Geriatrics-for-Specialists Initiative: An Eleven-Specialty Collaboration to Improve Care of Older Adults.

In the early 1990s, visionary leaders at the American Geriatrics Society and The John A. Hartford Foundation recognized that the marked and growing shortage of geriatrics healthcare professionals would lead to a U.S. healthcare system ill prepared to provide optimal care for the ever-increasing number of older Americans. Led by the late Dennis W. Jahnigen, MD, they set forth a plan to address this shortage by collaborating with surgical and related medical specialists to create a series of programs to foster the highest quality care of older adults. Their unique programmatic vision was that every physician, not just geriatricians, would have basic knowledge and skills in geriatric care, because geriatricians cannot and should not meet the need alone.

The movement of multidrug-resistant tuberculosis across borders in East Africa needs a regional and global solution.

Kevin Cain and colleagues reflect on the cross border movement of people from Somalia with MDR-TB and the implications for MDR-TB programs in East Africa.

Combined use of inactivated and oral poliovirus vaccines in refugee camps and surrounding communities - Kenya, December 2013.

Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, circulation of indigenous wild poliovirus (WPV) has continued without interruption in only three countries: Afghanistan, Nigeria, and Pakistan. During April-December 2013, a polio outbreak caused by WPV type 1 (WPV1) of Nigerian origin resulted in 217 cases in or near the Horn of Africa, including 194 cases in Somalia, 14 cases in Kenya, and nine cases in Ethiopia (all cases were reported as of March 10, 2014). During December 14-18, 2013, Kenya conducted the first-ever campaign providing inactivated poliovirus vaccine (IPV) together with oral poliovirus vaccine (OPV) as part of its outbreak response. The campaign targeted 126,000 children aged ≤59 months who resided in Somali refugee camps and surrounding communities near the Kenya-Somalia border, where most WPV1 cases had been reported, with the aim of increasing population immunity levels to ensure interruption of any residual WPV transmission and prevent spread from potential new importations. A campaign evaluation and vaccination coverage survey demonstrated that combined administration of IPV and OPV in a mass campaign is feasible and can achieve coverage >90%, although combined IPV and OPV campaigns come at a higher cost than OPV-only campaigns and require particular attention to vaccinator training and supervision. Future operational studies could assess the impact on population immunity and the cost-effectiveness of combined IPV and OPV campaigns to accelerate interruption of poliovirus transmission during polio outbreaks and in certain areas in which WPV circulation is endemic.

The growth in applications for Social Security Disability Insurance: a spillover effect from workers' compensation.

We investigate the determinants of application for Social Security Disability Insurance (DI) benefits in approximately 45 jurisdictions between 1981 and 1999. We reproduce findings of previous studies of the determinants of DI application then test the additional influence of changes to workers' compensation program benefits and rules on DI application rates. Our findings indicate that the programs are interrelated: When workers' compensation benefits declined and eligibility rules tightened in the 1990s, the DI application rate increased.

The lack of correspondence between work-related disability and receipt of workers' compensation benefits.

BACKGROUND: Previous studies suggest that many persons with disabilities caused by work do not receive workers' compensation benefits. METHODS: Data from surveys of persons with disabilities were used to estimate the proportion of disability due to work-related injuries and diseases. Studies examining the proportion of workers with work-related disability who received workers' compensation benefits were reviewed. Legal and other factors explaining the lack of receipt of workers' compensation benefits were examined. RESULTS: Many workers with disabilities caused by work do not receive workers' compensation benefits. The obstacles to compensation include increasingly restrictive rules for compensability in many state workers' compensation programs. CONCLUSIONS: A substantial proportion of persons with work-related disabilities do not receive workers' compensation benefits. The solutions to this problem, such as providing healthcare to workers regardless of the source of injuries or diseases, are complicated and controversial, and will be difficult to implement.

Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients.

BACKGROUND: Acutely ill older persons often experience adverse events when cared for in the acute care hospital. OBJECTIVE: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home. DESIGN: Prospective quasi-experiment. SETTING: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center. PARTICIPANTS: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. INTERVENTION: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital. MEASUREMENTS: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care. RESULTS: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001). LIMITATIONS: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences. CONCLUSIONS: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.

EMS provider findings and interventions with a statewide EMS spine-assessment protocol.

OBJECTIVE: To describe the utilization and findings with a statewide, prehospital spine-assessment protocol for emergency medical services (EMS) providers in a rural state. METHODS: The study was a prospective sample of EMS patients evaluated by prehospital providers for trauma-related injury during a one-year investigation period. Prehospital providers prospectively completed supplementary spine data-collection forms that reported patient demographics and EMS provider findings with the spine-assessment protocol. Data were analyzed using descriptive statistics. RESULTS: There were 207,545 EMS encounters during the study period, including 31,885 transports for acute trauma-related illness. Prehospital providers provided spine-assessment forms for 2,220 patient encounters. Providers reported a decision to immobilize 1,301 (59%) patients. For these immobilized patients, spine protocol findings included 416 (32%) patients deemed as unreliable, 358 (28%) with distracting injury, 80 (6%) with an abnormal neurologic examination, and 709 (54%) with spine pain or tenderness. Linkage of EMS and hospital data revealed seven acute spine fracture patients among the 2,220 reported encounters, all of whom were immobilized by EMS providers. CONCLUSIONS: Use of this prehospital spine-assessment protocol resulted in an EMS provider decision not to immobilize approximately 40% of EMS trauma patients. Few spine fracture patients were encountered during the investigational period, though all were immobilized.

Amiodarone and rural emergency medical services cardiac arrest patients: a cost analysis.

OBJECTIVE: Recent American Heart Association guidelines suggest amiodarone as an antiarrhythmic in refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). The authors sought to assess the impact of amiodarone use on outcomes and cost associated with this practice in a rural emergency medical services (EMS) state. METHODS: Statewide EMS records were reviewed for the calendar year 1999. Data reviewed included prehospital diagnosis, medications given by prehospital providers to patients with cardiac arrest, and procedures performed, including cardiopulmonary resuscitation (CPR) and defibrillation. Cost-benefit analysis assumed the cost of amiodarone treatment to be $137.65 per patient encounter. Absolute risk reduction (ARR) and number needed to treat (NNT) analysis utilized resuscitation rates published in the ARREST and ALIVE trials. RESULTS: During the study period, EMS providers diagnosed 2,189 patients as having cardiac arrest. Five hundred thirty-five (24.4%) cardiac arrest patients were defibrillated. One hundred sixty patients (7.3%), including 15 who did not receive defibrillation, were given lidocaine during resuscitation efforts. The annual cost increase from current practice for a statewide amiodarone VF/VT protocol was $21,822.40 (10,572.87%). The initial cost to stock EMS vehicles for this protocol would be $50,115.52. The cost-benefit analysis yielded a potential for one additional patient survival to hospital discharge in Maine per 3.125 years of system-wide practice at a cost of $68,840.00. CONCLUSION: Based on current data, instituting amiodarone treatment for refractory VF and pulseless VT in a rural EMS setting requires the investment of substantial resources, relative to current treatment strategies, for any potential survival benefit.