National Alcohol Survey of households in Trinidad and Tobago (NASHTT): Alcohol use in households.

BACKGROUND: To determine the patterns of alcohol use among households in Trinidad and Tobago (T&T) and to estimate the association between alcohol use and negative psychological, social, or physical events experienced by the household. METHODS: A convenience sample of 1837 households across T&T. We identified bivariate correlates of alcohol use, and heavy episodic drinking using chi-square and t-test analyses and used multivariable logistic regression to estimate adjusted associations between household alcohol use and experiences within the past 12 months adjusted for sociodemographic covariates. RESULTS: One thousand five hundred two households had complete data for all variables (82% response rate). Nearly two thirds (64%) of households included alcohol users; 57% of household that consumed alcohol also reported heavy episodic drinking. Households that reported alcohol consumption were significantly more likely to report illnesses within the households, relationship problems, and behavioral and antisocial problems with children. Among households where a member was employed, those who consumed alcohol were nearly twice as likely (OR = 1.98; 95% confidence interval (CI) 1.03, 3.82) to have a household member call in sick to work and 2.9 times as likely (OR = 2.9; CI 1.19, 7.04) to have a household member suffer work related problems compared with households who reported not consuming alcohol. CONCLUSIONS: Approximately two thirds of households in T&T reported using alcohol. These households were more likely to report psychological, physical, and social problems. These findings would support efforts to enforce current policies, laws, and regulations as well as new strategies to reduce the impact of harmful alcohol consumption on households in T&T.

Perceptions of hand hygiene practices in China.

Hand hygiene is considered one of the most important infection control measures for preventing healthcare-associated infections. However, compliance rates with recommended hand hygiene practices in hospitals remain low. Previous literature on ways to improve hand hygiene practices has focused on the USA and Europe, whereas studies from developing countries are less common. In this study, we sought to identify common issues and potential strategies for improving hand hygiene practices in hospitals in China. We used a qualitative survey design based on in-depth interviews with 25 key hospital and public health staff in eight hospitals selected by the Chinese Ministry of Health. We found that hospital workers viewed hand hygiene as paramount to effective infection control and had adequate knowledge about proper hand hygiene practices. Despite these positive attitudes and adequate knowledge, critical challenges to improving rates of proper hand hygiene practices were identified. These included lack of needed resources, limited organisational authority of hospital infection control departments, and ineffective use of data monitoring and feedback to motivate improvements. Our study suggests that a pivotal issue for improving hand hygiene practice in China is providing infection control departments adequate attention, priority, and influence within the hospital, with a clear line of authority to senior management. Elevating the place of infection control on the hospital organisational chart and changing the paradigm of surveillance to continuous monitoring and effective data feedback are central to achieving improved hand hygiene practices and quality of care.

Promotion of hand hygiene techniques through use of a surveillance tool.

Effective hand hygiene practice in a clinical healthcare setting is the most effective means to prevent, control and reduce healthcare-associated infections. Despite the introduction of hand hygiene practices and targeted campaigns, surveillance to ensure implementation of these techniques remains limited. Surveillance is widely accepted as an essential component to infection control campaigns. Therefore, we sought to design and test an easy-to-use surveillance instrument for hospital hand hygiene developed and piloted for three months in nine hospitals in China. This paper presents the resulting hand hygiene surveillance instrument as well as explicit guidelines for its implementation.

American health care paradox-high spending on health care and poor health.

BACKGROUND: For decades, US taxpayers have been lamenting the high cost of health care. Since the mid-1980s, Americans have had double-digit spending on health care. Despite this investment, Americans are less healthy than their European and Scandinavian counterparts across an array of health measures. AIM: We sought to explore how inadequate attention to the social, behavioral and environmental determinants of health may contribute to the American health care paradox of high health care spending and poor health outcomes. DESIGN: Mixed methods. METHODS: We report previous findings related from a 10-year analysis of national-level health and social service spending and health outcome data from the Organization of Economic and Cooperation and Development (OECD). We also put forth case studies representing different socioeconomic strata to illustrate the relationship between health care and social service spending and health. RESULTS: Although the US spending more of its GDP on health care than any other country, it is not a high spender when one sums spending on both health care and social services. The U.S. however has the lowest ratio of our social service spending to health care spending in the OECD, and countries with lower ratios on average have worse health outcomes. Cases from diverse socioeconomic strata demonstrate how limited attention to the social determinants of health can result in extremely high health care costs and poor health outcomes. CONCLUSIONS: Greater investment in addressing the social, behavioral and environmental determinants of health may foster better health without accelerating health care costs in America.

The impact of late career job loss on myocardial infarction and stroke: a 10 year follow up using the health and retirement survey.

BACKGROUND: Involuntary job loss is a major life event associated with social, economic, behavioural, and health outcomes, for which older workers are at elevated risk. OBJECTIVE: To assess the 10 year risk of myocardial infarction (MI) and stroke associated with involuntary job loss among workers over 50 years of age. METHODS: Analysing data from the nationally representative US Health and Retirement Survey (HRS), Cox proportional hazards analysis was used to estimate whether workers who suffered involuntary job loss were at higher risk for subsequent MI and stroke than individuals who continued to work. The sample included 4301 individuals who were employed at the 1992 study baseline. RESULTS: Over the 10 year study frame, 582 individuals (13.5% of the sample) experienced involuntary job loss. After controlling for established predictors of the outcomes, displaced workers had a more than twofold increase in the risk of subsequent MI (hazard ratio (HR) = 2.48; 95% confidence interval (CI) = 1.49 to 4.14) and stroke (HR = 2.43; 95% CI = 1.18 to 4.98) relative to working persons. CONCLUSION: Results suggest that the true costs of late career unemployment exceed financial deprivation, and include substantial health consequences. Physicians who treat individuals who lose jobs as they near retirement should consider the loss of employment a potential risk factor for adverse vascular health changes. Policy makers and programme planners should also be aware of the risks of job loss, so that programmatic interventions can be designed and implemented to ease the multiple burdens of joblessness.

Functional disability and health care expenditures for older persons.

BACKGROUND: The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons. METHODS: Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables. RESULTS: The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures. CONCLUSIONS: Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short- and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden.

Documentation of discussions about prognosis with terminally ill patients.

PURPOSE: Previous studies have suggested the importance of communicating with patients about prognosis at the end of life, yet the prevalence, content, and consequences of such communication have not been fully investigated. The purposes of this study were to estimate the proportion of terminally ill inpatients with documented discussions about prognosis, describe the nature and correlates of such discussions, and assess the association between documented discussions about prognosis and subsequent advance care planning. SUBJECTS AND METHODS: Inpatients (n = 232) at least 65 years old who had brain, pancreas, liver, gall bladder, or inoperable lung cancer were randomly selected from six randomly chosen community hospitals in Connecticut. The presence and content of discussions about prognosis, advanced care planning efforts, and sociodemographic and clinical factors were ascertained by comprehensive review of medical records using a standardized abstraction form. RESULTS: Discussions about prognosis were documented in the medical records of 89 (38%) patients. Physicians and patients were both present during the discussion in 46 (52%) of these cases. Time until expected death was infrequently documented. Having a documented discussion about prognosis was associated with documented discussions of life-sustaining treatments (adjusted odds ratio [OR] = 5.8; 95% confidence interval [CI]: 2.8 to 12.0) and having a do-not-resuscitate order (adjusted OR = 2.2; 95% CI: 1.1 to 4.2). CONCLUSIONS: Among terminally ill patients with cancer, discussions about prognosis as documented in medical charts are infrequent and limited in scope. In some cases, such documented discussions may be important catalysts for subsequent discussions of patient and family preferences regarding treatment and future care.

Goals for the care of frail older adults: do caregivers and clinicians agree?

PURPOSE: Establishing shared treatment goals for patients may improve the quality of care by facilitating achievement of appropriate and desired outcomes. The purpose of this study was to describe types of family caregiver and physician treatment goals for frail elderly patients who had a high prevalence of cognitive impairment, and to ascertain the level of agreement between family caregivers and physicians on principal treatment goals. SUBJECTS AND METHODS: We surveyed family caregivers and physicians for 200 consecutive older adults who were initially evaluated at the outpatient geriatric assessment center of a major teaching hospital. Treatment goals for patients were measured after a comprehensive geriatric assessment. RESULTS: Goals commonly chosen as most important by family caregivers and physicians pertained to day-to-day functioning (61 [31%] family caregivers, 81 [41%] physicians), behavior and emotional health (56 [28%] family caregivers, 50 [25%] physicians), and safety (40 [20%] family caregivers, 29 [15%] physicians). Although a substantial proportion of family caregiver and physician pairs shared at least one goal (157 [79%] of 200), agreement on presence or absence of individual categories of goals was poor (kappas from -0.19 to 0.28), and agreement on the most important goal was also poor (kappa 0.20). CONCLUSIONS: Agreement on treatment goals between family caregivers and physicians for patients at the study site was low. These results suggest that encounters between family caregiver and physician may need improvement. Further research is needed to assess whether lack of agreement is found in other settings, persists over time, and affects achievement of goals and optimal health outcomes.

Discussions about end-of-life care in nursing homes.

OBJECTIVE: To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the resident's wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions. DESIGN: Retrospective cohort study of residents admitted to nursing homes before and after the PSDA. SETTING: Six large (at least 120 licensed chronic care beds), randomly selected nursing homes in Connecticut. PARTICIPANTS: Six hundred randomly selected nursing home residents admitted during 1990 and 1994 to one of the six study nursing homes. MEASUREMENTS: Documented discussions concerning future treatment wishes were abstracted from residents' nursing home medical records. Participants in the discussion, as well as the timing (i.e., date) and content of the documented discussions were recorded. Sociodemographic and health status factors were also obtained from the medical record. RESULTS: A large majority of residents (71.5%) had no discussion of future treatment wishes documented in their medical record. However, the percentage of residents with documented discussions had increased since the implementation of the PSDA (36.7% post-PSDA vs 20.3% pre-PSDA). Of those in the post-PSDA cohort who had had discussions, 90% had only one discussion within the first year of admission, and more than half (58.1%) of those who had discussions discussed only life-support systems (cardiopulmonary resuscitation, artificial nutrition and hydration, and ventilation) rather than broader preferences for future treatment, including proxy decision-making. CONCLUSIONS: Despite the increased prevalence of discussions about future treatment wishes since the enactment of the PSDA, no discussions were documented for most residents. For those with documented discussions, such conversations occurred rarely and were narrow in scope, suggesting that residents' and families' roles in medical decision-making in nursing homes may be limited.

Factors associated with home versus institutional death among cancer patients in Connecticut.

OBJECTIVE: To assess the relationships between home death and a set of demographic, disease-related, and health-resource factors among individuals who died of cancer. DESIGN: Prospective cohort study. SETTING: All adult deaths from cancer in Connecticut during 1994. PARTICIPANTS: Six thousand eight hundred and thirteen individuals who met all of the following criteria: died of a cancer-related cause in 1994, had previously been diagnosed with cancer in Connecticut, and were age 18 and older at the time of death. MEASUREMENT: Site of death. RESULTS: Twenty-nine percent of the study sample died at home, 42% died in a hospital, 17% died in a nursing home, and 11% died in an inpatient hospice facility. Multivariate analysis indicated that demographic characteristics (being married, female, white, and residing in a higher income area), disease-related factors (type of cancer, longer survival postdiagnosis), and health-resource factors (greater availability of hospice providers, less availability of hospital beds) were associated with dying at home rather than in a hospital or inpatient hospice. CONCLUSIONS: The implications of this study for clinical practice and health planning are considerable. The findings identify groups (men, unmarried individuals, and those living in lower income areas) at higher risk for institutionalized death-groups that may be targeted for possible interventions to promote home death when home death is preferred by patients and their families. Further, the findings suggest that site of death is influenced by available health-system resources. Thus, if home death is to be supported, the relative availability of hospital beds and hospice providers may be an effective policy tool for promoting home death.

Data feedback efforts in quality improvement: lessons learned from US hospitals.

BACKGROUND: Data feedback is a fundamental component of quality improvement efforts, but previous studies provide mixed results on its effectiveness. This study illustrates the diversity of hospital based efforts at data feedback and highlights successful strategies and common pitfalls in designing and implementing data feedback to support performance improvement. METHODS: Open ended interviews with 45 clinical and administrative staff in eight US hospitals in 2000 concerning their perceptions about the effectiveness of data feedback in supporting performance improvement efforts were analysed. The hospitals were chosen to represent a range of sizes, geographical regions, and beta blocker improvement rates over a 3 year period. Data were organized and analyzed in NUD-IST 4 using the constant comparative method of qualitative data analysis. RESULTS: Although the data feedback efforts at the hospitals were diverse, the interviews suggested that seven key themes may be important: (1) data must be perceived by physicians as valid to motivate change; (2) it takes time to develop the credibility of data within a hospital; (3) the source and timeliness of data are critical to perceived validity; (4) benchmarking improves the meaningfulness of data feedback; (5) physician leaders can enhance the effectiveness of data feedback; (6) data feedback that profiles an individual physician's practices can be effective but may be perceived as punitive; (7) data feedback must persist to sustain improved performance. Embedded in several themes was the view that the effectiveness of data feedback depends not only on the quality and timeliness of the data, but also on the organizational context in which such efforts are implemented. CONCLUSIONS: Data feedback is a complex and textured concept. Data feedback strategies that might be most effective are suggested, as well as potential pitfalls in using data to promote performance improvement.

Goal-setting in clinical medicine.

The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning.

Goals in geriatric assessment: are we measuring the right outcomes?

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.

Health effects of involuntary job loss among older workers: findings from the health and retirement survey.

OBJECTIVES: To estimate the health consequences of involuntary job loss among older workers in the United States. METHODS: Using longitudinal data from the 1992 and 1994 waves of the Health and Retirement Survey, multivariate regression models were estimated to assess the impact of involuntary job loss on both physical functioning and mental health. Our analysis sample included 209 workers who experienced involuntary job loss between survey dates and a comparison group of 2,907 continuously employed workers. RESULTS: The effects of late-life involuntary job loss on both follow-up physical functioning and mental health were negative and statistically significant (p < .05), even after baseline health status and sociodemographic factors were controlled for. Among displaced workers, reemployment was positively associated with both follow-up physical functioning and mental health, whereas the duration of joblessness was not significantly associated with either outcome. DISCUSSION: The findings provide evidence of a causal relationship between job loss and morbidity among older workers. This relationship is reflected in both poorer physical functioning and mental health for workers who experience involuntary job loss. In addition to the economic consequences of worker displacement, there may be important health consequences of job loss, especially among older workers.

The impact of involuntary job loss on subsequent alcohol consumption by older workers: findings from the health and retirement survey.

OBJECTIVE: To estimate the effect of involuntary job loss on subsequent alcohol consumption by older workers in the United States. METHODS: Using longitudinal data from the 1992 and 1994 waves of the Health and Retirement Survey, the authors estimated multivariate models to assess the impact of involuntary job loss on subsequent alcohol use. Two outcomes were investigated: reported daily alcohol consumption and onset of drinking. The analysis sample included 207 workers who experienced involuntary job loss between survey dates and a comparison group of 2,866 continuously employed workers. RESULTS: After baseline alcohol consumption and a variety of socioeconomic and illness-related covariates were controlled, involuntary job loss was not associated (p>.05) with number of daily drinks consumed at follow-up. However, among those who did not consume alcohol at baseline, individuals who suffered involuntary job loss were twice as likely as continuously employed individuals to start drinking by follow-up (OR = 2.01; CI = 1.06-3.80). The majority of those who began drinking at follow-up reported drinking less than 1 drink per day. DISCUSSION: The findings provide evidence of a significant relationship between job loss and subsequent alcohol use among baseline nondrinkers. However, the magnitude of the changes in drinking was quite modest.

Institutional efforts to promote advance care planning in nursing homes: challenges and opportunities.

In an empirical study of Connecticut-area for-profit and nonprofit nursing homes, authors examine use of institution-specific advance care planning forms among nursing home residents.

Attitudes about care at the end of life among clinicians: a quick, reliable, and valid assessment instrument.

Several initiatives to improve care at the end of life involve educational programs to influence clinicians' attitudes about care for patients with terminal illnesses. The objective of this research was to develop and test a short and easily administered instrument for measuring physicians' and nurses' attitudes towards care at the end of life. The instrument was tested using a cross-sectional study of 50 clinicians (25 physicians and 25 nurses) from general medicine, cardiology, oncology, and geriatric medicine. Both reliability and validity were assessed, and the instrument was found to have acceptable test-retest reliability and construct validity. Such an assessment instrument may be useful in evaluating the impact of initiatives to modify attitudes towards terminal care and in improving the quality of care at the end of life.

Referral of terminally ill patients for hospice: frequency and correlates.

BACKGROUND: Despite the central role of hospice in end-of-life care, little is known about the proportion of terminally ill patients referred for hospice and the physician factors associated with hospice referral. METHODS: Cross-sectional data from a self-administered survey of 231 physicians were used to estimate the proportion of terminally ill patients who were referred for hospice and to assess the independent effects of physician factors on hospice referral. RESULTS: On average, physicians reported referring about 55% of their terminally ill patients for hospice; 26.7% of the physicians referred less than one quarter of their terminally ill patients. Physician specialty, board certification, and physicians' knowledge level about hospice were independently associated with the proportions of terminally ill patients referred for hospice. CONCLUSION: Many terminally ill patients are not referred for hospice care and physician factors influence the use of hospice significantly. The study suggests effective factors and groups to target with interventions to enhance the appropriate use of hospice.

Developing leadership in healthcare administration: a competency assessment tool.

Despite the many graduate programs that specialize in health administration, healthcare leaders and practitioners have expressed concern about the quality of preparation of health administration graduates. The purpose of this study was to facilitate one part of an integrated approach to leadership development that spans academic and practitioner settings. The approach was to design a competency assessment tool for early careerists who have two to five years of postgraduate experience and who aspire to fill senior leadership positions in complex, provider-based healthcare organizations. Open-ended interviews with key informants and a comprehensive review of relevant literature were done to identify and categorize a set of competencies relevant to early careerists. Based on data from key informants, specific work experiences and academic courses were mapped to each competency, indicating where and how such competencies might be developed. A simple rating system was then added to assess each competency, which resulted in the completion of the tool. Finally, the tool was piloted in a practitioner setting at the Massachusetts General Hospital Administrative Fellowship Program and in an academic setting at the Yale University Health Management Program. The resulting tool includes 52 competencies categorized into four domains: (1) technical skills (operations, finance; information resources, human resources, and strategic planning/external affairs); (2) industry knowledge (clinical process and healthcare institutions); (3) analytic and conceptual reasoning; and (4) interpersonal and emotional intelligence. Early experience with the tool suggests that it can facilitate career planning among graduate students, early careerists, and their mentors. Further, the tool can help directors of both academic and practitioner programs identify strengths and gaps in their existing curricula or training programs. By offering specific competencies linked to work experiences and graduate courses, the tool is an initial step toward promoting collaborative efforts between academic and practitioner programs.

Nurses' use of palliative care practices in the acute care setting.

This study examines the reported use of palliative care practices by nurses caring for terminally ill patients in the acute care setting. Randomly selected nurses (n = 180) from six randomly selected hospitals in Connecticut completed a self-administered questionnaire. Factors associated with use of palliative care practices were examined by using bivariate and multivariate analyses. Most nurses surveyed (88.5%) reported using palliative care practices when caring for their terminally ill patients. Factors associated with greater use included greater knowledge about hospice, having practiced nursing for less than 10 years, and having had hospice training in the past 5 years. A substantial proportion of nurses reported that they never discuss hospice (51.7 per cent of nurses) and prognosis (26.6 per cent of nurses) with their terminally ill patients. Educational preparation (bachelor's degree versus less education) was not associated with greater use of palliative care practices. Palliative care practices are commonly used by nurses in the acute care setting. However, many report having limited training and substantial gaps in knowledge about hospice among this group of nurses, suggesting greater attention to palliative care and hospice may be warranted in nursing educational programs.