Association of medication attitudes with non-persistence and non-compliance with medication to prevent fractures

Our objective was to assess the association of self-reported non-persistence (stopping fracture-prevention medication for more than 1 month) and self-reported non-compliance (missing doses of prescribed medication) with perceived need for fracture-prevention medication, concerns regarding long-term harm from and/or dependence upon medications, and medication-use self-efficacy (confidence in one's ability to successfully take medication in the context of their daily life).

INTRODUCTION

Non-persistence (stopping medication prematurely) and non-compliance (not taking medications at the prescribed times) with oral medications to prevent osteoporotic fractures is widespread and attenuates their fracture reduction benefit.

METHODS

Cross-sectional survey and medical record review of 729 patients at a large multispecialty clinic in the United States prescribed an oral bisphosphonate between January 1, 2006 and March 31, 2007.

RESULTS

Low perceived necessity for fracture-prevention medication was strongly associated with non-persistence independent of other predictors, but not with non-compliance. Concerns about medications were associated with non-persistence, but not with non-compliance. Low medication-use self-efficacy was associated with non-persistence and non-compliance.

CONCLUSIONS

Non-persistence and non-compliance with oral bisphosphonate medication have different, albeit overlapping, sets of predictors. Low perceived necessity of fracture-prevention medication, high concerns about long-term safety of and dependence upon medication , and low medication-use self-efficacy all predict non-persistence with oral bisphosphonates, whereas low medication-use self-efficacy strongly predicts non-compliance with oral bisphosphonate medication. Assessment of and influence of these medication attitudes among patients at high risk of fracture are likely necessary to achieve better persistence and compliance with fracture-prevention therapies.

Potential for bone turnover markers to cost-effectively identify and select post-menopausal osteopenic women at high risk of fracture for bisphosphonate therapy

INTRODUCTION AND HYPOTHESIS

Over half of all fractures among post-menopausal women occur in those who do not have osteoporosis by bone density criteria. Measurement of bone turnover may cost-effectively identify a subset of women with T-score >-2.5 for whom anti-resorptive drug therapy is cost-effective.

METHODS

Using a Markov model, we estimated the cost per quality adjusted life year (QALY) for five years of oral bisphosphonate compared to no drug therapy for osteopenic post-menopausal women aged 60 to 80 years with a high (top quartile) or low (bottom 3 quartiles) level of a bone turnover marker.

RESULTS

For women with high bone turnover, the cost per QALY gained with alendronate compared to no drug therapy among women aged 70 years with T-scores of -2.0 or -1.5 were $58,000 and $80,000 (U.S. 2004 dollars), respectively. If bisphosphonates therapy also reduced the risk of non-vertebral fractures by 20% among osteopenic women with high bone turnover, then the costs per QALY gained were $34,000 and $50,000 for women age 70 with high bone turnover and T-scores of -2.0 and -1.5, respectively.

CONCLUSION

Measurement of bone turnover markers has the potential to identify a subset of post-menopausal women without osteoporosis by bone density criteria for whom bisphosphonate therapy to prevent fracture is cost-effective. The size of that subset highly depends on the assumed efficacy of bisphosphonates for fracture risk reduction among women with both a T-score >-2.5 and high bone turnover and the cost of bisphosphonate treatment.

Cognitive impairment in hemodialysis patients is common

BACKGROUND

Hemodialysis patients are at high risk for cognitive impairment due to their older age and high prevalence of stroke and cardiovascular risk factors.

METHODS

Using a cross-sectional design, the authors measured cognitive function in 374 hemodialysis patients aged 55 years and older and an age-matched comparison group in Minneapolis and St. Paul, MN. Cognitive performance was measured in three domains: memory, executive function, and language. Subjects were classified as having no, mild, moderate, or severe cognitive impairment.

RESULTS

Of 338 subjects who completed testing in at least two of the three cognitive domains, 13.9% (95% CI 10.4, 18.1) were classified with mild impairment, 36.1% (31.0, 41.5) with moderate impairment, 37.3% (32.1, 42.7) with severe impairment, and 12.7% (9.4, 16.8) with normal cognition. Only 2.9% had a documented history of cognitive impairment. Factors associated with severe cognitive impairment on adjusted logistic regression were stroke (adjusted OR [AOR] 1.95; 95% CI 1.08, 3.49; p < 0.03), equilibrated Kt/V > 1.2 (1.67; 1.01, 2.75; p < 0.05), and education >12 years (0.32; 0.14, 0.72; p < 0.01). The AOR for severe cognitive impairment in a random sample of 101 hemodialysis patients vs an age-matched comparison group was 3.54 (1.28, 9.78; p < 0.02).

CONCLUSIONS

Moderate to severe cognitive impairment is common and undiagnosed in hemodialysis patients. Further studies are needed to determine whether dialysis exacerbates the cognitive impairment attributable to underlying disease. Cognitive testing in hemodialysis patients before dialysis initiation and periodically may be warranted.

Diurnal cycles of salivary cortisol in older adults

Cortisol has a well-documented circadian pattern. However, recent studies have demonstrated that individual variation in diurnal cortisol patterns occurs in young adult populations. Since older adults experience altered sleep-wake cycles and changes in circadian rhythmicity, we may see even greater variations in diurnal cortisol patterns in older adults. This study examined salivary cortisol patterns in 48 community dwelling older adults. Participants (mean age 76+/-6) collected saliva every 2 h over a three-day period. Cortisol was assayed by using RIA. Cortisol cycles were defined as inconsistent, typical or flat based on the slopes of two sequential daily cortisol patterns. Demographic, physical, psychological and behavioral measures were tested for group differences using t-tests and chi-square analyses. Forty-eight percent of the sample had inconsistent cycles, 50% had typical cycles and 2% had flat cycles. This sample had a higher percentage of inconsistent cycles and fewer flat cycles than reported for young adults (p=0.008) (Psychoneuroendocrinology 22 (1997) 89). Those with inconsistent cycles were younger and reported higher caffeine and food intake than those with typical cycles. This study demonstrates that normal diurnal rhythms of cortisol can be maintained in older adults, while day-to-day variation may increase.

A Randomized Clinical Trial of Outpatient Geriatric Evaluation and Management

OBJECTIVES

To measure the effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability and use of health services.

DESIGN

Randomized clinical trial.

SETTING

Ambulatory clinic in a community hospital.

PARTICIPANTS

A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568).

INTERVENTION

Comprehensive assessment followed by interdisciplinary primary care.

MEASUREMENTS

Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants' group status.

RESULTS

Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47-0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37-0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20-0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37-0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person.

CONCLUSION

Targeted outpatient GEM slows functional decline.

Construct validity of selected Automated Neuropsychological Assessment Metrics (ANAM) battery measures

The Automated Neuropsychological Assessment Metrics (ANAM) is a computerized library of tests designed to assess neurocognitive functioning across administrations (Kane & Reeves, 1997). This study was designed to examine neuropsychological constructs measured by selected ANAM measures and to compare them with traditional measures putatively assessing similar domains. The sample consisted of 191 outpatients with suspected neurocognitive dysfunction. Correlations and regressions indicated significant relationships between traditional and computerized tests measuring similar constructs. PCA results yielded a three-factor solution: Factor I (Processing Speed/Efficiency), Factor II (Retention/Memory), and Factor III (Working Memory).

What older people want from long-term care, and how they can get it

Seniors' long-term care preferences resemble those of younger persons with disabilities, but the two groups are treated differently. Younger persons with disabilities pursue the goal of social integration, whereas safety and efficiency receive undue emphasis and ageist differences prevail in the way older persons are served. Among the changes needed to help older consumers get what they want are empowering older persons and their agents to make better decisions, including providing them with more structure and better consumer information; revising attitudes toward safety and protection; and developing more vigorous advocacy by and for seniors.

How EverCare nurse practitioners spend their time

OBJECTIVES

To describe how nurse practitioners (NPs) employed by EverCare, a Medicare HMO serving exclusively nursing home residents, spend their working days.

DESIGN

A descriptive study based on structured self-reports.

SETTING

Nursing homes.

PARTICIPANTS

Seventeen NPs employed by EverCare in five sites.

MEASUREMENTS

Self-reports of time spent over a 2-week period and specific reports of how time was spent on selected cases.

RESULTS

NPs spend about 35% of their working day on direct patient care and another 26% in indirect care activities. Of the latter, 46% of the time was spent interacting with nursing home staff, 26% with family, and 15% with the physicians. The mean time spent on a given patient per day was 42 minutes (median 30); of this time 20 minutes was direct care (median 15).

CONCLUSIONS

NPs' activities are varied. Much of their time is spent communicating with vital parties, an important function that supports the physicians' primary care role and should enhance families' satisfaction with care.

Scaling the heights of quality of life

Measuring always involves abstracting reality. Measuring an abstraction like quality of life is a daunting task. Numerous conceptual and methodological issues must be addressed, but the challenges should not deter the journey.

The Minnesota Senior Health Options program: an early effort at integrating care for the dually eligible

BACKGROUND

Duplication of funding and resultant inefficiencies have prompted active consideration of pooling the funding for persons covered by both Medicare and Medicaid into a single managed care program. This study reports the initial results of the first such program.

METHODS

A sample of enrollees in Minnesota Senior Health Options (MSHO) and two sets of controls (within the same catchment area and outside it) as well as their families were interviewed to assess their functional status and satisfaction with their medical care. Respondents included those living in the community and those living in nursing homes.

RESULTS

The MSHO and control samples were generally alike in terms of demographics and illness patterns. The differences that were found reflected those attributable to geographic location more than program. The groups were also similar with regard to functional status. There were few satisfaction differences among the community-dwelling samples, but the MSHO nursing residents and especially their families expressed more satisfaction with several aspects of care.

CONCLUSIONS

Whereas no causal conclusions about outcomes can be drawn from a cross-sectional sample, there is no indication that managed care for the dually eligible population has profound impacts on care. However, the system of care provided to nursing home residents is appreciated over traditional care.

The cost effectiveness of post-acute care for elderly Medicare beneficiaries

This study used a novel method to examine the cost effectiveness of post-acute care (PAC) in different settings. The analysis found that home health care was more cost effective than PAC in skilled nursing facilities (SNFs) or rehabilitation facilities. The cost effectiveness for home health care was also more favorable relative to being home without formal care. Post-acute care in SNFs was not cost effective compared to being home without formal care. The cost-effectiveness analysis showed mixed support for PAC in rehabilitation facilities. These results, and the use of cost-effectiveness analysis in general, provide a basis for a more efficient Medicare reimbursement system for PAC.

Effects of using consumer and expert ratings of an activities of daily living scale on predicting functional outcomes of postacute care

To test the effects of using preference weights for activities of daily living (ADL) outcome measures derived from different sources, data from a large study of the outcomes of postacute care (PAC study) were analyzed using two different weightings for the ADL measures. Both were developed using the same magnitude estimation technique; one from a panel of long-term care experts (the expert rating system); the other from a group of elderly Medicare beneficiaries (the consumer rating system). Neither group was directly involved in the PAC study. Although ADL scores generated by both rating systems were highly correlated prior to hospitalization and at hospital discharge, the consumer and expert rating systems generated significantly different functional outcomes measured by the change of ADL scores with a few exceptions. Compared to the consumer rating system, the expert rating system generated a greater change in functional outcomes at each of three follow-up time points after hospital discharge. This study suggests that the choice of weights for ADL items is important.

Outcome trajectories for assisted living and nursing facility residents in Oregon

OBJECTIVE

To compare assisted living residents and nursing home residents on outcome trajectories for three outcomes: ability to perform activities of daily living (ADLs), psychological well-being, and pain and discomfort.

DATA SOURCES/STUDY SETTING

A representative sample of one-third of the census from 38 participating assisted living facilities (N = 605) and two-fifths of the census from 31 participating nursing facilities (N = 610).

STUDY DESIGN

A longitudinal design using hierarchical linear models to examine how setting (being in an assisted living setting or in a nursing home) affected growth trajectories for each outcome studied when adjusting for other resident characteristics.

DATA COLLECTION

Residents or their proxies were interviewed and chart reviews done at baseline, six months, and one year. All baseline data were collected between August 1995 and May 1996.

PRINCIPAL FINDINGS

We found differences in case mix between assisted living and nursing facility residents but no differences in outcome trajectories for ADLs, psychological well-being, and pain and discomfort. For ADLs and pain and discomfort on average, residents in both settings experienced change over the study period. For psychological well-being, residents experienced no change on average.

CONCLUSIONS

The lack of difference in growth trajectories for ADLs, pain and discomfort, and psychological well-being between the two settings was noteworthy.

Self-reported effectiveness and physician consultation rate in users of over-the-counter histamine-2 receptor antagonists

OBJECTIVE

Decreased physician visits for dyspepsia were predicted with the histamine-2 receptor antagonists (H2RA) release to over-the-counter (OTC) status. The aim of this study was to examine the presentation frequency for dyspeptic complaints before and after the OTC release of the H2RA and the self-reported effectiveness of OTC H2RA.

METHODS

Two cross-sectional surveys were used in a community sample. The patients comprised a random age- and sex-stratified sample of 1600 ambulatory adults in 1993 and 1800 in 1997. Self-report, valid mail surveys gathered information on healthcare seeking and gastrointestinal symptoms in 1993 and 1997 and antisecretory use in 1997.

RESULTS

Presentation frequency for dyspepsia was 22% in 1993 versus 23.5% in 1997. Only 16% of chronic users of the OTC H2RA obtained complete relief of symptomatic episodes. Use of an OTC H2RA was highly associated with presentation to a physician in the past year.

CONCLUSIONS

OTC H2RA infrequently provided the complete relief desired by patients. Presentation frequency to physicians for dyspeptic complaints did not change with availability of H2RA OTC.

Assessment in long-term care

Long-term care has begun to rely heavily on assessment as a basis for determining eligibility and payment for services, as well as for planning needed care. Mandated assessments have been introduced into nursing homes and will soon be required for home health care and rehabilitation. Many states use a formal structured assessment process to establish clients' eligibility for institutional or community-based care. The common feature of such assessment is attention to physical functioning, but other domains are also relevant, including affect, social function, cognition, pain and discomfort, and satisfaction. Taken together, this cluster is often referred to as quality of life. While some measures attempt to infer this information from clients' behavior, it is best obtained directly from clients' responses whenever possible. The other major component of a long term care assessment relates to obtaining information on clients' preferences and values. These data are important both for weighting the individual components of an assessment and for directly addressing preferences about the care and lifestyle available.

Clinical outcomes of PTCA in chronic renal failure: a case-control study for comorbid features and evaluation of dialysis dependence

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.

Medicare expenditures associated with Alzheimer disease

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.

Using structured implicit review to assess quality of care in the Program of All-Inclusive Care for the Elderly (PACE)

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.

Factor analysis of computerized and traditional tests used in mild brain injury research

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.

The optimal outcomes of post-hospital care under medicare

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.

Relationship between persistence of abdominal symptoms and successful outcome after cholecystectomy

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.

An exploration of the construct validity of the Heaton memory tests

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.

The implementation of the EverCare demonstration project

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.

Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial

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.

Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence

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.

Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index

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.

HMO membership and patient age and the use of specialty care for hospitalized patients with acute stroke: The Minnesota Stroke Survey

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.

Innovative healthcare for chronically ill older persons: results of a national survey

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.

Examining the efficiency of home care

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.

Adding values: an experiment in systematic attention to values and preferences of community long-term care clients

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.

Do hip replacements improve outcomes for hip fracture patients?

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.

Neuropsychological correlates of domestic violence

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.