bluuebunny/crossref_metadata_2025_split huggingface dataset:
Predictors of Pressure Ulcer Healing Among Long‐Term Care Residents
Authors: Berlowitz Dan R. , Brandeis Gary H. , Anderson Jennifer , Brand Harriet K. 
Published: April 2015

OBJECTIVES: To identify predictors of pressure ulcer healing among long‐term care residents.DESIGN: A retrospective cohort study.SETTING: Department of Veterans Affairs (VA) long‐term care facilities.PARTICIPANTS: All long‐term care residents with a pressure ulcer on April 1, 1993, who remained institutionalized as of October 1, 1993. Patients and pressure ulcer status were identified from the Patient Assessment File, a VA administrative database.MEASUREMENTS: Pressure ulcers were considered healed if patients were without an ulcer on October 1, 1993. Predictors of pressure ulcer healing were selected from among patient characteristics in the Patient Assessment File.RESULTS: Pressure ulcers were present in 7.7% of the long‐term care residents institutionalized as of April 1, 1993. Among the 819 pressure ulcer patients remaining institutionalized as of October 1, 1993, ulcers had healed in 442 (54.0%). Seventy‐two percent of patients with Stage 2 ulcers were ulcer‐free at 6 months, compared with 45.2% of patients with Stage 3 ulcers and 30.6% of those with Stage 4 ulcers (P < .001). Significant (P < .05) independent predictors of healing included pressure ulcer size (Odds ratio (OR) = 5.2 for Stage 2 ulcers, OR = 1.5 for Stage 3 ulcers), older age (OR = 1.5), and receiving rehabilitation services (OR = 1.3 for each additional type of therapy). Both immobility (OR = .3) and incontinence (OR = .7) were associated with ulcers not healing.CONCLUSIONS: Most Stage 2 pressure ulcers, and many larger ulcers encountered in long‐term care settings will heal. Baseline patient characteristics are important predictors of healing. Interventions may then be targeted at patients whose ulcers are unlikely to heal, and observed facility performance may be compared with expected outcomes.
Functional Outcome of Cognitively Impaired Hip Fracture Patients on a Geriatric Rehabilitation Unit
Authors: Goldstein Felicia C. , Strasser Dale C. , Woodard John L. , Roberts Vicki J. 
Published: April 2015

OBJECTIVES: To compare outcomes (physical functions and discharge destinations) of cognitively impaired and intact older hip fracture patients, and to identify cognitive skills related to functional gains.DESIGN: Prospective longitudinal study of hip fracture patients treated on an acute inpatient rehabilitation service, with evaluation of functional performance and living status determined at admission and discharge.SETTING: A specialized inpatient geriatric rehabilitation program at Wesley Woods Geriatric Hospital, which is affiliated with Emory University School of Medicine.SUBJECTS: Fifty‐eight hip fracture patients, 35 with and 23 without cognitive impairment.MEASUREMENTS: Cognitive functioning measured by the Mattis Dementia Rating Scale (MDRS); functional outcome assessed by the Functional Independence Measure (FIM); comparison of pre‐fracture with discharge living environments.MAIN RESULTS: Both cognitively impaired and intact hip fracture patients exhibited similar overall FIM motor improvements as well as functional gains in specific FIM areas measuring self‐care, sphincter control, and locomotion (e.g., walking). Cognitively intact patients, however, displayed significantly greater gains in mobility (e.g., transfers) at discharge. Cognitively impaired patients who lived in the community were as likely as intact patients to return to the community. Patients who entered the program at a modified dependence level (FIM 3–5) and achieved motor independence at discharge (FIM 6–7) had higher MDRS initiation/perseveration and memory scores.CONCLUSIONS: Hip fracture patients with cognitive impairments can achieve positive outcomes as defined by functional improvement and discharge destination. Intensive post‐fracture rehabilitation in the early phase of recovery may promote functional independence and a return to the community for older patients at risk for nursing home placement. Future research should examine the long‐term maintenance of these improvements and explore how rehabilitation interventions can be altered to enhance outcome.
A Comparison of Nursing Home‐Acquired Pneumonia Patients with Patients with Community‐Acquired Pneumonia and Nursing Home Patients Without Pneumonia
Authors: Marrie Thomas J. , Blanchard Wade 
Published: April 2015

OBJECTIVES: To determine the factors responsible for mortality and characteristics unique to patients with nursing home acquired pneumonia (NHAP).DESIGN: A prospective study of 71 patients with NHAP, 79 patients admitted from nursing homes for conditions other than pneumonia (NP), and 93 patients with community‐acquired pneumonia (CAP).SETTING: A teaching hospital that serves as the community hospital for the City of Halifax.RESULTS: The 32% in‐hospital mortality rate for NHAP was higher than the 14% rate for CAP (P < .05) but not significantly higher than the 23% mortality rate for NP patients. The most important determinants for long‐term (52 weeks) outcome were complications during hospital stay, odds ratio for mortality 3.55, and self sufficiency at time of admission, odds ratio for mortality 0.306. While bacteremia rates were similar at 8% for NHAP, 13% for CAP, and 17% for NP, there was a trend toward a higher rate of pneumococcal bacteremia in the CAP group. CAP patients were more likely to receive ventilatory support, 13% versus 3% for NHAP and 4% for no pneumonia patients despite similar levels of hypoxemia in the two pneumonia groups.CONCLUSIONS: The in‐hospital mortality rate for NHAP is higher than that for CAP. The 1‐year survival rate is determined by self‐sufficiency at time of admission and absence of complications during hospital stay and is not group (e.g., nursing home) dependent.
Foot Position Awareness in Younger and Older Men: The Influence of Footwear Sole Properties
Authors: Robbins Steven , Waked Edward , Allard Paul , McClaran Jacqueline , Krouglicof Nicholas 
Published: April 2015

OBJECTIVES: To test the hypotheses that foot position awareness is related positively to stability, positively to shoe sole hardness, and negatively to shoe sole thickness, and that foot position awareness declines with advancing years.SETTING: Older subjects were consecutive volunteers from a medical clinic; younger subjects were volunteers from the community.DESIGN: Randomized‐order, cross‐over, controlled comparison.PARTICIPANTS: Older subjects were a random sample of 13 healthy men, mean age 72.58 years, SD ± 4.50. Younger subjects were a random sample of 13 male subjects from the general population, mean age 28.13 years, SD ± 3.96. Additional selection criteria were absence of disabilities influencing ability to walk and no history of frequent falls.MEASUREMENTS: Balance failure frequency, defined as falls per 100 meters of beam walking; rearfoot angle in degrees, measured via an optical position measurement system; perceived maximum supination when walking, in degrees, estimated by subjects using a ratio scale; foot position error, in degrees, was defined as the rearfoot angle minus perceived maximum supination.RESULTS: Foot position error during walking: (1) increases with advancing years; footwear conditions absolute mean error for older sample of 15.48°, SE ± 1.56°, and younger sample 5.44°, SE ± 1.03° (P > .001); (2) is positively related to stability (r = .367, P < .001); (3) is positively related to midsole thickness (F(1,11) = 19.89, P < .001); (4) is negatively related to midsole hardness (F(2,22) = 29.80, P < .001); (5) correlates best with perceived maximum supination (r = .901, P < .001).CONCLUSION: Foot position awareness is related causally to stability; shoes with thin, hard soles provide better stability for men than those with thick, soft midsoles. Foot position awareness declines with advancing years.
An Analysis of the Use of the Telephone in the Management of Patients in Skilled Nursing Facilities
Authors: Fowkes William , Christenson Diane , McKay David 
Published: April 2015

OBJECTIVE: To characterize the nature of telephone communication in the care of patients in skilled nursing facilities, noting numbers of calls, reasons for communication, and the outcomes of the interactions, and to implement a voice mail system to manage the burden of communication more effectively and describe the impact of this system.DESIGN: An archival descriptive study of phone message data covering a period of 1 year in a defined population of nursing home patients, with an intervention and an evaluation of a voice mail system at the conclusion of the year's study.SETTING: A long‐term care practice associated with an urban family practice residency program.PARTICIPANTS: Medical care providers, the staffs of 13 skilled nursing facilities, and an average of 207 covered patients followed for 1 year.INTERVENTION: At the termination of the descriptive study, a voice mail system was instituted, and the impact on phone communication was documented.MAIN OUTCOME MEASURES: Total numbers of calls were tabulated by patient and by facility. Reasons for calls, outcomes, and timing were tabulated. The impact of a voice mail system on the communication between nursing home staff and medical providers was characterized.RESULTS: A total of 10,264 calls were received from 13 skilled nursing facilities in regard to an average of 207 continuously covered long‐term care patients, which is an average of nearly 50 calls per patient per year. Acute illness accounted for only 5% of calls, and most communications were routine. Though a new treatment was instituted about one‐third of the time, no new order was issued in response to 23% of received calls. Hospitalization occurred as the result of about one in two hundred calls. A recent tabulation of 692 calls received during 1 month revealed that 93% of calls are now received through voice mail and about one in five of these calls do not need to be returned.CONCLUSIONS: There is a significant telephone call burden associated with care of patients in skilled nursing facilities. Most of these calls are routine, regulation driven, and often no return call is necessary. For many reasons, including poor reimbursement, much of the medical care delivered occurs as a result of these calls, and methods of managing the communication burden to allow prioritization both by the staff nurse and the physician need to be found. In the practice described, the voice mail system is a positive step in this direction.
The Impact of Thiazide Diuretics on the Initiation of Lipid‐Reducing Agents in Older People: A Population‐Based Analysis
Authors: Monane Mark , Gurwitz Jerry H. , Bohn Rhonda L. , Glynn Robert J. , Levin Raisa , Monette Johanne , Avorn Jerry 
Published: April 2015

OBJECTIVE: The objective of this study was to examine how often treatment for hyperlipidemia followed the use of thiazides, compared with the use of other antihypertensive drugs, in older patients.DESIGN: Retrospective follow‐up of all health claims filed over a 12‐month period.SETTING: New Jersey Medicaid and Medicare programs.PARTICIPANTS: A total of 9274 enrollees, aged 65 to 99, who were newly initiated on antihypertensive medications from 1981–1989.MEASUREMENTS: We measured rates of lipid‐reducing agent (LRA) initiation among patients in the 2 years following antihypertensive initiation (thiazide, non‐thiazide drug, or combinations of the two) compared with rates among patients not currently taking antihypertensive agents. We used Cox regression analyses to estimate relative risks (RR), accounting for switching in antihypertensive therapy and for time when drug therapy was not currently available according to pharmacy refill records.RESULTS: There were 226 patients (2.4%) in the cohort who were started on LRA during the follow‐up period. After adjusting for potential confounders, we found no significant relationship between LRA initiation and overall thiazide use (RR 1.47, 95% CI 0.89‐2.40), or other antihypertensive use, relative to no current exposure. However, use of high‐dose thiazides (≥50 mg) was associated significantly with LRA initiation (RR 1.97, 95% CI 1.12‐3.45). Factors associated with decreased incidence of LRA use included age ≥ 85 (RR 0.59, 95% CI 0.36‐0.96), black race (RR 0.58, 95% CI 0.37‐0.91), and nursing home residency (RR 0.20, 95% CI 0.11‐0.35).CONCLUSION: Use of low‐cost and effective thiazide diuretics in older hypertensives was not associated with more common initiation of lipid‐reducing agents, except with high‐dose use of thiazides currently seen as inappropriate in most cases. Age and race were important determinants of LRA use.
Models of Geriatrics Practice: Post‐Hospital Sub‐Acute Care: An Example of a Managed Care Model
Authors: von Sternberg T. , Hepburn K. , Cibuzar P. , Convery L. , Dokken B. , Haefemeyer J. , Rettke S. , Ripley J. , Vosenau V. , Rothe P. , Schurle D. , Won‐Savage R. 
Published: April 2015

OBJECTIVE: This article describes Transitional Care Centers (TCC), an innovative sub‐acute care program developed by a large managed care organization (HealthPartners in Minnesota) in partnership with five area nursing homes. The purpose of the TCC is to promote continuity of care for frail older members covered under a TEFRA risk contract.DESIGN: This is a retrospective study of the experiences and outcomes of enrollees who received TCC compared with a like group of enrollees who received customary continuity care through contract services.SETTING: The TCCs are established contractually in five area nursing homes; these facilities keep at least 15 beds available to the health plan for round‐the‐clock, 7 days per week admissions for sub‐acute care. Designated staff from these facilities and designated geriatric nurse practitioners and geriatricians from HealthPartners follow established targeting, admissions, assessment, care planning, and discharge planning procedures to provide team care for these patients at the facilities.PARTICIPANTS: The TCC program is targeted to patients requiring rehabilitation therapy (post‐cardiovascular accident, post‐fracture/replacement) who are deconditioned, or those with uncomplicated infections (urinary tract infection, pneumonia). A total of 1144 patients participated in the TCC program in the 1‐year program under report, and 253 were surveyed in regard to their experience. One hundred Health‐Partners physicians were surveyed about the program.RESULTS: Post‐acute length of stay in the TCC was substantially lower than that in customary care settings in contract nursing homes (14.3 versus 20.5 days). Rehospitalization rates from these units were comparable to or better than those from other sub‐acute units. Patient and primary care physician satisfaction with the units was high. The program provided economic benefit to both partners. The health plan's negotiated rate for the TCC units was 38% less than that paid in noncontractual facilities.CONCLUSION: The TCC partnership provides rehabilitative and geriatric evaluation services in settings more conducive to and less costly than such care usually, and yields improvements in care and utilization outcomes.
Prevalence of Undiagnosed Non‐Insulin‐Dependent Diabetes Mellitus and Impaired Glucose Tolerance in a Cohort of Older Persons with Hypertension
Authors: Johnson Karen C. , Graney Marshall J. , Applegate William B. , Kitabchi Abbas E. , Runyan John W. , Shorr Ronald I. 
Published: April 2015

OBJECTIVE: To determine the prevalence of undiagnosed non‐insulin‐dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in a cohort of older persons with hypertension. To examine the usefulness of screening for NIDDM in this study population.DESIGN: Cross‐sectional study.SETTING: University of Tennessee, Memphis and the General Clinical Research Center (GCRC).PATIENTS: Ninety‐five participants in the Trial of Nonphar‐macologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study.MEASUREMENTS: A standard oral glucose tolerance test (OGTT) with insulin and C‐peptide levels was performed before the beginning of the TONE intervention.RESULTS: In this cohort, 43 participants (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had IGT, and 11 (11.6%) had undiagnosed NIDDM. The positive predictive value for NIDDM of a fasting glucose ≥ 115 mg/dL in our participants was 57%. Hyperinsulinemia occurred in only one participant, a subject in the IGT group.CONCLUSIONS: Our data demonstrate that undiagnosed NIDDM is common in our cohort of older persons who are being treated for essential hypertension and that impaired glucose tolerance may be more common than in the general population of the same age. Further, our data show that the vast majority of this older, obese, hypertensive cohort did not have fasting hyperinsulinemia. We also infer that a fasting glucose alone has a low positive predictive value for screening of NIDDM in our older cohort. As the prevalence of NIDDM and impaired glucose tolerance in older hypertensive patients in the general population is unknown, we believe that further investigation is needed to characterize the relationship of hypertension, glycemic status, and hyperinsulinemia in the general population.
How Older Patient Preferences Are Influenced by Consideration of Future Health Outcomes
Authors: Mazur Dennis J. 
Published: April 2015

OBJECTIVE: To determine patients' willingness to accept intubation and ventilatory support (IVS) when the best outcome available is a state involving both cognitive and physical/behavioral deficits.DESIGN: Structured interviews with patients seen consecutively in a continuity care general medicine clinic.SETTING: A university‐based Department of Veterans Affairs Medical Center.SUBJECTS: A total of 113 patients (mean age = 67.3 years, age range 42–89; mean level of formal education = 12.6 years, range 2–24).MEASUREMENTS: Patients were asked to consider whether they would permit their physicians to intubate them and put them on ventilatory support when the best outcome to be expected was one of three future health care states, presented in the following order: State 1, where their mental and physical state of recovery would be exactly like their current mental and physical states at the time of their visit to the general medicine clinic (the patient's current baseline mental and physical functioning); State 2, involving cognitive compromise; State 3, involving both cognitive and physical/behavioral compromise.RESULTS: One patient refused IVS on State 1; 20.4% (23/113) of patients refused IVS on State 2; 23.0% (26/113) refused IVS on State 3; and 49.6% (56/113) reported they would accept IVS resulting in all three states. Six of 113 patients (5.3%) reported they would leave the decision up to their physician beginning with State 1 and continuing through State 3. One patient reported that he would leave the decision (State 1 through State 3) up to his wife. A reported history of stroke is related to patients' expressed dislike of IVS that would leave them with residual deficits.CONCLUSION: The results suggest that a substantial number of our older male veteran population would prefer intubation and ventilatory support if presented with a situation in which the best outcome that a physician could offer them was cognitive, physical, and behavioral dysfunction. These results also indicate that those patients who have had a stroke seem to be less inclined to accept IVS in more severe outcomes states.
Do Acute Care for Elders Units Increase Hospital Costs? A Cost Analysis Using the Hospital Perspective
Authors: Covinsky Kenneth E. , King Joseph T. , Quinn Linda M. , Siddique Reshmi , Palmer Robert , Kresevic Denise M. , Fortinsky Richard H. , Kowal Jerome , Landefeld C. Seth 
Published: April 2015

OBJECTIVE: To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self‐care activities with the costs of usual care.DESIGN: A randomized controlled study.PARTICIPANTS: A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324).MEASURES: The hospital's resource‐based cost of caring for patients was determined from the hospital's cost‐accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost.RESULTS: The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual‐care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual‐care unit. Ninety‐day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety‐day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar.CONCLUSION: Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual‐care ward even though the intervention ward required a commitment of hospital resources.
Acute Upper Gastrointestinal Hemorrhage in Older People: A Prospective Study in Two Neighboring Districts
Authors: Nankhonya J. M. , Datta‐Chaudhuri M. L. , Bhan G. L. 
Published: April 2015

OBJECTIVE: To study the distribution of mucosal lesions and outcomes in older people with acute upper gastrointestinal hemorrhage (UGIH).DESIGN: Prospective case study.SETTING: Two neighboring district hospitals with similar admission policies.SUBJECTS: Consecutive patients aged 75 years or older admitted with hematemesis and/or melena during the study period.OUTCOME MEASURES: Length of hospital stay, mortality, surgical intervention, and transfusion requirements.RESULTS: A total of 109 patients were entered into the study. Of these, 106 (97%) underwent gastroscopy, and bleeding sites were identified in 98%. Upper gut malignancies were identified in eight patients, ulcerative esophagitis in 32, benign gastric ulcers in 24, and duodenal ulcers in 23 patients. Forty‐seven percent had severe anemia on admission (Hb <10 g/dL). Thirty‐eight patients were referred for surgery, and eight were operated on, with one postoperative death. Six other patients died, five of whom had malignancies. The overall mortality of 6% reduced to 2% if those with malignancy were excluded. The 92 patients discharged had a median hospital stay of 15 days (range 2–30).CONCLUSIONS: Older people with acute UGIH have advanced upper gut pathology with preponderance of esophageal lesions. Classical symptoms seem lacking, but mortality can be decreased despite adverse comorbid factors. Lower thresholds for endoscopy are advocated in older adults, and comparative studies of UGIH symptoms with younger patients are required.