after surgery to the dyspeptic category. Predictors of persistence of a most bothersome symptom were dyspeptic symptom category, worse operative risk and self-rated health status, symptom duration longer than 6 months, and no previous episodes of acute cholecystitis. The major correlate of not achieving a very successful outcome (15.2% of patients) was the presence of postoperative abdominal pain. Other predictors included worse self-rated health status and physical functioning, symptom duration longer than 6 months before surgery, and no previous episodes of acute cholecystitis. CONCLUSIONS Symptoms categorized as dyspeptic were more likely to persist than were biliary symptoms, although all symptoms showed a decrease in prevalence after cholecystectomy. More attention to the rationale for gallbladder removal and clarification of patient expectations for symptom relief might be necessary to improve outcomes after elective cholecystectomy.
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DiPino RK, Kabat MH, Kane RL. An exploration of the construct validity of the Heaton memory tests. Arch Clin Neuropsychol 2000; 15:95-103. [PMID: 14590554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
Abstract
The Heaton techniques for assessing memory differ from most other memory measures by employing the combination of learning trials, repeated exposure to test stimuli, and 4-hour recall measures. The present study was designed to explore the relationship between the Heaton Story and Figure memory procedures, the California Verbal Learning Test (CVLT), and measures of attention, word fluency, and spatial perception. Data from 126 individuals were analyzed. Three separate factor analyses were performed that examined measures of attention, learning, and recall. Each revealed a three-factor solution accounting for 71, 70, and 72% of the variance, respectively. Regression analyses supported the visual components of Figure Memory and the verbal components of Story Memory obtained in the factor analyses. Overall, the findings supported the independence of the Heaton Memory procedures and the role of spatial factors in performance of Figure Memory. Additionally, both Figure and Story Memory shared variance with the CVLT, supporting the validity of both procedures as memory measures.
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DiPino RK, Kabat MH, Kane RL. An Exploration of the Construct Validity of the Heaton Memory Tests. Arch Clin Neuropsychol 2000. [DOI: 10.1093/arclin/15.2.95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kane RL, Huck S. The implementation of the EverCare demonstration project. J Am Geriatr Soc 2000; 48:218-23. [PMID: 10682954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
EverCare represents a creative approach to providing medical services to long-stay nursing home patients. It offers a capitated package of Medicare-covered services with more intensive primary care provided by nurse practitioners. The program's underlying premise is that better primary care will result in reduced hospital use. This work examines the implementation of the program in six locations. It identifies some of the issues that must be addressed if the program is to succeed both operationally and financially.
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Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, Friedewald WT, Siu AL, Shelanski ML. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA 2000; 283:59-68. [PMID: 10632281 DOI: 10.1001/jama.283.1.59] [Citation(s) in RCA: 597] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. OBJECTIVE To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. DESIGN Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. SETTING Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. PATIENTS Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). MAIN OUTCOME MEASURES Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. RESULTS No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05). CONCLUSIONS In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.
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Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC. Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2000; 43:9-16; discussion 16-7. [PMID: 10813117 DOI: 10.1007/bf02237236] [Citation(s) in RCA: 808] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.
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Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 1999; 42:1525-32. [PMID: 10613469 DOI: 10.1007/bf02236199] [Citation(s) in RCA: 553] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index. METHODS The Fecal Incontinence Severity Index is based on a type x frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores. RESULTS Surgeons and patients had very similar weightings for each of the type x frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale. CONCLUSIONS Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool.
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Smith MA, Shahar E, McGovern PG, Kane RL, Doliszny KM, Arnett DK, Luepker RV. HMO membership and patient age and the use of specialty care for hospitalized patients with acute stroke: The Minnesota Stroke Survey. Med Care 1999; 37:1186-98. [PMID: 10599600 DOI: 10.1097/00005650-199912000-00002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of older patients enrolling in health maintenance organizations (HMOs) is increasing. Concerns have been raised that older patients may be targeted by HMOs for more stringent cost-containment mechanisms, including reduced access to expensive specialty care. OBJECTIVES We investigated the relationship between membership in an HMO and the decision to consult with a neurologist or admit to a neurology ward for patients hospitalized with acute stroke. We then compared 1-year mortality of patients who received neurology care to the 1-year mortality of those who did not receive neurology care. DESIGN Retrospective medical record review. SUBJECTS A sample of hospitalized acute stroke patients (age range, 30-79 years) who were discharged from Minneapolis-St. Paul metropolitan hospitals with a diagnosis code of acute cerebrovascular disease from 1991 to 1993. MEASURES Trained nurses abstracted the medical records. Stroke events (n = 2,320) were validated using clinical criteria and neuroimaging reports. Mortality data were obtained from the Minnesota Death Index. RESULTS Among patients enrolled in HMOs, 30% of validated stroke patients did not receive neurology care in comparison with 19% of patients not enrolled in HMOs. After adjusting for patient mix and hospital characteristics, the odds of receiving neurology care were half as great for patients enrolled in HMOs as compared with patients not enrolled in HMOs (odds ratio [OR] = 0.52, 95% confidence interval [CI] 0.36-0.74). The association of membership in HMOs with lower use of neurology care was concentrated in older patients. Within each age group, the odds ratios and 95% CI of receiving neurology care for patients enrolled in HMOs versus patients not enrolled in HMOs were: < 55 years (1.06, 0.42-2.67), 55 to 64 years (0.54, 0.34-0.87), 65 to 74 years (0.51, 0.36-0.71), and >75 years (0.40, 0.24-0.68). Using Cox regression, 30-day mortality did not differ between patients who received neurology care and those who did not. Among 30-day survivors, the mortality hazards ratio (HR) during the next 11 months for patients who received neurology care was 71% of the hazard for patients who did not receive neurology care (HR = 0.71, 95% CI = 0.55-0.91). CONCLUSIONS These data suggest that membership in an HMO was associated with reduced access to neurology care for older patients with acute stroke and that patients who received neurology care had a lower risk of death during the year after their stroke. It remains to be determined if these differences in outcome are caused by true differences in stroke management or by unmeasured characteristics.
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Bowman C, Johnson M, Venables D, Foote C, Kane RL. Geriatric care in the United Kingdom: aligning services to needs. BMJ (CLINICAL RESEARCH ED.) 1999; 319:1119-22. [PMID: 10531110 PMCID: PMC1116908 DOI: 10.1136/bmj.319.7217.1119] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/20/1999] [Indexed: 11/04/2022]
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Boult C, Kane RL, Pacala JT, Wagner EH. Innovative healthcare for chronically ill older persons: results of a national survey. THE AMERICAN JOURNAL OF MANAGED CARE 1999; 5:1162-72. [PMID: 10621082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To describe the origin, scope, operations, funding, and outcomes of innovative healthcare programs for chronically ill older persons. STUDY DESIGN Cross-sectional survey. METHODS A national expert panel nominated chronic illness programs they believed to be innovative and field tested. The directors of the 31 eligible programs provided descriptive information in 60-minute semistructured telephone interviews. RESULTS The innovative programs we surveyed tended to target their services to high-risk patients, use teams of providers to deliver care, designate providers to coordinate multiple components of complex care plans, and shift care from higher- to lower-cost environments and/or redesign the delivery of primary care. CONCLUSIONS Recent innovations in healthcare programs hold considerable promise for improving the outcomes of chronic care, but most have yet to be rigorously evaluated.
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Abstract
This article focuses on the "efficiency" or cost-effectiveness of home care. Because home care encompasses a range of services targeted to many populations, it is necessary to take cognizance of case mix and clarify its goals to assess effectiveness. Goals for home care can be thought of as meeting and/or compensating for client dependency needs or making a difference in the client's clinical trajectory. The latter implies comparing actual to expected outcomes, where outcomes can cover a wide range of domains addressing quality of care and quality of life. Inferring the effect of treatment (i.e., home care) on various outcomes will likely rely heavily on epidemiological techniques that, in turn, rely on sophisticated statistical techniques. Problems measuring the costs of care include how to handle the costs of informal care and deciding whose costs should be of primary concern. Better data about the costs, and experimentation with different forms of caregiving, need to be pursued.
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Kane RL. Policy development and quality of care. THE JOURNAL OF LONG TERM CARE ADMINISTRATION 1999; 21:29-35. [PMID: 10133926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Kane RA, Degenholtz HB, Kane RL. Adding values: an experiment in systematic attention to values and preferences of community long-term care clients. J Gerontol B Psychol Sci Soc Sci 1999; 54:S109-19. [PMID: 10097781 DOI: 10.1093/geronb/54b.2.s109] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We tested the effects of providing case managers with tools to assess and respond to client values and preferences on their subsequent knowledge of clients' values and their practices in arranging long-term care. METHOD Using a quasi-experimental design with newly enrolled, cognitively intact clients, we compared case managers, clients, and care plans at the experimental and control agency. RESULTS Three weeks after enrollment, experimental clients were significantly more likely to report that case managers had asked them about their own preferences and offered them choices about services. Actual client values reported at the 3-month follow-up were similar for the two groups, with experimental case managers only slightly more accurate judges of their clients' responses to values questions. At follow-up, experimental case managers reported more case activity tailoring plans to client preferences, a finding confirmed by record reviews. Client acuity, measured by ADL functioning and prior hospital use, was associated with less perceived discussion of client preferences during the initial care planning process, but more case activity related to client preferences during the first three months. DISCUSSION The study suggests it is possible to sensitize case managers to the importance of assessing and acting on client values. Getting them to do so consistently, however, may require changes in the practice environment.
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Burns RB, Moskowitz MA, Ash A, Kane RL, Finch M, McCarthy EP. Do hip replacements improve outcomes for hip fracture patients? Med Care 1999; 37:285-94. [PMID: 10098572 DOI: 10.1097/00005650-199903000-00008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. OBJECTIVES To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). DESIGN Prospective cohort study. PARTICIPANTS We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. MEASUREMENTS We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). RESULTS Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). CONCLUSIONS Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.
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Cohen RA, Rosenbaum A, Kane RL, Warnken WJ, Benjamin S. Neuropsychological correlates of domestic violence. VIOLENCE AND VICTIMS 1999; 14:397-411. [PMID: 10751047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Neuropsychological functioning was assessed in 39 males who had committed domestic violence (batterers) and compared to 63 nonviolent (both maritally discordant and satisfied) subjects recruited by advertisement. Subjects were subsequently divided into two groups (head injured, nonhead injured) and these groups were also contrasted as a function of batterer status. Tests were administered to assess for cognitive and behavioral functions, including executive dysfunction, hypothesized to be a factor contributing to propensity for violence. Questionnaires and structured clinical interviews were used to assess marital discord, emotional distress, and violent behaviors. Batterers differed from nonbatterers across several cognitive domains: executive, learning, memory, and verbal functioning. Batterers were reliably discriminated from nonbatterers based on three neuropsychological tasks: Digit Symbol, Recognition Memory Test-Words, Wisconsin Card Sorting Test. Neuropsychological performance was the strongest correlate of domestic violence of all clinical variables measured. However, the inclusion of two other variables, severity of emotional distress and history of head injury, together with the neuropsychological indices provided the strongest correlation with batterers status. Among batterers, neuropsychological performance did not vary as a function of head injury status, indicating that while prior head injury was correlated with batterer status, it was not the sole basis for their impairments. The findings suggest that current cognitive status, prior brain injury, childhood academic problems, as well as psychosocial influences, contribute along with coexisting emotional distress to a propensity for domestic violence.
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