Geographic Access and Service Use in a Community-Based Sample of Cognitively Impaired Elders

Objective: The purpose of this research was to determine whether geographic access influences service utilization in a community-based sample of older adults with cognitive impairment. Methods: A telephone screener for cognitive impairment was administered to 9,100 elderly Arkansans with caregivers, resulting in a sample with 317 elder/caregiver dyads. Self-reported service utilization was collected for three sectors: home health, physical health, and mental health. Geographic access was measured from (a) self-reported awareness of services in each sector and (b) the travel time to the closest provider in each sector calculated using a Geographic Information System. Results: Travel time significantly predicted home health service utilization while perceived awareness significantly predicted mental health service utilization. Neither measure of geographic access predicted use of physical health services. Discussion: Because rural elders with less geographic access receive fewer home/mental health services, they may be at greater risk for hospitalization or nursing home placement.

Racial differences in women's prodromal and acute symptoms of myocardial infarction

BACKGROUND

Minority women, especially black and Hispanic women, have higher rates of coronary heart disease and resulting disability and death than do white women. A lack of knowledge of minority women's symptoms of coronary heart disease may contribute to these disparities.

OBJECTIVE

To compare black, Hispanic, and white women's prodromal and acute symptoms of myocardial infarction.

METHODS

In total, 545 black, 539 white, and 186 Hispanic women without cognitive impairment at 15 sites were retrospectively surveyed by telephone after myocardial infarction. With general linear models and controls for cardiovascular risk factors, symptom severity and frequency were compared among racial groups. Logistic regression models were used to examine individual prodromal or acute symptoms by race, with adjustments for cardiovascular risk factors.

RESULTS

Among the women, 96% reported prodromal symptoms. Unusual fatigue (73%) and sleep disturbance (50%) were the most frequent. Eighteen symptoms differed significantly by race (P<.01); blacks reported higher frequencies of 10 symptoms than did Hispanics or whites. Thirty-six percent reported prodromal chest discomfort; Hispanics reported more pain/discomfort symptoms than did black or white women. Minority women reported more acute symptoms (P < .01). The most frequent symptom, regardless of race, was shortness of breath (63%); 22 symptoms differed by race (P <.01). In total, 28% of Hispanic, 38% of black, and 42% of white women reported no chest pain/discomfort.

CONCLUSIONS

Prodromal and acute symptoms of myocardial infarction differed significantly according to race. Racial descriptions of women's prodromal and acute symptoms should assist providers in interpreting women's symptoms.

The Influence of Integration on the Expenditures and Costs of Mental Health and Substance Use Care: Results from the randomized PRISM-E Study

We compared the healthcare costs associated with an integrated care model to an enhanced referral model for the treatment of depression, anxiety, and at-risk drinking from the randomized Primary Care Research in Substance Abuse and Mental Health for the Elderly study. We examined total healthcare costs and cost components, separately for Veteran's Affairs and non-VA participants. No differences in total health expenditures were detected between study arms. No differences in behavioral health expenditures were detected for non-VA sites, but the VA integrated arm had slightly higher ($38; p<0.05) behavioral health costs. Differences in other types of services use were detected.

Human subjects protection issues in QUERI implementation research: QUERI Series

BACKGROUND

Human Subjects protections approaches, specifically those relating to research review board oversight, vary throughout the world. While all are designed to protect participants involved in research, the structure and specifics of these institutional review boards (IRBs) can and do differ. This variation affects all types of research, particularly implementation research.

METHODS

In 2001, we began a series of inter-related studies on implementing evidence-based collaborative care for depression in Veterans Health Administration primary care. We have submitted more than 100 IRB applications, amendments, and renewals, and in doing so, we have interacted with 13 VA and University IRBs across the United States (U.S.). We present four overarching IRB-related themes encountered throughout the implementation of our projects, and within each theme, identify key challenges and suggest approaches that have proved useful. Where applicable, we showcase process aids developed to assist in resolving a particular IRB challenge.

RESULTS

There are issues unique to implementation research, as this type of research may not fit within the traditional Human Subjects paradigm used to assess clinical trials. Risks in implementation research are generally related to breaches of confidentiality, rather than health risks associated with traditional clinical trials. The implementation-specific challenges discussed are: external validity considerations, Plan-Do-Study-Act cycles, risk-benefit issues, the multiple roles of researchers and subjects, and system-level unit of analysis.

DISCUSSION

Specific aspects of implementation research interact with variations in knowledge, procedures, and regulatory interpretations across IRBs to affect the implementation and study of best methods to increase evidence-based practice. Through lack of unambiguous guidelines and local liability concerns, IRBs are often at risk of applying both variable and inappropriate or unnecessary standards to implementation research that are not consistent with the spirit of the Belmont Report (a summary of basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research), and which impede the conduct of evidence-based quality improvement research. While there are promising developments in the IRB community, it is incumbent upon implementation researchers to interact with IRBs in a manner that assists appropriate risk-benefit determinations and helps prevent the process from having a negative impact on efforts to reduce the lag in implementing best practices.

Alcohol consumption among older adults in primary care

BACKGROUND

Alcohol misuse is a growing public health concern for older adults, particularly among primary care patients.

OBJECTIVES

To determine alcohol consumption patterns and the characteristics associated with at-risk drinking in a large sample of elderly primary care patients.

DESIGN

Cross-sectional analysis of multisite screening data from 6 VA Medical Centers, 2 hospital-based health care networks, and 3 Community Health Centers.

PARTICIPANTS

Patients, 43,606, aged 65 to 103 years, with scheduled primary care appointments were approached for screening; 27,714 (63.6%) consented to be screened. The final sample of persons with completed screens comprised 24,863 patients.

MEASUREMENTS

Quantity and frequency of alcohol use, demographics, social support measures, and measures of depression/anxiety.

RESULTS

Of the 24,863 older adults screened, 70.0% reported no consumption of alcohol in the past year, 21.5% were moderate drinkers (1-7 drinks/week), 4.1% were at-risk drinkers (8-14 drinks/week), and 4.5% were heavy (>14 drinks/week) or binge drinkers. Heavy drinking showed significant positive association with depressive/anxiety symptoms [Odds ratio (OR) (95% CI): 1.79 (1.30, 2.45)] and less social support [OR (95% CI): 2.01 (1.14, 2.56)]. Heavy drinking combined with binging was similarly positively associated with depressive/anxiety symptoms [OR (95%): 1.70 (1.33, 2.17)] and perceived poor health [OR (95% CI): 1.27 (1.03, 1.57)], while at-risk drinking was not associated with any of these variables.

CONCLUSIONS

The majority of participants were nondrinkers; among alcohol users, at-risk drinkers did not differ significantly from moderate drinkers in their characteristics or for the 3 health parameters evaluated. In contrast, heavy drinking was associated with depression and anxiety and less social support, and heavy drinking combined with binge drinking was associated with depressive/anxiety symptoms and perceived poor health.

Disparities in use of antipsychotic medications among nursing home residents in Arkansas

Pilot work was conducted to determine whether there were racial disparities in the use of second-generation antipsychotic medications in a sample of 2,717 residents of nursing homes in Arkansas in 2001. Chi square analysis and a logistic regression model were used to examine the relationship between residents' race and likelihood of receiving a second-generation antipsychotic. Other independent variables included in the model were age, gender, and the location of the nursing home. The results indicated racial disparities in use of second-generation antipsychotics among the nursing home residents, with African-American residents less likely to receive these medications than residents from other racial or ethnic groups.

A Conceptual Model of Pain Assessment for Noncommunicative Persons With Dementia

PURPOSE

Our objectives are to present a conceptual model of the pain assessment process in persons with dementia and discuss methods for validating our model within this population.

DESIGN AND METHODS

This conceptual work is based on an integrative review and current pain theory, pain assessment research in demented and nondemented populations, and research on the science of self-report.

RESULTS

We present a multidimensional model of pain assessment that emphasizes the role of the external rater. Our model posits that a nociceptive stimulus leads to pain sensation, followed by pain perception, followed by the exhibition of external signs of pain by the patient, followed by an external rater's observation and interpretation of those external signs. Further, the model specifies the effects of nociceptive stimulus factors on pain sensation; patient-specific factors on pain perception; method-specific factors on external sign observation; and rater-specific factors on external sign interpretation.

IMPLICATIONS

Pain assessment in persons with dementia must go beyond a unidimensional model of pain assessment. This multidimensional model also directly addresses the challenges of using external ratings to assess pain in persons with dementia. Finally, we present clinical recommendations for applying the model to pain assessment endeavors and research recommendations for evaluating models of pain in this population.

NOPPAIN: a nursing assistant-administered pain assessment instrument for use in dementia

The Non-Communicative Patient's Pain Assessment Instrument (NOPPAIN) is a nursing assistant-administered instrument for assessing pain behaviors in patients with dementia. This study investigated the validity of the NOPPAIN. Twenty-one nursing assistants (NAs) with no prior training in using the NOPPAIN watched six videos, each portraying a bed-bound patient with severe dementia receiving personal care from a nursing assistant and responding with a different level of pain intensity. The NAs completed a NOPPAIN rating for each video. The NAs were also presented with each possible pair of videos and asked to identify the video showing the most pain. Results indicated the NAs were quite accurate in their ratings of the videos, providing excellent preliminary evidence on the use of the NOPPAIN for detecting pain in nursing home patients with dementia.

Informed Consent: A Process to Facilitate Older Adults' Participation in Research

Trust is the foundation of the informed consent process. According to Kass et al., Yet only through vigilance and humility will we, as investigators, be able to live up to the trust that is placed in us; and only if that trust is deserved can the research enterprise survive (1996, p. 28). Therefore, further research should examine the effect of the informed consent process in limiting older adults' participation. Only by re-evaluating the first point of contact, implementing creative strategies to overcome barriers to the informed consent process, and validating these strategies through research will nurses facilitate the inclusion of older adults in research.

Identifying factors critical to implementation of integrated mental health services in rural VA community-based outpatient clinics

The purpose of this study was to gain a better understanding of the critical components associated with implementing integrated mental health care services in rural VA community-based outpatient clinics (CBOCs). In-person semi-structured interviews were conducted with 20 health care providers and staff within a year after placing a trained advanced practice nurse (APN) to provide mental health/substance abuse (MH/SA) care at 2 rural CBOCs in the southeastern United States. Four raters independently evaluated interview transcripts and conducted content analysis to summarize the interview results. The results indicate that key contextual factors related to leadership, staff attitudes and beliefs, and unique organizational factors of the clinic and the community can affect the success of such clinical innovations. In addition to providing descriptive information about the attitudes, beliefs, and experiences of CBOC personnel regarding implementation of integrated MH/SA services using APNs, the study findings suggest several domains that could be explored in future studies of integrated mental health service delivery to rural veterans through primary care.

Effects of sustained audit/feedback on self-reported health status of primary care patients

PURPOSE

Because limited audit/feedback of health status information has yielded mixed results, we evaluated the effects of a sustained program of audit/feedback on patient health and satisfaction.

METHODS

We conducted a group-randomized effectiveness trial in which firms within Veterans Administration general internal medicine clinics served as units of randomization, intervention, and analysis. Respondents to a baseline health inventory were regularly mailed the 36-Item Short Form (SF-36) and, as relevant, questionnaires about six chronic conditions (ischemic heart disease, diabetes, chronic obstructive pulmonary disease, depression, alcohol use, and hypertension) and satisfaction with care. Data were reported to primary providers at individual patient visits and in aggregate during a 2-year period.

RESULTS

Baseline forms were mailed to 34,050 patients; of the 22,413 respondents, 15,346 completed and returned follow-up surveys. Over the 2-year study, the difference between intervention and control groups (as measured by difference in average slope) was -0.26 (95% confidence interval [CI]: -0.79 to 0.27; P=0.28) for the SF-36 Physical Component Summary score and -0.53 (95% CI: -1.09 to 0.03; P=0.06) for the SF-36 Mental Component Summary score. No significant differences emerged after adjusting for deaths. There were no significant differences in condition-specific measures or satisfaction between groups after adjustment for provider type, panel size, and number of intervention visits, or after analysis of patients who completed all forms.

CONCLUSION

An elaborate, sustained audit/feedback program of general and condition-specific measures of health/satisfaction did not improve outcomes. To be effective, such data probably should be incorporated into a comprehensive chronic disease management program.

Development of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey

BACKGROUND/OBJECTIVES

Coronary heart disease (CHD) is the number one cause of death in women, yet, little is known about women's symptoms. Early symptom recognition of CHD in women is essential but most instruments do not assess both prodromal and acute CHD symptoms. Our aims were to develop an instrument validly describing women's prodromal and acute symptoms of myocardial infarction and to establish reliability of the instrument, the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS).

METHODS

Four studies contributed to the content validity and reliability of this instrument. Two qualitative studies provided the list of symptoms that were confirmed in study 3. The resulting instrument assesses 37 acute and 33 prodromal symptoms. In study 4, 90 women were retested 7 to 14 days after their initial survey. We used the kappa statistic to assess agreement across administrations.

RESULTS

The women added no new symptoms to the MAPMISS. The average kappa of acute symptoms was 0.52 and 0.49 for prodromal. Next we calculated a weighted score. The mean acute score for time 1 was 19.4 (SD = 14.43); time 2 was 12.4 (SD= 8.79) with Pearson correlation indicating stability (r = .84; P < .01). The mean prodromal score at time 1 was 23.80 (SD= 24.24); time 2 was 26.79 (SD = 30.52) with a Pearson correlation of r = .72; P < .01.

CONCLUSIONS

The tool is comprehensive, has high content validity, and acceptable test-retest reliability. Low kappas were related to few women having those symptoms. The symptom scores remained stable across administrations.

Women's early warning symptoms of acute myocardial infarction

BACKGROUND

Data remain sparse on women's prodromal symptoms before acute myocardial infarction (AMI). This study describes prodromal and AMI symptoms in women.

METHODS AND RESULTS

Participants were 515 women diagnosed with AMI from 5 sites. Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, we surveyed them 4 to 6 months after discharge, asking about symptoms, comorbidities, and demographic characteristics. Women were predominantly white (93%), high school educated (54.8%), and older (mean age, 66+/-12), with 95% (n=489) reporting prodromal symptoms. The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men. The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3+/-4.8; range, 0 to 29) than prodromal (mean, 5.71+/-4.36; range, 0 to 25) symptoms. The average prodromal score, symptom weighted by frequency and intensity, was 58.5+/-52.7, whereas the average acute score, symptom weighted by intensity, was 16.5+/-12.1. These 2 scores were correlated (r=0.61, P<0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology.

CONCLUSIONS

Most women have prodromal symptoms before AMI. It remains unknown whether prodromal symptoms are predictive of future events.

Gender, kinship and caregiver burden: the case of community-dwelling memory impaired seniors

BACKGROUND

This study examined whether there were gender and kinship (spouse, child, more distant relative) differences in caregiver burden. It further examined the constellation of gender and kinship by examining whether adult daughter caregivers experienced greater burden compared to wives, husbands, sons, and other more distant relatives.

METHODS

The sample consisted of 305 family caregivers of memory-impaired individuals who were age 70 years or older and resided in non-institutional settings in Arkansas. A cross-sectional design was employed using validated measures to assess both the memory-impaired elders' and family caregivers' self-reported physical and memory status.

RESULTS

After controlling for the age and health status characteristics of the memory-impaired elder, sociodemographic and health status characteristics of the family caregiver, and the caregiver coping response (measured by the sense of coherence), multiple regression analyses found kinship, but not gender differences in caregiver burden. Adult children experienced more caregiver burden than more distant relatives. There were no significant differences in caregiver burden between adult children and spouses. Adult daughters had greater caregiver burden scores compared to more distant relatives, but had comparable scores to wives, sons, and husbands. Other significant correlates of burden included caregiver personal characteristics (age and ethnicity) and the sense of coherence.

CONCLUSIONS

The study discusses the practice implications of adult children and adult daughters' propensity to suffer burden when caring for their memory-impaired parents living in the community. It also discusses the relevance of caregiver personal characteristics and the sense of coherence as correlates of burden.

Purification and characterization of the aromatic desulfinase, 2-(2'-hydroxyphenyl)benzenesulfinate desulfinase

2-(2(')-Hydroxyphenyl)benzenesulfinate desulfinase (HPBS desulfinase) catalyzes the cleavage of the carbon-sulfur bond of 2-(2(')-hydroxyphenyl)benzenesulfinate (HPBS) to form hydroxybiphenyl and sulfite. This is the final step in the desulfurization of dibenzothiophene, the organosulfur compound used to study biodesulfurization of petroleum middle distillate. HPBS desulfinase was purified 1600-fold from Rhodococcus IGTS8. The purification was monitored using a spectrofluorimetric assay and SDS-PAGE. The pI of HPBS desulfinase is 5.6, the temperature optimum is 35 degrees C, and the pH optimum is 7.0. HPBS desulfinase has a K(m) of 0.90+/-0.15 microM and a k(cat) of 1.3+/-0.07 min(-1). Several analogs were tested for their ability to act as substrates or inhibitors of HPBS desulfinase. No alternative substrates and very few inhibitors were identified. HPBS desulfinase activity decreases in the presence of Cu(2+) and Zn(2+), while no metals significantly enhance enzyme activity. HPBS desulfinase is susceptible to tyrosine, tryptophan, and cysteine specific modification agents.

Challenges to the use of nonpharmacologic interventions in nursing homes

The Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987, stated that nursing homes should try nonpharmacologic interventions before resorting to pharmacologic agents when addressing problem behaviors among residents. Since that time, the use of pharmacologic agents has decreased, but there is little evidence to suggest that the use of nonpharmacologic interventions has increased. Psychosocial models describe problem behaviors as complex phenomena that require individualized strategies based on a resident's unique characteristics. Categories of intervention include social contact, behavior therapy, staff training, structured activities, environmental interventions, and a combination of therapies. This article discusses internal barriers to the use of nonpharmacologic interventions based on the Porras stream organization model: organizing arrangements, social factors, technology, and physical setting. Also, external barriers related to the regulatory, legal, and economic sectors are discussed. The authors offer recommendations for overcoming these barriers.

Integrating Health Services Research Into Nursing Doctoral Programs: The Evolution of Nursing Research

Traditionally, nursing research has focused on the effect of an intervention on selected patients without considering the influence of the system of care and its myriad characteristics. Health services research (HSR) focuses on organization and financing of health services; access to health care; quality of care; clinical evaluation and outcomes research; informatics and clinical decision making; practitioner, patient, and consumer behavior; health professions workforce; health policy formulation and analyses; and health care model and service use. Doctoral students can benefit from HSR's broad perspective if it is included in existing nursing curricula. Ultimately, HSR could help the nursing profession achieve the capacity to develop health policy and new systems of health care for the 21st century.

Reported practices of primary care physicians in the diagnosis and management of dementia

The shortage of geriatric specialists in the US may require that primary care physicians (PCPs) receive more education on diagnosing and managing dementia since the number of older Americans with dementia will increase from about five million in 2010 to up to 14 million in 2050. Thus, we administered a brief, anonymous questionnaire to determine PCPs' diagnostic, referral, and management practices to a convenience sample of 142 PCPs in Arkansas. We reworded a Scottish survey to conform to terminology used in the US and added items on referral practices. The PCPs who reported difficulty establishing the diagnosis of dementia had more difficulty telling the diagnosis (O.R = 3.59, p < 0.004). The PCPs were less likely (p < 0.001) to tell the patient if they suspected dementia (73%) than if they were sure the patient had dementia (88%). In both cases, they were more likely to tell the family (92% & 100%, respectively), although this difference was not statistically significant. The PCPs discussed disease progression and driving risks with patients and families, but few referred them to social workers or community agencies. Findings support training PCPs in the diagnosis and management of persons with dementia and providing tools to improve care.

Rural-urban differences in service use for memory-related problems in older adults

The reduced availability of providers and travel difficulties in rural areas may thwart older rural adults from getting the care they need for memory-related problems. The purpose of this study was to determine whether rural-urban differences exist in the probability of any service use of primary care physicians and mental health specialists in a full sample of older adults and in a subset of impaired respondents. In the full sample, rural respondents were 0.66 times as likely (p = .06) to have used primary care physicians for memory-related problems compared with urban respondents. In the subgroup, rural individuals were 0.26 times as likely (p = .02). In both groups, there were no rural-urban differences in the probability of mental health specialty use for memory-related problems. Further investigations are necessary to determine the causes.

Do you know them when you see them? Women's prodromal and acute symptoms of myocardial infarction

This study described women's prodromal and acute symptoms associated with myocardial infarction (MI) based on interviews with 76 women who had experienced an MI in the previous year. Sixty-eight women experienced prodromal symptoms including unusual fatigue (70%), shortness of breath (53%), and pain in the shoulder blade/upper back (47%). All women experienced acute symptoms including chest pain/discomfort (90%), unusual fatigue (59%), shortness of breath (59%), and shoulder blade/upper back discomfort (42%). Although women in this study reported numerous prodromal symptoms, none had received a new diagnosis of coronary heart disease (CHD) prior to MI. Practitioners must develop an awareness of and a more comprehensive approach to treating women at risk for CHD. Further research to elucidate prodromal and acute symptom clusters is needed to assist practitioners in early diagnosis of CHD in women.

Dementia diagnostic guidelines: methodologies, results, and implementation costs

OBJECTIVE

To facilitate the diagnostic process for dementia. Five guidelines and four consensus statements on specific diagnostic recommendations, specialist referral recommendations, and costs of recommended diagnostic procedures were compared and summarized.

DATA SOURCES AND SELECTION

A MEDLINE search from 1984 to 1999 and queries to experts yielded 14 guidelines and consensus statements that addressed the diagnosis of dementia. Only nine documents which had national or international scopes were reviewed.

METHODS

Comparisons were made on the specific diagnostic criteria for patient history, clinical examination, functional assessment, laboratory tests, neuroimaging, and other diagnostic tests, as well as specialist referral recommendations and costs for the recommended diagnostic procedures. The first three authors reviewed independently each document and completed a table on specific recommendations in each document. To settle disagreements about specific recommendations, they discussed them until they reached a consensus. To interpret the intent of vague statements, they used their best judgment.

RESULTS

The documents differed in content, recommendations, and development methodology. They were based on either expert opinion or scientific evidence, or both. Although the nine documents were nearly unanimous in several recommendations, including assessing the presenting problem, taking a medical history, conducting physical and neurological examinations, and assessing the patient's mental and cognitive status, considerable differences in recommendations were common. Such differences led to large differentials in the estimated costs (range, $190 to $2,001) for recommended diagnostic assessments.

CONCLUSIONS

A systematic approach to diagnostic recommendations for dementia may induce greater consistency among guidelines and consensus statements. The current approach leads to considerable variability in recommendations and estimated costs.

Vertical integration strategies: revenue effects in hospital and Medicare markets

The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.

Compliance with sulfonylureas in a health maintenance organization: a pharmacy record-based study

OBJECTIVE

To determine which factors affect compliance with sulfonylureas in a population served by a health maintenance organization in Southern California.

METHODS

Retrospective analysis of pharmacy records and healthcare utilization data for two years (April 1993-March 1995), and a survey mailed to patients. Patients treated with sulfonylureas were selected for analysis on the basis of their prescription profile. Compliance was measured from the pharmacy records as the proportion of days the patient was in possession of the prescribed medications. Patient compliance with sulfonylureas was modeled as a function of four clusters of determinants: patient-related attributes, drug regimen characteristics and complexity, health status and disease-related variables, and characteristics of the interaction with healthcare providers.

RESULTS

786 patients were identified for analysis (49.1% women, mean age 59 y). The mean compliance rate was 83% +/- 22% SD. Compliance was significantly positively related with age and self-reported level of medication-taking compliance at baseline. Factors shown to have an inverse relationship with compliance were treatment complexity, perception of general health, and being a newly treated patient (adjusted R2 for the final model = 0.148).

CONCLUSIONS

Our results suggest that factors found to be associated with noncompliant behavior (e.g., being a newly treated patient, self-reported compliance, regimen complexity) can be assessed by physicians and pharmacists as a routine practice.

The Kaiser Permanente/USC Patient Consultation Study: change in quality of life. University of Southern California

The impacts of two models of pharmacist consultation on patient function and health-related quality of life (HRQOL) relative to a control model were studied. Patients in the random-assignment study and the areawide study of the Kaiser Permanente/USC Patient Consultation Study were surveyed three times over a two-year period. The patients were receiving pharmaceutical services under the Kaiser Permanente model of consultation (KP model), a state model of consultation, or a control model and were stratified according to prescription drug use. A global visual-analogue scale and Short Form-36 were used to assess HRQOL. In the areawide study, only 2 of 42 comparisons of the effects of the KP or state model on HRQOL were significant; both were associated with the state model and involved only small increases. In the random-assignment study, 3 of 21 estimated effects of the KP model on HRQOL were positive and significant; 2 of these were significantly different between the KP model and the state model. Although the KP and state models of consultation were associated with some changes in HRQOL, the overall influence was not consistent and not clinically important.

The Kaiser Permanente/USC Patient Consultation Study: patient satisfaction with pharmaceutical services. University of Southern California

The impacts of two models of pharmacist consultation on patient satisfaction with pharmaceutical services relative to a control model were studied. Patients in the random-assignment and areawide studies of the Kaiser Permanente/USC Patient Consultation Study were asked to rate their satisfaction with six aspects of the service they received at the pharmacy. The patients were receiving pharmaceutical services under the Kaiser Permanente (KP) model of consultation, a state-mandated model, or a control model. They were assigned to risk categories according to their pattern of prescription drug use. Differences in satisfaction among the three consultation models for all patients and for each risk group and correlations between satisfaction items were determined. The KP and state models of consultation were associated with better satisfaction than the control model on five of the six satisfaction items. In the high-risk patient groups, the KP and state models were associated with higher levels of satisfaction than the control model. In the low-risk group, the state model was associated with higher levels of satisfaction than the control model; results for low-risk patients assigned to the KP model were inconsistent between the random-assignment study and the areawide study. Overall satisfaction appeared to be a suboptimal measure of satisfaction with consultation. Overall satisfaction was more closely related to satisfaction with waiting time and with whether the pharmacy staff was helpful and caring than with the three items reflecting satisfaction with the content of the consultation. Patients were more satisfied under the state model of pharmacist consultation or the KP model of consultation, which resulted in more-intensive counseling for fewer patients, than under a control model.

The Kaiser Permanente/USC Patient Consultation Study: change in use and cost of health care services

The impacts of three alternative models of pharmacist consultation on the use and cost of health care services were studied. Two studies were conducted concurrently in an HMO over two years. In one, 6000 patients were randomly assigned to one of three consultation models; in the other, the three models were implemented in six geographic regions of California (4600 patients). The models were (1) consultation about new or changed prescriptions as mandated by state law (state model), (2) consultation focused on selected high-risk ambulatory care patients (Kaiser Permanente [KP] model), and (3) a control model. The patients were surveyed three times about their health status and satisfaction, and computerized data on health care use and cost were collected. The effect of the consultation models on the use and cost of health care services was examined across five risk groups that were based on drug-use profiles. An additional 37,750 patients (10% of the patients residing in the areawide study sites) were included in a supplemental analysis of the use and cost of health care services. There was no indication in the random-assignment study that pharmacist consultations affected either drug costs or the cost of office visits. Similar results were found in the areawide study, with the exception that the KP model was associated with lower drug costs than the control model. In the 10% sample, the KP model appeared to be associated with lower office visit costs but higher drug costs. Both models were associated with a lower likelihood of a hospital admission and with lower total health care costs for some high-risk patients compared with the control model. Counseling patients about their medications may be unlikely to reduce medication costs or the cost of office visits but may reduce the likelihood of hospital admissions and the overall costs of health care services; a combination of counseling patients at high risk for drug-related problems and counseling all patients about any new or changed prescription should be considered.

Factors affecting patient compliance with antihyperlipidemic medications in an HMO population

OBJECTIVE

To identify factors that influence compliance in patients taking antihyperlipidemic medications.

STUDY DESIGN

This was a retrospective cohort study in which computerized pharmacy records were used to estimate medication compliance in patients in a Health Maintenance Organization from 1993 to 1995.

PATIENTS AND METHODS

Data on 772 patients on antihyperlipidemic medications were obtained from pharmacy and healthcare utilization claims and from a cross-sectional survey. The medication compliance ratio for each patient was calculated from the prescription profile. Patient compliance was modeled as a function of four clusters of determinants: patient characteristics, complexity of drug regimen, health status, and patient-provider interaction. Correlation between specific characteristics and compliance was estimated by logistic regressions.

RESULTS

Approximately 37% of patients complied with at least 90% or more of their antihyperlipidemic medications. The following variables had a significant influence on compliance: female gender (odds ratio [OR], 0.64), baseline compliance (high: OR, 3.42; medium: OR, 1.86), perceived health status (SF-36 bodily pain score: OR, 1.02; SF-36 vitality score: OR, 0.97), comorbidity (OR, 0.90), and number of daily doses of antihyperlipidemic medications (OR, 0.60).

CONCLUSIONS

The findings suggest that women, patients with comorbidities, patients reporting high SF-36 vitality scores, and patients with multiple doses of antihyperlipidemic medications are less likely to be compliant. Patients who self-report good compliance with previous medications are more likely to comply. This information may be used to target interventions at patients who are likely to be noncompliant with their medication regimens.

A multidisciplinary team approach to managing Alzheimer's disease

Patients with Alzheimer's disease experience a range of symptoms that may overwhelm the patients, their families, and the people responsible for their care. With today's drive to reduce health care costs, any plan for managing these patients must produce maximum effectiveness at the lowest possible cost. A multidisciplinary team potentially offers both effective and efficient dementia care by eliminating duplicative or ineffective services and maintaining the optimum health of the patient and family.

A pilot study of cervical screening in an inner city area--lessons for a national programme

The objectives of this study were to examine aspects of organization of a proposed national screening programme based in general practice. The target population of women aged 25-59 years and their general practitioners (GPs), in a defined inner city area, was identified from a population register of persons eligible for free medical services; a computerized system was developed for invitations and record linkage of cytology results. Smears were examined in one laboratory and follow up of women with abnormal smears was undertaken by one gynaecologist. A random sample of non-responders was surveyed by questionnaire. Response following two invitations was only 20%. Practices with male doctors only had significantly lower response rates (P < 0.001) than those with a female doctor/nurse. A survey of non-responders showed that over 20% of addresses were incorrect and 16% of those interviewed were ineligible for smear tests. A preference for a female to undertake smears was expressed by 67%, and 77% believed that the purpose of the cervical smear was to detect cancer. An accurate population register, health promotion, support for GP practices, provision of alternative venues for smear tests, development of computer systems, accurate data entry and fail-safe follow up are aspects of a cervical screening service which must be addressed prior to setting up a national service.

Emotional support for cancer patients: what do patients really want?

For many cancer patients and their families the experience of cancer is an intensely stressful one. Emotional support is important for most cancer patients during their illness and can be gained from different people and services. This study evaluates patients' attitudes to different sources of support and rates their satisfaction with sources already used. A total of 431 patients completed a questionnaire covering the use of different sources, including individuals, support groups and information sources. The questionnaire also incorporated validated measurements of anxiety, depression and locus of control. The results revealed that the three most important sources of emotional support were senior registrars (73%) and family (73%), followed by consultants (63%). Patients would prefer doctor- and nurse-led support groups to patient only-led groups (26% vs 12%). Pamphlets, such as the BACUP booklets, proved the most important of the informational sources sought (50%). A total of 86% of patients were satisfied or very satisfied with the emotional support received. Patients who expressed dissatisfaction with their emotional support were significantly more likely to be anxious and depressed (P < 0.001). Patients who used information sources were more likely to have a higher locus of control over the course of their disease. These results show how important the doctor's role is in the provision of emotional support.

Ascertaining dementia by expert panel in epidemiologic studies of nursing home residents

A new method for ascertaining dementia in epidemiologic research and the results of a study to evaluate it are described. The method relies on an expert panel of clinicians reviewing clinically relevant information collected by lay evaluators to arrive at a diagnosis based on DSM-III-R criteria. The approach was developed to study dementia in a statewide sample of over 2400 new admissions to 59 nursing homes in Maryland. Expert panel ascertainment of dementia was compared to that obtained by direct clinical evaluation for 100 nursing home residents. Agreement between the panel and direct assessment was 76% (kappa = 0.59) using a three-category classification of dementia, no dementia, and indeterminate. This ascertainment strategy provides an alternative to methods currently in use and is particularly well-suited for populations with a high prevalence, in those dispersed over large geographic areas, and when timely, cost-effective evaluations are required.

Measuring the impact of patient counseling in the outpatient pharmacy setting: the research design of the Kaiser Permanente/USC patient consultation study

This article describes the research method used to measure the impact of three alternative models of patient counseling in the outpatient pharmacy setting. The study was conducted in pharmacies operated by the Southern California region Kaiser Permanente Medical Care Program. Both random assignment and large-scale geographic area research designs were used. The presentation of the research design includes discussions of data collection and patient sampling methods; the measurement of patient outcomes, including measures of health care costs and utilization, patient functional status, and quality of life. Demographic data are presented for the study population, including an analysis of potential biased selection of patients electing to participate in random assignment. Data are also presented documenting potential selection bias across geographically determined treatment groups in the geographic area design arm. Finally, the article presents the analysis plan for the study and discusses study limitations.

Measuring of impact of patient counseling in the outpatient pharmacy setting: development and implementation of the counseling models for the Kaiser Permanente/USC Patient Consultation Study

The Southern California region Kaiser Permanente Medical Care Program, which serves 2.2 million patients, and the University of Southern California School of Pharmacy have designed and implemented a patient consultation study to determine the cost-effectiveness of three different approaches to providing pharmacist consultation to outpatients. This paper describes the development and implementation of these three models. A total of 107 pharmacies (approximately 600 pharmacists) participated in the study and were assigned to provide one of the models of patient consultation, designated the Kaiser Permanente (KP) model, the state model, and the control model. The KP model (20 pharmacies) provided targeted pharmaceutical care services to high-risk patients based on drug use. The state model (67 pharmacies) provided California-mandated patient consultation to patients with new or changed prescriptions, instructions for use, relevant warnings and precautions, storage requirements, and the importance of compliance. The control model (20 pharmacies) provided consultation when deemed necessary by the pharmacist and provided care similar to that provided before mandatory consultation in California. The KP and state models used the same pharmacist/technician/clerk resources, but the control pharmacies limited personnel resources to those existing before the mandatory consultation law was passed in California. The paper describes the KP model in detail and provides a literature-based rationale for targeting particular high-risk patients for expanded services. The paper also describes the training process, gives an example of a high-risk patient intervention, provides information on documenting pharmacist interventions in all models, and explains the method used for monitoring implementation of the models.

Exercise intensity does not effect body composition change in untrained, moderately overfat women

OBJECTIVE

To determine whether exercise intensity effects a change in body composition.

DESIGN/SUBJECTS

Twelve untrained, moderately overfat, weight-stable women were randomly assigned to a high-intensity (80% VO2max) or low-intensity (50% VO2max) exercise group. Subjects trained four times per week for 12 weeks in monitored sessions, with a duration sufficient to expend 300 kcal. During this time, subjects were instructed to maintain their normal diet and activity patterns.

OUTCOME MEASURES

Pretesting and posttesting included measurement of height, weight, body fat (via hydrostatic weighing), seven skinfold sites, seven circumference sites, and VO2max.

STATISTICAL ANALYSES

Results were analyzed using the Student's t test and paired samples t test.

RESULTS

Posttesting revealed no significant between-group differences for change in weight, percent body fat, fat mass, fat-free mass, sum of skinfold measurements, or sum of circumference measurements. Mean weight loss was 0.7 lb for the high-intensity group (P = .55) and 3.3 lb for the low-intensity group (P = .03). Hydrostatic data revealed that each group lost an identical amount of fat (5.0 lb), but the high-intensity group gained more than twice as much fat-free mass (4.3 vs 1.8 lb). The greater increase in fat-free mass by the high-intensity group explains why the low-intensity group had a greater absolute weight loss.

APPLICATIONS/CONCLUSIONS

This study suggests that fat loss is a function of energy expended rather than exercise intensity. Therefore, if fat loss is the goal and time is limited, persons should exercise safely at as high an intensity as tolerable to expend as much energy as possible during their allotted time.

Building a professional environment in long-term care. The role of clinical career development

1. To be successful, an organizational career development program must include a differentiation of the responsibilities for which the various parties (employer, employee, career counselor) will be held accountable. 2. Project outcomes revealed that the career mobility program was attractive to nursing personnel and facility management personnel alike. However, it was more attractive to nonlicensed than licensed personnel. 3. Of the staff who participated and were promoted, the majority remained in their jobs. The program was most successful in enhancing retention with personnel who received within-level promotions. 4. The process of career development requires collaboration and support from all levels of leadership and staff throughout the organization. A career development program, including a career mobility program with a strong career counseling component, can serve as a catalyst in professionalizing the long-term care work environment.

Intermittent high frequency ventilation. Clinical evaluation of a new mode of ventilation

In this first clinical study of a new mode of ventilation, called intermittent high frequency ventilation (IHFV), a comparison was made in ten patients after myocardial revascularization, between normal ventilation, high frequency ventilation (HFV) and IHFV at 15, 60, 100 and 160 breaths per min (b.p.m.). During IHFV the ventilation was interrupted for 3 s 7 times per min. The measured mean trapped gas volumes were 219 ml at 60 b.p.m. and 716 ml at 160 b.p.m. At 160 b.p.m. during IHFV, the mean, mean airway pressures, pulmonary artery (PAP) and capillary wedge pressures and the Paco2 were decreased, while the cardiac output increased. When the Paco2 was maintained constant, IHFV also allowed a reduction in the mean peak and mean airway pressures. This new mode of ventilation can prevent sustained increases in the lung volume and provide a reduction in intrapulmonary pressures. It also permits the measurement of the trapped gas volume and end-tidal CO2 gas concentrations several times a minute for the clinical management of patients during high frequency ventilation.

The effect of the American Heart Association step one diet on hyperlipidemia following renal transplantation

Cardiovascular disease is a frequent cause of morbidity and mortality following renal transplantation. The percentage of deaths due to ischemic cardiovascular disease and cerebrovascular accidents nearly equals that caused by infection among patients receiving their first transplant, according to data from the European Dialysis and Transplant Association Registry. Hypercholesterolemia is a risk factor for cardiovascular disease frequently identified following renal transplantation, and diets low in fat and cholesterol have been suggested as treatment. Previous studies have not reported the response of LDL cholesterol to dietary treatment, and it is this form of cholesterol that is most closely related to cardiovascular disease. The American Heart Association has provided nutritionists with guidelines for the treatment of hyperlipidemic patients which include the Step One Diet. Previous dietary studies of renal transplant recipients have allowed a slightly higher intake of fat than that currently recommended by the AHA. We wondered if an easily reproducible diet well known to nutritionists such as the AHA Step One Diet would be effective in lowering cholesterol levels in hyperlipidemic renal transplant recipients. The purpose of our study was not to define the mechanisms of posttransplant hyperlipidemia, but rather to assess the effectiveness of dietary intervention on hyperlipidemia following renal transplantation.

Effect of sternotomy and cardiopulmonary bypass on airway pressures and respiratory mechanics during high frequency ventilation

The airway pressures at ventilatory frequencies of 15, 60, 100, 120 and 150 breaths per minute were measured in eight adult patients undergoing coronary artery bypass grafting. Measurements were made perioperatively at four stages: precardiopulmonary bypass with the chest closed, precardiopulmonary bypass with the chest open, postcardiopulmonary bypass with the chest open and postcardiopulmonary bypass with the chest closed. In five patients thoracic compliance and airways resistance were also measured at these times. Neither sternotomy nor cardiopulmonary bypass made any significant difference to the airway pressures during normal and high frequency ventilation, nor were lung mechanics affected.

Dietary effects of the esters of butyric, caproic, caprylic, capric, lauric, myristic, palmitic, and stearic acids on food intake, weight gain, plasma glucose, and tissue lipid in the male white rat

Eight saturated fatty acid esters were fed to male white rats for 30 days in a 1/81 fractional factorial experiment in which diets contained 12-38% of their total energy as lipid. Marked increases in food intake, feed efficiency, and weight gain were achieved when lipid provided 36% of diet energy, and when that lipid was more than half caproate, caprate, myristate, and/or stearate. Caproate was the only saturated fatty acid to increase plasma glucose levels. The feeding of stearate or caprylate decreased plasma and liver cholesterol. Caprate increased liver fat. The short-chain fatty acids (butyrate to myristate) increased the concentration of fat in the carcass.