Improving community ambulation after hip fracture: protocol for a randomised, controlled trial.

INTRODUCTION: After a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients. PRIMARY OBJECTIVE: To evaluate the effect of a specific multi-component physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation. DESIGN: Parallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants. PARTICIPANTS AND SETTING: A total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions. INTERVENTIONS: Participants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists' adherence to the treatment protocol, and the participants' receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period. MEASUREMENTS: The primary outcome (community ambulation) is the ability to walk 300 m or more in 6minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6minutes, cognitive status, and nutritional status. ANALYSIS: Analyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks. DISCUSSION: This multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.

Primary care physician recommendations for colorectal cancer screening. Patient and practitioner factors.

BACKGROUND: Current guidelines for colorectal cancer screening do not specify the role of age or comorbidity in patient selection. Reported screening practices may thus be influenced by patient, as well as physician, characteristics. METHODS: A questionnaire was sent to primary care physicians in 10 states to determine recommendations for fecal occult blood testing (FOBT) and sigmoidoscopy in 4 pairs of clinical vignettes that varied by patient age (65 or 75 years) and comorbidity (none, mild, moderate, and terminal). RESULTS: Among the 884 respondents (50%), most physicians recommended FOBT in all vignettes except those with a terminal illness and fewer than half recommended sigmoidoscopy in any vignette. Physician recommendations were influenced by comorbidity, but one third still recommended FOBT for terminally ill patients and less than 50% recommended sigmoidoscopy for patients with no comorbidity. Differences in recommended screening between vignettes that differed only in patient age were small. Among all subgroups of physicians, at least 30% recommended FOBT in terminally ill patients and no more than 60% recommended sigmoidoscopy in healthy patients. CONCLUSIONS: Primary care physicians were much more likely to recommend screening with FOBT than sigmoidoscopy, regardless of patient and practitioner factors. Although physician recommendations were influenced by patient comorbidity and age, they frequently recommended FOBT in clinically inappropriate settings and failed to recommend sigmoidoscopy when appropriate. Broad-based interventions to improve appropriate screening practices may be needed.

Health status versus quality of life in older patients: does the distinction matter?

PURPOSE: Although health-related quality of life in older people is generally assessed by measuring specific domains of health status, such as activities of daily living or pain, the association between health-status measures and patients' perceptions of their quality of life is not clear. Indeed, it is controversial whether these health-status measures should be considered measures of quality of life at all. Our objective was to determine the association between health-status measures and older patients' perceptions of their global quality of life. SUBJECTS AND METHODS: We performed a cross-sectional study of 493 cognitively intact patients 80 years of age and older, interviewed 2 months after a hospitalization. We measured patients' self-assessed global quality of life and four domains of health status: physical capacity, limitations in performing activities of daily living, psychological distress, and pain. RESULTS: Each of the four scales was significantly correlated with patients' global perceptions of their quality of life (P <0.001). The ability of the health-status scales to discriminate between patients with differing global quality of life was generally good, especially for the physical capacity (c statistic = 0.72) and psychological distress scales (c statistic = 0.70). However, for a substantial minority of patients, scores on the health-status scales did not accurately reflect their global quality of life. For example, global quality of life was described as fair or poor by 15% of patients with the highest (best tertile) physical capacity scores, 25% of patients who were independent in all activities of daily living, 21% of patients with the least psychological distress (best tertile), and by 30% with no pain symptoms. Similarly, global quality of life was described as good or better by 43% of patients with the worst physical capacity (worst tertile), 49% of patients who were dependent in at least two activities of daily living, 47% of patients with the most psychological distress (worst tertile), and 51% of patients with severe pain. CONCLUSION: On average, health status is a reasonable indicator of global quality of life for groups of older patients with recent illness. However, disagreement between patients' reported health status and their perceptions of their global quality of life was common. Therefore, assumptions about the overall quality of life of individual patients should not be based on measures of their health status alone.

Differences in the treatment of patients with acute myocardial infarction according to patient age.

OBJECTIVE: To identify age-related differences in the treatment of patients with acute myocardial infarction. DESIGN: Retrospective cohort study. SETTING: Two university-affiliated medical centers with integrated clinical programs. PATIENTS: 329 patients admitted with acute myocardial infarction in 1988-1990 for whom complete medical records were available. Study exclusions included patients transferred from other hospitals specifically to undergo angiography or other cardiac procedures, nursing home residents, patients with metastatic cancer or dementia, and patients in whom "do not resuscitate" orders were written during the first 2 hospital days. MEASUREMENTS: Medical records were reviewed to determine socio-demographic data, comorbidity, admission severity of illness, medications, the use of specific diagnostic and therapeutic modalities during and after hospitalization, treatment limitations, and patient outcomes. MAIN RESULTS: Chronological age of patients was related to the use of several diagnostic and therapeutic modalities. Using logistic regression to adjust for comorbidity, severity, infarct size and location, and other covariates, patients 75 years and older were 12 times less likely to receive thrombolytic therapy, 8 times less likely to undergo coronary angiography, and 7 times less likely to undergo coronary angioplasty than patients less than 65 years of age. However, age was not related to the use of other modalities, including echocardiography or gated blood pool scanning, pulmonary artery catheterization, and transvenous pacing. Finally, in a logistic regression model, the risk of in-hospital death was 4 times greater for patients 75 years and older than patients less than 65 years. CONCLUSIONS: Physicians' management of patients with acute myocardial infarction differed greatly according to patient age for some diagnostic and therapeutic modalities, but not for others. These findings indicate that generalizations about age-related practice variations should not be based on analysis of a single procedure. Moreover, judgments about the appropriateness of age-related differences in management require knowledge of the relative effectiveness of management strategies in older and younger patients.

How well are community-living women treated for osteoporosis after hip fracture?

OBJECTIVES: To examine whether women with recent hip fracture are receiving adequate treatment for osteoporosis. To examine patient and physician characteristics associated with adequate treatment for osteoporosis. DESIGN: Cross-sectional study with prospective and retrospective data collection. SETTING: Hartford County, Connecticut. PARTICIPANTS: Sixty community-living women age 65 and older identified from hospital databases with an International Classification of Diseases, Ninth Revision, code for nontraumatic hip fracture. MEASUREMENTS: Treatment for osteoporosis, healthcare utilization, primary care physician's specialty, Katz activities of daily living scale, Lawton instrumental activities of daily living scale, Short Portable Mental Status Questionnaire, Medical Outcomes Study Short Form 12, and Physical Activity Scale for the Elderly. RESULTS: Only 13% of participants were receiving adequate treatment for osteoporosis as defined by the National Osteoporosis Foundation (NOF) guidelines for osteoporosis, 47% reported partial treatment that did not meet NOF guidelines, and 40% were receiving no treatment for osteoporosis. No patient or physician characteristics were associated with the adequacy of treatment for osteoporosis in this small sample. CONCLUSIONS: Few of the women in our study were receiving adequate treatment for osteoporosis after hip fracture. There exists an opportunity to educate postmenopausal women and physicians about the importance of treatment for osteoporosis to increase the number of women offered and receiving osteoporosis treatment, especially older postmenopausal women with established, severe osteoporosis as evidenced by recent hip fracture.

Delivery of preventive services to older black patients using neighborhood health centers.

OBJECTIVES: Older black patients are at risk for underutilization of preventive services. Our objectives were to assess the delivery of five preventive services in Title 330-funded health centers in low income neighborhoods in Cleveland, Ohio, and to determine the association of health system factors and health status with the delivery of these services. DESIGN: A cross-sectional study. SETTING: Four neighborhood health centers in low income neighborhoods of Cleveland, Ohio. PARTICIPANTS: A total of 683 black men and women, aged 70 and older, who regarded the health center as their primary source of outpatient care. MEASUREMENTS: Demographic characteristics, independence in basic and instrumental activities of daily living, comorbidity scores, and perceived access were determined by telephone interview. We reviewed charts to determine whether each of five preventive service goals were obtained: influenza vaccination within 1 year; pneumococcal vaccination at any time; mammography within 2 years; Papanicolau screening within 1 year or twice at any time in the past with documentation of normal results; and fecal occult blood testing within 2 years. RESULTS: The defined goals for influenza vaccination, pneumococcal vaccination, mammography, Papanicolau screening, and fecal occult blood testing were achieved for 59%, 64%, 59%, 51%, and 17% of patients, respectively. Influenza and pneumococcal vaccines were obtained more often in persons with greater comorbidity. Mammography and Papanicolau smear were obtained more often in patients without of ADL or IADL impairments. The four clinical sites varied substantially in the delivery of each preventive service. More frequent office visits were associated with greater delivery of all five preventive services. This relationship persisted in multivariable analyses controlling for health status and clinical site. CONCLUSIONS: This study shows that Title 330 federally supported neighborhood health center sites providing primary care to older blacks in Cleveland achieved high rates of performance in four of the five recommended preventive services. In addition, preventive services practices were associated with prognostically relevant health status information. The frequency of office visits was related strongly and consistently to the performance of the various preventive services, indicating that more, not fewer, office visits may be necessary to achieve Healthy People 2000 targets. J Am Geriatr Soc 48:124-130, 2000. Key words: preventive services; blacks; access to care; geriatrics; primary care

Do acute care for elders units increase hospital costs? A cost analysis using the hospital perspective.

OBJECTIVE: To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self-care activities with the costs of usual care. DESIGN: A randomized controlled study. PARTICIPANTS: A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324). MEASURES: The hospital's resource-based cost of caring for patients was determined from the hospital's cost-accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost. RESULTS: The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual-care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual-care unit. Ninety-day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety-day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar. CONCLUSION: Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward even though the intervention ward required a commitment of hospital resources.

Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital.

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization. OBJECTIVE: To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: A total of 1,531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997. INTERVENTION: ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness. MEASUREMENTS: The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction. RESULTS: Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05). CONCLUSIONS: ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.

Effects of functional status changes before and during hospitalization on nursing home admission of older adults.

BACKGROUND: Functional status changes before and during hospitalization may have important effects on outcomes in older adults, but these effects are not well understood. We determined the influence of functional status changes on the risk of nursing home (NH) admission after hospitalization. METHODS: Subjects were 551 general medical patients > or = 70 years old (66% female; mean age = 80 years) admitted from home to a large Midwestern teaching hospital. Functional status change measures were based on patients' need for assistance in five personal activities of daily living (ADL) 2 weeks prior to hospital admission, the day of admission, and the day of discharge. Sociodemographic and clinical characteristics were included in multivariate models predicting NH admission. RESULTS: Functional status change categories were: stable in function before and during hospitalization (45% of study patients); decline in function before and improvement during hospitalization (26%); stable before and decline during hospitalization (15%); decline before and no improvement during hospitalization (13%). In multivariate analyses, patients in the decline-no improvement group (odds ratio [OR] = 3.19; 95% confidence interval [CI] = 1.46-6.96) and patients in the stable-decline group (OR = 2.77; 95% CI = 1.29-5.96) were at greater risk for NH admission than patients in the stable-stable group. In a multivariate model that controlled for ADL function at hospital discharge, functional status change was no longer statistically significantly associated with NH admission. CONCLUSIONS: Discharge function is a key risk factor for NH admission among hospitalized older adults. Because functional status changes before and during hospitalization are key determinants of discharge function, they provide important clues about the potential to modify that risk. Functional recovery during a hospital stay after prior functional decline, and prevention of in-hospital functional decline after prior functional stability, are important targets for clinical intervention to minimize the risk of NH admission.

Effect of prospective reimbursement on nursing home costs.

OBJECTIVE: This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. DATA SOURCES/STUDY SETTING: The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. STUDY DESIGN: This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. PRINCIPAL FINDINGS: Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. CONCLUSIONS: Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.

Impact of the Maine Medicaid waiver for the mentally retarded.

To evaluate the impact of Maine's Medicaid waiver for the mentally retarded, baseline and 1-year followup data were obtained for 191 waiver clients and a comparison population of 115 persons excluded from the program because of enrollment limits. Program effectiveness was evaluated through measures of changes in clients' personal and community living skills. Medicaid and other data were used to establish individual and aggregate costs. It was found that the waiver program is a cost-effective alternative to intermediate care placements but that client screening is necessary to limit the enrollment of clients not at risk of institutional placement.

Information and service needs among active and former family caregivers of persons with Alzheimer's disease.

This study interprets results of a needs assessment completed by active and former caregivers of relatives with Alzheimer's disease (AD). Self-administered questionnaires yielded data about information and service needs at the time of diagnosis and at the time of the survey. Implications point to the need for high-quality educational material throughout the caregiving career, improved training for health professionals about AD, and an important role for former caregivers as resources to disseminate knowledge about AD to still-active caregivers and others in their own communities.

Health care triads and dementia care: Integrative framework and future directions.

Physicians are usually the first contact in the health care system for persons with dementia and their family caregivers. This paper provides a synopsis of research findings and knowledge gaps regarding interactions among these participants in the health care triad-primary care physicians, family caregivers, and persons with dementia. Research traditions that inform knowledge about health care triads and dementia care include: older patient-physician relationships; the stress-coping social-support health model that dominates family caregiver research; the social learning-self-efficacy model; and literature on the quality of medical care. An integrative framework is presented to illustrate how the quality of interaction in dementia care encounters may be influenced by specific characteristics of members of the health care triad. Domains of dementia care interaction include symptom diagnosis, symptom management, medication management, support service linkage, and emotional support. The integrative framework also links the quality of interaction in these domains with health-related outcomes relevant to each of the health care triad members. Most empirical research in this area has found that family caregivers are dissatisfied with many aspects of physicians' dementia care, but measurement techniques vary widely and little is known about how the quality of physician care is associated with health-related outcomes. Physician surveys have shown that they are least certain about the quality of support service linkage advice they provide. Virtually no research has examined how the person with dementia experiences medical care encounters with physicians and their family members. Much remains to be learned about the longitudinal experience of each member of the health care triad, and how the quality of dementia care encounters changes over the course of the disease process. In this era of rapidly expanding educational and support service interventions for persons with dementia and their family caregivers, as well as computer-based information about dementia care, the influence of these external factors on health care triad interactions and outcomes also remains to be studied.

Pressure ulcer prevalence in Ohio nursing homes: clinical and facility correlates.

Pressure ulcers remain a common medical problem in nursing homes, despite the development of clinical guidelines for prevention and treatment. Prevention involves low technology but vigilant care. If the disease progresses, infections can develop, and surgery may be necessary to prevent death. This article examines pressure ulcer correlates in a representative sample of 15,121 nursing home residents in 1994 in the state of Ohio. The prevalence of pressure ulcers was 12%, 8% for Stage 2 or greater. The study found that many nursing home residents remain at great risk of developing pressure ulcers. Important risk factors included a history of cured pressure ulcers, new admission and readmissions, dependencies in activities of daily living, weight loss and dehydration, diabetes, edema, and incontinence. After controlling for clinical factors, residents in rural facilities were less likely to have a pressure ulcer. These findings suggest that the quality of pressure ulcer care in nursing homes could improve.

Outcomes-based trial of an inpatient nurse practitioner service for general medical patients.

Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n= 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P>0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P>0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions.

A two-phase study of the reliability of computerized morbidity data.

This paper reports the results of a detailed examination of morbidity data collected at the Department of Family Medicine, Brown University Program in Medicine. The reliability study was conducted in two phases, spanning five years, with two distinct aims: (1) to assess the extent of consistency between morbidity data stored in the computer and those data abstracted from medical records, and (2) to determine the impact on data reliability of a standardized, precoded encounter form. This form was implemented between the first and second phases of the study. It was found that morbidity data stored in the computer represents 80 to 85 percent of identifiable morbidity in the medical records. In addition, approximately 8 percent of the computer stored health problems were either incorrectly coded or not found in the medical records. The data reliability improved between the two phases, which points to a positive impact of the encounter form in this setting. Several important methodological issues related to identification and coding of health problems surfaced during the study. These issues are discussed and are relevant to all researchers working with computerized morbidity data in family practice.

Resource use & patient outcomes in Medicare home care.

To what extent are patient outcomes associated with the amount of home care resources used by patients over episodes of Medicare home care? How can we use the Outcome and Assessment Information Set (OASIS) to improve planning and practical knowledge about the relationship between resource use and patient outcomes? This article addresses the questions and provides readers with some insightful answers.

Health care triads and dementia care: integrative framework and future directions.

Physicians are usually the first contact in the health care system for persons with dementia and their family caregivers. This paper provides a synopsis of research findings and knowledge gaps regarding interactions among these participants in the health care triad--primary care physicians, family caregivers, and persons with dementia. Research traditions that inform knowledge about health care triads and dementia care include: older patient-physician relationships; the stress-coping social-support health model that dominates family caregiver research; the social learning-self-efficacy model; and literature on the quality of medical care. An integrative framework is presented to illustrate how the quality of interaction in dementia care encounters may be influenced by specific characteristics of members of the health care triad. Domains of dementia care interaction include symptom diagnosis, symptom management, medication management, support service linkage, and emotional support. The integrative framework also links the quality of interaction in these domains with health-related outcomes relevant to each of the health care triad members. Most empirical research in this area has found that family caregivers are dissatisfied with many aspects of physicians' dementia care, but measurement techniques vary widely and little is known about how the quality of physician care is associated with health-related outcomes. Physician surveys have shown that they are least certain about the quality of support service linkage advice they provide. Virtually no research has examined how the person with dementia experiences medical care encounters with physicians and their family members. Much remains to be learned about the longitudinal experience of each member of the health care triad, and how the quality of dementia care encounters changes over the course of the disease process. In this era of rapidly expanding educational and support service interventions for persons with dementia and their family caregivers, as well as computer-based information about dementia care, the influence of these external factors on health care triad interactions and outcomes also remains to be studied.