Use of low-dose computed tomography to assess pulmonary tuberculosis among healthcare workers in a tuberculosis hospital.

BACKGROUND: According to the World Health Organization, China is one of 22 countries with serious tuberculosis (TB) infections and one of the 27 countries with serious multidrug-resistant TB strains. Despite the decline of tuberculosis in the overall population, healthcare workers (HCWs) are still at a high risk of infection. Compared with high-income countries, the TB prevalence among HCWs is higher in low- and middle-income countries. Low-dose computed tomography (LDCT) is becoming more popular due to its superior sensitivity and lower radiation dose. However, there have been no reports about active pulmonary tuberculosis (PTB) among HCWs as assessed with LDCT. The purposes of this study were to examine PTB statuses in HCWs in hospitals specializing in TB treatment and explore the significance of the application of LDCT to these workers. METHODS: This study retrospectively analysed the physical examination data of healthcare workers in the Beijing Chest Hospital from September 2012 to December 2015. Low-dose lung CT examinations were performed in all cases. The comparisons between active and inactive PTB according to the CT findings were made using the Pearson chi-square test or the Fisher's exact test. Comparisons between the incidences of active PTB in high-risk areas and non-high-risk areas were performed using the Pearson chi-square test. Analyses of active PTB were performed according to different ages, numbers of years on the job, and the risks of the working areas. Active PTB as diagnosed by the LDCT examinations alone was compared with the final comprehensive diagnoses, and the sensitivity and positive predictive value were calculated. RESULTS: A total of 1 012 participants were included in this study. During the 4-year period of medical examinations, active PTB was found in 19 cases, and inactive PTB was found in 109 cases. The prevalence of active PTB in the participants was 1.24%, 0.67%, 0.81%, and 0.53% for years 2012 to 2015. The corresponding incidences of active PTB among the tuberculosis hospital participants were 0.86%, 0.41%, 0.54%, and 0.26%. Most HCWs with active TB (78.9%, 15/19) worked in the high-risk areas of the hospital. There was a significant difference in the incidences of active PTB between the HCWs who worked in the high-risk and non-high-risk areas (odds ratio [OR], 14.415; 95% confidence interval (CI): 4.733 - 43.896). Comparisons of the CT signs between the active and inactive groups via chi-square tests revealed that the tree-in-bud, cavity, fibrous shadow, and calcification signs exhibited significant differences (P = 0.000, 0.021, 0.001, and 0.024, respectively). Tree-in-bud and cavity opacities suggest active pulmonary tuberculosis, whereas fibrous shadow and calcification opacities are the main features of inactive pulmonary tuberculosis. Comparison with the final comprehensive diagnoses revealed that the sensitivity and positive predictive value of the diagnoses of active PTB based on LDCT alone were 100% and 86.4%, respectively. CONCLUSIONS: Healthcare workers in tuberculosis hospitals are a high-risk group for active PTB. Yearly LDCT examinations of such high-risk groups are feasible and necessary.

[Survey of hemodialysis inpatients in long-term care facilities].

OBJECTIVE: In Japan, the number of elderly patients on hemodialysis has markedly increased in recent years. We conducted a survey to confirm the current status of inpatient hemodialysis patients and dialysis facilities with the aim of providing better care. MATERIAL AND METHODS: The subjects were 57 dialysis patients admitted to the Jishu Hospital for three consecutive months or longer as of February 2004. The survey was conducted by obtaining informed-consent from the patients and their families. The patients were interviewed and a questionnaire was sent to their families. The survey items were as follows; 1) patient characteristics, 2) domestic status, 3) physical and mental condition and 4) awareness concerning the hospital. RESULTS: The survey showed that dementia is present in almost all elderly hemodialysis patients and they require some degree of assistance for the activities of daily living. In addition, 57.9% patients had already been admitted to or had visited two or more hospitals. The current status of inpatients had improved slightly. Although the period of hospitalization was longer than one year in 64.9% of respondents, it had decreased by around 13% in comparison with that in the previous survey at 1997. These results were considered to be caused by increases in inpatient dialysis facilities, aging-related deaths, and by patients switching to home care after discharge because of the higher economic burden. In the interview, some patients were satisfied with inpatient life, but about one half of the patients said they wanted home care. Key caregivers for patients are mainly middle-aged or older family members (> 50 years old), indicating that caregivers are aging. On the other hand, the present study showed that hospitalization provides advantages for family life, such as improvements in peace of mind, life rhythm, leisure time and physical condition. CONCLUSION: Since the aging of dialysis patients results in a decrease in physical activity and progression of dementia, long-term hospitalization has a high potential to induce bedridden patients. In addition to the requirement for more long-term facilities, efforts should be made to improve physical activities and inhibit the progression of dementia.

Differences in patient and clinic characteristics at CARE Act funded versus non-CARE Act funded HIV clinics.

The Ryan White CARE Act supports comprehensive care to persons with HIV infection. With an annual budget of over $1 billion, it is the largest federally funded programme for HIV care in the USA. We analysed data from the HIV Costs and Services Utilization Study, a nationally representative sample of HIV patients. Patient data were collected in 1996-97 and clinic data were collected in 1998-99. We examined whether CARE Act funded clinics differed from other HIV clinics in (1) the characteristics of their patients, and (2) their organization, staffing, and services. We found that patients at CARE Act clinics were younger, less educated, poorer, and more likely to be female, non-white, unemployed, uninsured, and have heterosexual contact as an HIV risk factor, compared to patients at other HIV clinics. CARE Act clinics tended to specialize in HIV care, had more infectious disease specialists, had fewer total patients, and provided more support services (e.g. mental health, nutrition, case management, child care). These results are consistent with findings of other studies that were limited by non-probability samples or restricted geographical areas.

Characteristics of Ryan White and non-Ryan White funded HIV medical care facilities across four metropolitan areas: results from the Antiretroviral Treatment and Access Studies site survey.

The Ryan White Comprehensive AIDS Resources Emergency Act 1990 (CARE Act) is one of the largest federal programmes funding medical and support services for individuals with HIV disease. Data that report services and gaps in service coverage from the organizational perspective are very limited. The Antiretroviral Treatment and Access Studies included a mail survey of 176 HIV medical care facilities in four US inner cities on clinic characteristics, services and practices, and patient characteristics. Characteristics of 143 (85%) responding Ryan White (RW) funded and non-RW funded facilities are described. RW funded facilities reported offering more services than non-funded facilities including evening/weekend hours (49% vs. 18%), transportation (71% vs. 22%), and on-site risk reduction counselling (88% vs. 55%). More RW funded facilities reported offering on-site adherence support services, such as support groups (44% vs. 12%), formal classes (20% vs. 2%), and pillboxes (83% vs. 43%), and served a larger proportion of uninsured patients (41% vs. 4%) than non-funded facilities. Our analysis showed that the RW funded HIV care facilities offered more clinic, non-clinic, and adherence support services than non-RW funded facilities, indicating that the disparities in services were still related to CARE Act funding, controlling for private-public facility type.

Long-term care hospitals under Medicare: facility-level characteristics.

Though accounting for only a small percentage of total Medicare spending, long-term care hospitals (LTCHs) (defined as having an average length of stay [LOS] of 25 days or more) have been growing, in number and in Medicare expenditures, at a rapid rate in recent years. Because they have not been widely studied, we conducted research to describe the characteristics of this increasingly important Medicare provider type. We found that most LTCHs specialize in the provision of respiratory care or rehabilitation. Information from this study can help inform the development of a Medicare prospective payment system for LTCHs.

Do patients with alcohol dependence use more services? A comparative analysis with other chronic disorders.

OBJECTIVE: The primary purpose of this research was to compare the service use of patients diagnosed with alcohol dependence to the service use of patients diagnosed with other chronic illnesses. The secondary purpose was to determine the impact of comorbid alcoholism on the service use of patients with chronic illnesses. METHODS: The sample included 67,878 veterans diagnosed with alcohol dependence, depression, or diabetes who were treated by the Department of Veterans Affairs in 1993. The number of inpatient days and outpatient visits over a 4-year period (1991 to 1995) were compared using regression models to control for differences in casemix. RESULTS: Controlling for casemix, patients treated for alcohol dependence had significantly fewer outpatient visits than patients treated for either depression or diabetes. Patients treated for alcohol dependence also had significantly fewer inpatient days than patients treated for depression, but significantly more inpatient days than patients treated for diabetes. Comorbid alcoholism was prevalent among patients treated for depression and diabetes. Comorbid alcoholism increased the number of inpatient days for patients treated for depression or diabetes and increased the number outpatient visits for patients with depression. However, comorbid alcoholism decreased the number of outpatient visits for patients treated for diabetes. CONCLUSIONS: Results suggest that patients with alcohol use disorders should not be singled out as being more costly to treat than patients with other chronic illnesses. These findings are in stark contrast to those from studies comparing individuals with alcohol use disorders to relatively healthy individuals sampled from at-risk populations.

Development of a crosswalk from the Minimum Data Set 2.0 to the Alberta Resident Classification System.

Ontario has mandated the use of the Minimum Data Set 2.0 (MDS) to classify patients in all chronic care hospital beds as of July 1996. The MDS, widely used in several other jurisdictions, has been shown to have several advantages over other assessment systems. However, Ontario currently classifies residents of homes for the aged and nursing homes under the Alberta Resident Classification System (ARCS). Since there is not a single system to assess the elderly in institutional settings, it is not possible to create a funding system for all institutions based on patient rather than facility characteristics. The author reports on the development of a crosswalk algorithm to compute ARCS levels of care based on clinical items from the MDS. This algorithm may be used to support a transitional approach to move to a funding system for long-term care based on Resource Utilization Groups (RUG-III).

A decision-making aid for long-term care waiting list policies: modelling first-come, first-served vs. needs-based criteria.

A chronic care hospital in London, Ontario, was faced with the question of whether to continue to admit applicants on a first-come, first-served basis, or to implement a needs-based admission criterion To provide information relevant to this decision, a simple computer modelling technique was used to model the waiting list under both policies. Analysis of the results indicated substantial variability in the need for care demonstrated by waiting list applicants, and individual placement priority under the two schemes. Descriptions of individuals affected by the proposed change in policy provided additional information. The information provided by the waiting list analysis contributed to the decision-making process about waiting list policy. The method used is applicable to waiting list management decisions in other institutions.

Identifying an appropriate case mix measure for chronic care: evidence from an Ontario pilot study.

With the move toward rate-based funding for chronic care hospitals, a case mix measure that describes chronic care patients in a valid and reliable manner is needed. A pilot study was done in Ontario to evaluate the effectiveness of three classification systems that have been implemented elsewhere. It was recommended that work continue on the basis that Ontario will implement the Resource Utilization Groups (RUG-III) system for activity measurement and funding of chronic care patients.

Applying RUG-III in Japanese long-term care facilities.

A U.S. nursing home case-mix system, Resource Utilization Group, Version III (RUG-III), was tested in a variety of Japanese long-term care facilities. Staff time and resident characteristics were measured for a sample of 871 patients. Acceptable reliability was found for items defining RUG-III, and the system explained 44% of the variance in wage-weighted staff time (cost). Also, Japanese and U.S. costs had similar patterns across RUG-III categories. However, there was wide discrepancy between the stated purpose of Japanese facilities and their patient populations, and the current payment mechanism did not reflect actual use of resources.

Palliative fever management in Alzheimer patients. quality plus fiscal responsibility.

Aggressive medical treatment of infections does not affect the progressive course of dementia of the Alzheimer type (DAT) and has limited effect on the mortality rate. Utilization of health care resources and discomfort during a fever episode were compared in three differing treatment conditions: in 18 patients in a dementia special care unit (DSCU) who received palliative management, 26 patients in a DSCU who were treated aggressively, and 17 DAT patients in traditional long-term care units who were treated aggressively. Both groups of patients in the DSCU had lower discomfort scores, lower utilization of high-cost health care resources, and higher utilization of analgesics and narcotics. A nursing model of care incorporating hospice concepts into the DSCU is suggested.

[Evaluation of the level of dependency of persons placed in establishments for chronic patients. Development of a survey instrument and studies of validity, pertinence and performance]. / Evaluation du niveau de dépendance des personnes placées en établissements pour patients chroniques. Développement d'un instrument et études de validité, de pertinence et de performance.

With the aim to achieve a more equitable budgetary allocation to nursing homes, an instrument for the evaluation of the patients' dependency has been developed and tested in 55 institutions, for a total of about 23000 observations. Statistical analyses show that the internal validity of the gathered data is quite good. The tool criteria are judged relevant by experts, and the tool performance is adequate: its use should permit the constitution of groups (clustering) of nursing homes homogeneous from the point of view of their nursing care load.

A prospective study of long-term care institutionalization among the aged.

A statewide probability sample of 1,625 elders living in Massachusetts are studied prospectively to identify key determinants of long-term care (LTC) institutionalization. One-hundred forty-seven elders, 9 per cent of the original cohort, entered a LTC institution during the six-year investigation. Using logistic multiple regression, we examine the predictive power of 19 independent variables grouped into six categories: demographic characteristics, attitude, social context, long-term care needs, physical disability, and mental/emotional disability. Five variables are significantly related to institutionalization: advancing age, using ambulatory aids, mental disorientation, living alone, and using assistance to perform "instrumental" ADL (activities of daily living). These results may be helpful to those trying to target non-institutional services to elders for use as substitutes for institutional long-term care. They may also help explain why recent experimental tests of substituting non-institutional care for institutional services have been less than successful.