Complexity of Chronic Conditions' Impact on End-of-Life Expense Trajectories of Medicare Decedents.

OBJECTIVE: The aim of this study is to determine if the pattern of monthly medical expense can be used to identify individuals at risk of dying, thus supporting providers in proactively engaging in advanced care planning discussions. BACKGROUND: Identifying the right time to discuss end of life can be difficult. Improved predictive capacity has made it possible for nurse leaders to use large data sets to guide clinical decision making. METHODS: We examined the patterns of monthly medical expense of Medicare beneficiaries with life-limiting illness during the last 24 months of life using analysis of variance, t tests, and stepwise hierarchical linear modeling. RESULTS: In the final year of life, monthly medical expense increases rapidly for all disease groupings and forms distinct patterns of change. CONCLUSION: Type of condition can be used to classify decedents into distinctly different cost trajectories. Conditions including chronic disease, system failure, or cancer may be used to identify patients who may benefit from supportive care.

Patient Readiness to Exercise After Cardiac Surgery: Development of the Readiness to Change Exercise Questionnaire.

BACKGROUND: Readiness to change plays a significant role in patient adherence to an exercise regimen; thus, accurate assessment of readiness to change is necessary to direct interventions. To date, an accurate scale for measuring readiness to exercise after cardiac surgery is not available. OBJECTIVES: The purpose of this study was to develop the Readiness to Change Exercise Questionnaire for use among Thai cardiac surgery patients and to evaluate its psychometric properties. METHODS: The Readiness to Change Exercise Questionnaire was developed based on the Transtheoretical Model, a comprehensive literature review, and input from experts and cardiac surgery patients. Participants were 533 patients who had undergone cardiac surgery within the previous 3 months. The study was conducted in 7 hospitals in 4 geographical regions of Thailand. RESULTS: Confirmatory factor analysis showed satisfactory goodness of fit for the 13-item scale. The analysis supported a 4-factor structure corresponding to 4 readiness stages: precontemplation, contemplation, preparation, and action. Cronbach's α coefficients were .68 for precontemplation, .75 for contemplation, .72 for preparation, and .75 for action. CONCLUSIONS: The scale was found to be a valid and reliable instrument for the determination of patient readiness to exercise after cardiac surgery. However, further testing of the scale is needed to confirm its concurrent and predictive validity.

The relationship between acculturation and oral contraceptive use among Korean immigrant women.

We explored the relationship between acculturation and beliefs, attitudes, norms, and intention regarding oral contraceptive use among Korean immigrant women using acculturation and the theory of reasoned action (TRA) as the frameworks. A total of 1,494 Korean surname-based telephone numbers were sampled in New York City. One hundred forty-five Korean immigrant women completed a telephone survey. The findings support the assumption that acculturation affects intention to use oral contraceptives indirectly only through one or more of the TRA components. Acculturation could function as an antecedent to changes in beliefs, attitudes, norms, and intention in this population. Acculturation assessment tools could provide health professionals insight into how to better approach this population on such culturally sensitive health issues as contraceptive use.

Psychometric testing of four transtheoretical model questionnaires for the behavior, completing health care proxies.

The purpose of the study was to develop four questionnaires based on the transtheoretical model (TTM) to assess the behavior, completing a healthcare proxy (HCP). The aims were to (a) operationalize the four TTM constructs for completing a HCP and (b) evaluate the psychometric properties of the questionnaires. The questionnaires were constructed and content validity established using an expert panel. Internal consistency values for each questionnaire and subscales within each questionnaire were >.79. Confirmatory factor analysis provided evidence that decisional balance and the processes of change questionnaires each contained two factors. Our data support validity and reliability of the TTM questionnaires related to HCP completion.

Thai Family Health Routines: scale development and psychometric testing.

The aims of the study were to develop and test the psychometric properties of the Thai Family Health Routines (TFHR) scale, a 70-item self-report questionnaire used to measure the health of Thai families through their routine behaviors in daily life. Development of the TFHR was based on the structural domains of Denham's Family Health Model. The TFHR scale was initially composed of 85 items and tested on 1,040 families living in the central region of Thailand. The confirmatory factor analysis, with an acceptable factor structure model, yielded 70 items aligned with six factors: self-care, safety and prevention, mental health behavior, family care, family caregiving, and illness care routines. The preliminary psychometric properties demonstrated that the TFHR scale had satisfactory internal consistency, criterion validity, and construct validity. The test results suggested that the TFHR scale has potential benefits for family and community nurses to assess Thai family health for both research and clinical purposes.

Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity.

Individualized music--a different approach to the restraint issue.

Rehabilitation nurses who work with geriatric patients are concerned about reliance on physical restraints, as are all nurses. Controversy exists as to the benefits and risks, as well as the ethical and legal consequences, of their use. Nurses are ambivalent about using restraints, believing that they affect patients' freedom, self-respect, and self-reliance; they also often believe that there are no appropriate alternatives. This pilot study explored the use of music as a potential alternative to using physical restraints with hospitalized patients. The research question was: Will patients have more positive behaviors, as measured by the Restraint Music Response Instrument (RMRI), while out of restraints and listening to preferred music compared with the patients not listening to music who are out of restraints while being observed? Forty medical-surgical patients participated in the study and were randomized into either the experimental group (music) or the control group (no music). The mean age of the 21 males and 19 females was 76.6 years (range 56-94). A t test for equality of means was used to determine if there were differences in the number of positive and negative behaviors in the preintervention, intervention, and postintervention phases between the two groups. There was a significant difference (p < .01) in behaviors during the intervention phase. Patients who listened to preferred music had more positive behaviors while out of restraints than patients who were out of restraints but not exposed to music.

The influence of individualized music on patients in physical restraints: a pilot study.

This pilot study explored the relationship between listening to preferred music and the behavioral responses of patients who are physically restrained. Thirty patients, ranging in age from 65 to 93, participated in one of three groups. The first group included patients who were out of restraining devices while listening to preferred music. Patients in the second group were out of restraining devices and not exposed to music. The third group comprised patients who were in restraining devices while listening to preferred music. Listening to preferred music had no significant effect on decreasing patients' negative behaviors or on increasing positive behaviors observed during the intervention phase of the study. The higher mean scores for positive behaviors and lower mean scores for negative behaviors for the first group may indicate some benefits to patients who are out of restraints and listening to preferred music.

Applying the transtheoretical model to health care proxy completion.

BACKGROUND: For many, an important health decision is whether or not to document end-of-life wishes using an advance directive (e.g., health care proxy). To date, interventions targeting this health behavior have had little effect on increasing advance directive completion rates. Health behavior models, such as the transtheoretical model (TTM) could be useful for understanding the health decision-making processes used along a continuum, from no intention to complete an advance directive to completing one and discussing it with an appointed advocate. PURPOSE: To explore the applicability of the TTM for a previously understudied health behavior-completing a health care proxy (HCP). METHOD: Four established TTM measures for completing a HCP (stages of change, processes of change, decisional balance, and self-efficacy) were administered to 566 adults with coverage from 1 of 2 health insurance companies. Separate analyses of variance were used to test the relationships between the independent variable (stages of change) and dependent variables (processes of change, decisional balance, self-efficacy scores). RESULTS: Consistent with other TTM research both the experiential and the behavioral processes of change revealed the lowest scores in the precontemplation stage peaking in the preparation stage. The pattern of pros and cons was replicated from previous TTM studies, with the 2 scores crossing over just prior to the preparation stage. Self-efficacy scores incrementally increased across the stages of change with the largest effect evident from the precontemplation to preparation stage. CONCLUSION: The models developed from this study can be used to guide the development of stage-based interventions for promoting health care proxy completion.

Oncology nurses' knowledge, attitudes, and experiences regarding advance directives.

PURPOSE/OBJECTIVES: To determine oncology nurses' knowledge of, attitudes toward, and experiences with advance directives (ADs). DESIGN: Descriptive, correlation survey. SAMPLE: Usable responses from 794 (21% return) of 3,840 randomly selected members of the Oncology Nursing Society. The typical respondent was female, Caucasian, married or living as married, middle-aged, and Christian. METHODS: A mailed survey using the Knowledge, Attitudinal, and Experiential Survey on Advance Directives instrument. MAIN RESEARCH VARIABLES: Knowledge, attitudes, experiences, confidence, and ADs. FINDINGS: Overall, oncology nurses were most knowledgeable about ADs in general (70% correct) and less knowledgeable about the Patient Self-Determination Act (51% correct) and their state laws (53% correct). The mean total knowledge score based on the three subscales was 17.4 out of a possible 30, or 58% correct. The nurses' experience with ADs was measured using a five-item subscale with a mean score of 4 (SD = 1.11). They were less confident in their ability to assist patients with completing ADs. Respondent attitudes reflected an advocacy role in end-of-life decisions. Attitude items were reviewed individually. Respondents strongly agreed (97%) with the statement that patients should receive sufficient medication to relieve pain even though it may hasten death, which reflects the emphasis in oncology on adequate pain management at the end of life. CONCLUSIONS: Nurses' knowledge scores were low. Nurses in the study were not highly confident in their ability to assist patients with ADs. Demographic variables generally did not influence knowledge, confidence, or experience scores. IMPLICATIONS FOR NURSING: More education related to ADs is needed and could be administered through in-service classes or continuing education. Nurses' responses indicated that they need more time to assist patients with completing ADs. This is difficult in the current practice environment but must be recognized as critically important.