Neurocognitive functioning in chronic fatigue syndrome

Although substantial research has been conducted on chronic fatigue syndrome (CFS) over the past decade, the syndrome remains poorly understood. The most recent case definition describes CFS as being characterized both by disabling fatigue and by subjective reports of difficulty with concentration and "short-term" memory. However, research into the neurocognitive and psychological functioning of individuals with CFS has provided mixed objective results. The current paper reviews studies that have examined the neurocognitive and/or psychological functioning of individuals with CFS. Changes in research design and instruments employed to study individuals with CFS are suggested.

Use of post-hospital care by Medicare patients

BACKGROUND

Medicare's introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post-hospital care. Medicare coverage provides for various types of post-hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post-hospital care.

METHODS

A Total of 2248 consecutive Medicare patients having one of five diagnosis related groups (DRGs), who were about to be discharged from 52 hospitals in three cities in 1988-1989, were enrolled in the study. These DRGs comprised approximately one-eighth of all Medicare hospital discharges and 40% of all Medicare-paid post-hospital care. Patients were interviewed in person before discharge and again 6 weeks after discharge. Clinical severity measures were developed from information abstracted from each patient's medical record. For each DRG, multinomial logit regression equations were developed to identify factors associated with the choice of one of four possible discharge locations: home with no formal care, home health care, nursing home care, or rehabilitation.

RESULTS

Discharge location could be predicted correctly in 52 to 71% of cases, depending on the DRG. This level of predictive accuracy was significantly greater than relying on the modal discharge location, which accounted for 33 to 62% of cases. Most of the predictive power came from information gathered at the discharge interview. The variables associated significantly with the discharge location varied with the DRG and location examined. Living alone and functional dependency at discharge were the significant predictors found most often.

CONCLUSIONS

Rather than assuming that everyone is discharged to the modal location, patient discharge location can be predicted. Much of the explanation can be traced to a few variables such as functional status and living situation. The lack of greater accuracy suggests that factors other than those identified as important by clinical panels are involved in discharge planning for Medicare patients.

Effect on physical functioning of care in adult foster homes and nursing homes

This study tested the effects on physical functioning of substituting adult foster care (AFC) for nursing home care. Secondary data from Oregon's Medicaid agency were used to compare change in ADL functioning of 1,032 nursing home and 279 AFC residents. Maximum likelihood estimation was used to analyze selection of long-term care setting and change in functioning. One-third of surviving AFC residents would have been better off in a nursing home, whereas almost all nursing home residents were placed appropriately. Further research on outcomes that clients value most along with efforts to support functioning are needed.

Who cares? The size, scope, and composition of the caregiver support system

The informal care networks of 242 impaired older people were examined in terms of the primary caregiver and secondary helpers. Most primary caregivers had at least one secondary helper; 88% identified helpers who provided hands-on help, 19% reported that helpers contributed financially, and 44% had helpers involved in care decisions. The size of the network was larger for direct care compared to financial or decision-making assistance. Almost half of primary caregivers reported that their spouse helped. It was expected that after controlling for characteristics of the primary caregiver and of the older person, that characteristics of the secondary caregiver network would influence the amount and type of primary caregiver assistance and formal care used by the older person. However, both hours and type of care by the primary caregiver were independent of size, scope, and composition of the secondary helper network. This independence suggests that efforts to alter the secondary caregiver network may have limited effects on the primary caregiver.

Developing a new metric for ADLs

BACKGROUND

Most ADL summary measures add up the number of dependencies. They assume an equal weighting among items and require an arbitrary definition of dependency.

METHODS

A panel of experts in geriatrics was asked to rate a set of ADL and IADL components in terms of the contribution of each to overall dependency using a magnitude estimation (ME) technique. The ratings were done for both domains and for levels of function within each domain. The resultant scores were compared with the usual dependency count approach.

RESULTS

The distribution of weighted items appears to have face validity. The pattern of dependency traced by the ME model was intermediate between those created by simple counts with two different definitions of dependency. The ME approach has stronger statistical properties than the ordinal scoring approach.

CONCLUSIONS

The ME approach appears to be a reasonable and workable method for creating a measure that permits meaningful statements about the mean value of functional dependencies. This result can be used for any comparison of means, such as across individuals, across aggregates of individuals, or across time.

Long-term care

Long-term care has come to include both an acute component and the more traditional chronic component. The growth in subacute care has occurred under private prepaid auspices but has also been stimulated by changes in Medicare funding for hospitals. Quality improvement techniques, such as critical pathways, have been applied to long-term care.

Improving the quality of long-term care

Quality of long-term care can be improved by changing the strategies used to monitor it. Nursing home care has been the subject of intensive regulations, while it has been neglected by physicians. Newer forms of long-term care are coming under stricter oversight, which may stifle the innovations they offer. Greater but different attention is needed: more creativity can be fostered with better accountability by emphasizing long-term care outcomes. It is unrealistic to require that long-term care patients will improve; good outcomes are defined as doing as well as or better than expected. The Minimum Data Set for nursing homes offers a mechanism to generate data on many pertinent outcomes. An outcomes focus would encourage more collective action by the various parties involved in providing long-term care, including physicians. Clinicians are reluctant to assume responsibility for outcomes they feel unable to strongly influence, but they must recognize that part of their role is to engender cooperation from the myriad participants in long-term care, including patients and their families. Better-quality long-term care may cost more, but it may be possible to use less expensive personnel more creatively if current regulations are modified. Managed care arrangements offer one vehicle for reorganizing care and could provide the appropriate incentives to make positive changes. However, they could also lead to minimalist strategies. Accountability for realistic outcomes can provide the needed countervailing regulatory pressure.

Developing a measure of health outcomes in survivors of childhood cancer: a review of the issues

The success of treatment for childhood cancer has prompted greater attention to issues of quality of life for the survivors. Work on health-related quality of life has proceeded faster for adults than for children. This paper reviews the results of such work for adults and points to the potential for applications in children. Specific problems in adapting measures and in interpreting the results in the context of a child's development are discussed. An approach to the assessment of the health-related quality of life for survivors of childhood cancer is proposed.

The outcomes of elective laparoscopic and open cholecystectomies

BACKGROUND

The demand for evidence of effectiveness for medical care has prompted the development of epidemiologic approaches to relating the outcomes of care to treatment. This study compares the outcomes of care for patients undergoing the newly introduced laparoscopic cholecystectomy with the results from conventional open cholecystectomies.

METHODS

Consecutive cases of elective cholecystectomy from 35 hospitals (all of the metropolitan and selected rural hospitals in Minnesota) were enrolled in the study. Patients were interviewed on admission to establish baseline symptoms and functional status and to confirm risk factors. Their medical records were abstracted to yield information on risk factors, treatment, and hospital complications. To establish outcomes, patients were sent a questionnaire about their symptoms and functional status six months postoperatively.

RESULTS

Of 3,448 patients studied, 2,490 (72 percent) had a laparoscopic procedure, including 195 cases that were converted to open cholecystectomies. Functional status data were obtained on 2,481 cases (76 percent). Laparoscopic operation was associated with more operative complications (odds ratio 3.02, p < 0.001), but with fewer general complications (odds ratio 0.32, p < 0.001). The mean time to return to work was 15 days for laparoscopic cases compared to 31 days for open procedures (p < 0.001). The only functional outcome difference between the two procedures was that patients who underwent laparoscopic cholecystectomies were more likely than those with conventional cholecystectomies to be able to perform their usual activities at follow-up evaluation (p < .001). There was evidence of a learning curve; the more laparoscopic procedures a surgeon performed, the fewer the operative (p < 0.01) and general (p < 0.0001) complications. There was no indication that the availability of laparoscopic operation was associated with more operations being performed.

CONCLUSIONS

Laparoscopic operation seems to represent a significant advance in getting patients back to a normal life sooner. More attention needs to be given to which patients are most likely to benefit from cholecystectomy of either type. Epidemiologic approaches can be useful in assessing the effectiveness of care. Partnerships between providers and researchers can produce useful effectiveness data by supplementing available clinical records with more detailed outcome data.

Creating practice guidelines: the dangers of over-reliance on expert judgment

Discussions about the role of practice guidelines and the strength of the evidence on which they are based should begin with a set of more basic questions: What is the function of such guidelines and what forces shape their use?

At least two forces can be seen behind the press for guidelines. On the one hand, guidelines can be used to improve the quality of care by raising the general level of practice to meet at least the standards set by experts. At the other, they become vehicles for cost containment.

By international standards, the United States spends a disproportionate share of its gross domestic product on health care. The majority of spending increases are traceable to the growth in technology. Whether couched as a concern that resources could be better used to provide other parts of the population with more effective health care or as a general concern that money spent on health might be better used for other social goods, a notion exists that less is better.

Head injury in partner-abusive men

Research into etiology of marital aggression has focused primarily on psychosocial, political, and cultural factors, to the exclusion of physiological influences. Fifty-three partner abusive men, 45 maritally satisfied, and 32 maritally discordant, nonviolent men were evaluated for past history of head injury, by a physician who was not informed of group membership and aggression history. Logistic regressions confirmed that head injury was a significant predictor of being a battered. The implications of these findings for both marital aggression and post-head injury rehabilitation are discussed.

Integrating an outcomes information system into managed care for substance abuse

The following paper describes a program launched recently to combine the efforts of two very different sectors of the outcomes management field--a managed behavioral healthcare company and a research-oriented academic center--and to pragmatically integrate outcomes data collection into routine clinical assessment and treatment processes in the substance abuse treatment field. This program has important implications not only for the behavioral healthcare industry's ability to satisfy external demands for outcomes data, but also as a foundation for better internal management and quality improvement processes.

A controlled trial of outpatient geriatric evaluation and management

OBJECTIVE

To evaluate the effects of targeted outpatient geriatric evaluation and management (GEM).

DESIGN

Controlled clinical trial. Elderly persons were identified as being at high risk for hospital admission on the basis of their responses to a short, mailed, self-administered questionnaire. The high-risk elders who chose to participate in the GEM program were compared to those who continued to receive usual care.

SETTING

Outpatient GEM clinic at an urban university hospital.

SUBJECTS

Elderly Medicaid recipients whose probability of repeated hospital admission (Pra) within 4 years was calculated as 40% or greater (Pra > or = 0.40).

MAIN OUTCOME MEASURES

Mortality, use of institutional services, satisfaction.

RESULTS

Of the 1210 persons who were sent questionnaires, 624 responded (response rate = 51.6%), of whom 154 (24.7%) were deemed to be a high risk for hospitalization. Of these, 43 received GEM (experimental subjects); 111 received usual care (controls). At baseline, the experimental and control groups' demographic and health-related characteristics did not differ significantly. The average experimental subject was 76.5 years old, had 9.6 significant medical problems, and took 6.7 significant long-term prescription medications. During the program's first 17 months of follow-up, the experimental subjects had lower annual rates of mortality (2.9% vs 19.2%, P = 0.03) and emergency room use (0.6 vs 1.0 visits, P = 0.01) than did the controls. The experimental subjects also tended to use nursing homes, but not hospitals, at a lower rate than the controls. All of the experimental subjects rated the program as either excellent (81.0%) or good (19.0%); 100% said they would recommend it to others. Their established primary physicians rated the GEM services as appropriate and helpful.

CONCLUSION

Targeted outpatient GEM was associated with reduced mortality, reduced use of emergency rooms, and a trend toward reduced use of nursing homes.

Looking for physical therapy outcomes

Assessing the outcomes of physical therapy will be difficult in many instances, because it is difficult to separate the specific contribution of physical therapy from the effects of overall rehabilitative efforts. Nonetheless, more studies are needed to establish what works, both specifically and overall. Appropriate care should be defined on the basis of what has been shown to be effective. In most instances, this knowledge will come from quasi-experimental designs that utilize epidemiological methods. In designing effectiveness studies, careful attention needs to be paid to defining the treatment in terms of type and amount of care. Other factors that will affect the outcome, including baseline performance, risk factors, and environment, must be adequately dealt with in the analysis. Rehabilitation's success depends on the patient's performance in his or her actual living situation, not just in a controlled environment. Blaming the community for failing to provide a supportive environment will not exonerate rehabilitation's responsibility.

Perspectives on home care quality

Home care quality assurance (QA) must consider features inherent in home care, including: multiple goals, limited provider control, and unique family roles. Successive panels of stakeholders were asked to rate the importance of selected home care outcomes. Most highly rated outcomes were freedom from exploitation, satisfaction with care, physical safety, affordability, and physical functioning. Panelists preferred outcome indicators to process and structure, and all groups emphasized "enabling" criteria. Themes highlighted included: interpersonal components of care; normalizing life for clientele; balancing quality of life with safety; developing flexible, negotiated care plans; mechanisms for accountability and case management. These themes were formulated differently according to the stakeholders' role. Providers preferred intermediate outcomes, akin to process.

Chronic conditions that lead to functional limitation in the elderly

BACKGROUND

The role of chronic medical conditions in elderly persons' loss of functional abilities is intuitively important but not well defined. This analysis was designed to identify chronic medical conditions that lead to the development of severe functional limitation.

METHODS

Functionally intact members of a multistage probability sample (n = 6,862) of all noninstitutionalized U.S. civilians age 70 years or older were interviewed in 1984. Based on data from the National Death Index and from follow-up telephone interviews in 1988 with survivors, subjects were classified as functionally intact, functionally limited (unable to perform one or more of seven essential activities), or decreased.

RESULTS

After adjusting for the effects of exercise habits and demographic, socioeconomic, and psychosocial factors, we found that the best predictors of the development of functional limitation were cerebrovascular disease (OR = 2.14; 95% CL = 1.16, 3.98) and arthritis (OR = 1.51; 95% CL = 1.08, 2.11). The contribution of coronary artery disease also approached statistical significance (OR = 1.49; 95% CL = 0.99, 2.27).

CONCLUSION

In the future, the primary prevention or effective treatment of cerebrovascular disease, arthritis, and possibly coronary artery disease may produce a modest reduction in the incidence of severe functional limitation.

Post-hospital home health care for Medicare patients

Medicare patients in five diagnosis-related groups (DRGs) associated with heavy use of post-hospital care discharged from 52 hospitals in 3 cities were followed up at 6 weeks, 6 months, and 1 year to determine the factors associated with their being discharged home with or without home health care and the correlates of improvement in their functional status. Models correctly predicted those discharged home from those going to institutions in a range from 54 to 82 percent of cases. The amount of the variance in the change in function for those who went home (with or without home health care) explained by the models tested ranged from 19 percent to 73 percent. Total Medicare costs for the patients who went home were considerably less in the year subsequent to the hospitalization compared with those discharged to institutional care.

Implications of the Clinton health reform plan for older persons and long-term care

The Clinton plan for older persons and those in need of long-term care offers short-term problems and long-term promises. Final judgment depends in part on the level of commitment assumed for various aspects of the plan. In the near term, even under the best scenario, there will be problems of discoordination as certain groups (like the dually eligible and those needing long-term care) are caught in the gaps between the new and the old. In the longer term, there are potential gains from a more integrated system of care that can accommodate both acute and chronic care and eliminate the administrative incentives to shift fiscal responsibility. Medicare was passed in an effort to correct a disparity. It would be ironic if its existence created a new one. At the same time, older persons are currently better served than many uninsured younger persons. Before they open their mouths to grab for the bone in the water, they had best hang on to the one they have.