Impairment of executive cognitive control in type 2 diabetes, and its effects on health-related behavior and use of health services.

We evaluated whether, among persons with type 2 diabetes: (1) impaired executive cognitive functioning (ECF) is more common than among people without diabetes; (2) ECF is associated with the capacity to engage in instrumental health-related behaviors; and (3) worse ECF is associated with increased health services utilization. A population-based sample of 1,063 older people was interviewed regarding medical history and health services utilization; participants were administered the Mini Mental State Exam and the Behavioral Dyscontrol Scale, a measure of ECF. Participants with diabetes performed more poorly on cognitive measures than those without diabetes. Among those with diabetes, lower ECF was associated with more outpatient care and with ever having been in a nursing home. Impaired behavioral self-regulation may affect the capacity to engage in behaviors that could improve clinical status, resulting in greater health services use. The findings suggest the possibility of a positive feedback loop, with ECF deficits adversely affecting adherence, in turn leading to greater cognitive impairment-an issue for future research.

The taxonomy of telemedicine.

The purpose of this article is to present a taxonomy for telemedicine. The field has markedly grown, with an increasing number of applications, a variety of technologies, and newly introduced terminology. A taxonomy would serve to bring conceptual clarity to this burgeoning set of alternatives to in-person healthcare delivery. The article starts with a brief discussion of the importance of taxonomy as an information management strategy to improve knowledge sharing, facilitate research and policy initiatives, and provide some guidance for the orderly development of telemedicine. We provide a conceptual context for the proliferation of related concepts, such as telehealth, e-health, and m-health, as well as a classification of the content of these concepts. Our main concern is to develop an explicit taxonomy of telemedicine and to demonstrate how it can be used to provide definitive information about the true effects of telemedicine in terms of cost, quality, and access. Taxonomy development and refinement is an iterative process. If this initial attempt at classification proves useful, subject matter experts could enhance the development and proliferation of telemedicine by testing, revising, and verifying this taxonomy.

Nurses' assessment of rehabilitation potential and prediction of functional status at discharge from inpatient rehabilitation.

The goals of this study were to evaluate the accuracy of nurses' predictions of rehabilitation potential in older adults admitted to inpatient rehabilitation facilities and to ascertain whether the addition of a measure of executive cognitive function would enhance predictive accuracy. Secondary analysis was performed on prospective data collected for 362 Medicare beneficiaries enrolled in a national, multicenter study of rehabilitation outcomes. Ordinary least squares regression analysis was performed. Nurses' admission prognoses for rehabilitation potential predicted patients' functional status for observed activities of daily living upon discharge (r = 0.20, R = 0.04, P< 0.001). The addition of a measure of executive cognitive function, the Behavioral Dyscontrol Scale, significantly enhanced the variance explained by the model (r = 0.48, R = 0.23, P< 0.001). Nurses' prediction of functional outcome for hip fracture patients was significant (r = 0.26, R=0.07, P< 0.001). Predictions for patients with medical-surgical diagnoses did not achieve significance (r = 0.12, R = 0.02, P = 0.13). The findings show the independence of nursing prognoses and the level of executive cognitive function, and suggest that inclusion of this measurement of executive cognitive function may significantly enhance the accuracy of nursing prognoses. Development and implementation of related nursing education might be warranted. Further research is needed to ascertain the best method to introduce assessment of executive cognitive function into the rehabilitation environment.

Acceptability of telepsychiatry in American Indians.

Telepsychiatry differs from in-person treatment in terms of its delivery mechanism, and this dissimilarity may increase cultural differences between the provider and the patient. Because cultural competence and identification can impact patient satisfaction ratings, we wanted to explore whether cultural differences in our study population influenced telepsychiatric and in-person interviews. Here, we compared the acceptability of conducting psychiatric assessments with rural American Indian veterans by real-time videoconferencing versus inperson administration. The Structured Clinical Interview for DSM-IIIR (SCID) was given to participants both in person and by telehealth. A process measure was created to assess participants' responses to the interview type concerning the usability of the technology, the perceptions of the interviewee/interviewer interaction, the cultural competence of the interview, and satisfaction with the interview and the interview process. The process measure was administered to 53 American Indian Vietnam veterans both in-person and by real-time interactive videoconferencing. Mean responses were compared for each participant. Interviewers were also asked several of the same questions as the participants; answers were compared to the corresponding participant responses. Overall, telepsychiatry was well received and comparable in level of patient comfort, satisfaction, and cultural acceptance to in-person interviews. We also found evidence to suggest that interviewers sometimes interpreted participant satisfaction as significantly less favorable than the participants actually responded. Despite the potential of videoconferencing to increase cultural differences, we found that it is an acceptable means for psychiatric assessment of American Indian veterans and presents an opportunity to provide mental health services to a population that might otherwise not have access.

The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.

We conducted semistructured interviews with telemedicine program administrators as part of a national survey of physicians and managers regarding attitudes toward, and knowledge of, telemedicine. Telemedicine administrators were interviewed regarding factors affecting physician adoption of interactive video (IAV) telemedicine. The seven networks with which these managers were affiliated represented "traditional" telemedicine programs, primarily providing specialty teleconsultation via IAV. These programs were located in different geographic regions, and included both consulting and referring sites. We include data only for well-established networks for which multiple administrators responded. Data were analyzed using standard qualitative research methods. We conclude that reimbursement issues are important determinants of the rate of adoption, but that by themselves they do not fully account for the slow diffusion of IAV telemedicine. Likewise, appeals to physicians as rational decision-makers are necessary but insufficient means of increasing the volume of telemedicine within a network. Telemedicine networks and administrators that have been effective in persuading physicians to practice telemedicine or to refer patients demonstrate an emphasis on aggressive recruitment of physicians who will be involved actively in one or the other role. Most efforts to encourage physicians to adopt telemedicine, however, have focused on the supply of specialists, rather than stimulating demand among primary care providers who have patients to refer. Habit was identified as an important, albeit overlooked, factor explaining physician adoption of telemedicine.

Alternatives to randomized controlled trials in telemedicine.

Research designs other than true experiments may be useful in the evaluation of telemedicine. Potential methods include those that do not rely on randomization and tight control of the intervention, and analysis of existing administrative and clinical databases. Quasi-experimental designs may also be useful, especially when conducted in association with careful statistical methods that allow the investigator to control for certain differences between groups. Databases, such as those maintained by the Centers for Medicare and Medicaid Services, contain information on both outcomes and claims, as well as disease/procedure registries and electronic health records. This may provide a potential tool for understanding the effects of telemedicine on access to care in conjunction with costs and quality. These different approaches have advantages and disadvantages, but may be useful in telemedicine, where the conduct of randomized controlled trials is generally very expensive and frequently not feasible.

Racial and ethnic disparities in the outcomes of elderly home care recipients.

The purpose of this study was to examine racial/ethnic disparities in functional outcomes of elderly home health care recipients. Analyses were conducted using Outcome and Assessment Information Set (OASIS) data for a nationally representative sample of home health care episodes for patients aged 65 and older. Risk-adjusted regression analyses examined the association between race/ethnicity and functional outcomes. Fourteen outcome measures reflected improvement in specific functional areas (e.g., ambulation) and two reflected overall functional change. Non-Hispanic Whites (Whites) experienced substantially better functional outcomes than did home health care recipients of other racial/ethnic backgrounds. The disparity in outcomes was most pronounced between Whites and African Americans.