Cost-effectiveness of Veterans Administration hospital-based home care. A randomized clinical trial.

A randomized design was used to examine the cost-effectiveness of a Veterans Administration hospital-based home care program that case managed inpatient and outpatient care. Patients (N = 419) with two or more functional impairments or a terminal illness were randomized to hospital-based home care (n = 211) or customary care (n = 208). Functional status, satisfaction with care, and morale were measured at baseline and at 1 and 6 months after discharge from the hospital; health care utilization was tracked for 6 months. Findings included significantly higher (0.1 on a three-point scale) patient and caregiver satisfaction with care at 1 month and lower Veterans Administration and private sector hospital costs ($3000 vs $4245) for the experimental group. Net per person health care costs were also 13% lower in the experimental group. We conclude that this model of hospital-based home care is cost-effective and that its expansion to cover these two patient groups throughout the Veterans Administration system can improve patient care at no additional cost.

The Foot Function Index: a measure of foot pain and disability.

A Foot Function Index (FFI) was developed to measure the impact of foot pathology on function in terms of pain, disability and activity restriction. The FFI is a self-administered index consisting of 23 items divided into 3 sub-scales. Both total and sub-scale scores are produced. The FFI was examined for test-retest reliability, internal consistency, and construct and criterion validity. A total of 87 patients with rheumatoid arthritis were used in the study. Test-retest reliability of the FFI total and sub-scale scores ranged from 0.87 to 0.69. Internal consistency ranged from 0.96 to 0.73. With the exception of two items, factor analysis supported the construct validity of the total index and the sub-scales. Strong correlation between the FFI total and sub-scale scores and clinical measures of foot pathology supported the criterion validity of the index. The FFI should prove useful for both clinical and research purposes.

Impacts of foot orthoses on pain and disability in rheumatoid arthritics.

Rheumatoid arthritis (RA) frequently causes foot pain and swelling that affect ambulation. Pharmaceutical management of pain and disability is standard in clinical practice. The use of functional posted foot orthoses, as an adjunct to pharmaceutical treatment, is a promising treatment for managing foot pain and disability in RA. Its effectiveness, however, has not been rigorously evaluated. We performed a double-blind clinical trial using foot orthoses vs. placebo orthoses in the management of the rheumatoid arthritic foot, while subjects continued customary treatment. On the basis of findings of no effect on disability and pain measures, this study indicates no benefit of functional posted foot orthoses over placebos.

Program factors that influence utilization of adult day care.

Health planners, policymakers, and providers urgently require methods and information that explain the factors that affect health services utilization. This information is especially critical for planning programs that are effective in maintaining the burgeoning elderly population in community care. In this study, correlation and regression analyses examined the characteristics of adult day care (ADC) centers that were associated with utilization as operationalized by demand for and actual attendance in 822 centers. Community, client population, services and activities, and structural characteristics were associated with demand per center whereas the social environment of the ADC center was not. The attendance rate was most strongly affected by services and activities and structural characteristics. The significance of the study, its limitations, and future directions for research are discussed.

Impact of long-term home care on mortality, functional status, and unmet needs.

This article reports the outcomes of a four-year follow-up evaluation of the Five Hospital Program, a long-term home care program in Chicago. Outcomes assessed include the mortality, comprehensive functional status, and perceived unmet needs of its frail elderly clientele (mean age 81 years at entry). The evaluation utilized a pretest, multiple posttest design with a comparison group consisting of similarly elderly and impaired individuals receiving OAA Title III-C home-delivered meals. Consecutively accepted treatment (N = 157) and comparison group clients (N = 156) were interviewed using the OARS Multidimensional Functional Assessment Questionnaire at baseline, 9 months, and 48 months after acceptance to care. A multivariate analysis of mortality rates revealed no between-group differences attributable to treatment on this outcome. Major findings included significantly better cognitive functioning and reduced unmet needs in the treatment group at nine months. A longer-range, continued beneficial effect of treatment on cognitive status was also observed at 48 months. We conclude that long-term home care provided important benefits to clients at both 9 and 48 months, with no effect on mortality. However, we suggest that the four-year findings be interpreted with caution, since only a small percentage of clients (18 percent) were still alive and receiving active care in the community at that time.

Impact of long-term home care on hospital and nursing home use and cost.

This article reports the long-range impact of a long-term home care program in Chicago on hospital and nursing home use and on overall health care costs over four client-years of observation. The evaluation utilized a quasi-experimental design with a comparison group composed of clients who received home-delivered meals. The health services utilization experience of consecutively accepted treatment (N = 157) and comparison group (N = 156) subjects was monitored for 48 client-months following acceptance to care. Imputed costs were then assigned to each type of care measured. Findings include a significantly lower risk of permanent admission to sheltered and intermediate-level nursing home care in the treatment group but no difference in risk of permanent admission to skilled-level nursing home care. Despite savings in low-intensity nursing home days, preliminary findings indicate that total costs of care were 25 percent higher in the treatment group. However, these costs are accompanied by significant quality-of-life benefits in the treatment group (reported elsewhere).

The whole is greater than the sum of its parts: the anatomy of the Department of Veterans Affairs Medical District 17 Health Services Research and Development Field Program.

The Medical District 17 Health Services Research and Development (HSR&D) Field Program was funded by the Veterans Administration (now the Department of Veterans Affairs--VA) in January 1983. This article describes the organization, progress, and accomplishments of this field program, and it provides a review of the breadth of health services research that is being conducted in Medical District 17. Overall, the field program has conducted research that addresses significant problems in the delivery of health care within the VA system. Resource utilization, cost effectiveness, and the care of geriatric patients have been some of the areas in which the Medical District 17 HSR&D Field Program has provided important research findings for VA. The field program plans to continue its response to the needs of VA. Moreover, HSR&D investigators will be collaborating with researchers of other services to conduct research that is both enlightening and highly relevant to the delivery of health care to the nation's veterans. The proposal for an HSR&D field program was developed by the Edward A. Hines Jr. VA Hospital in collaboration with the Center for Health Services and Policy Research (CHSPR) of Northwestern University. The program was funded in January 1983, as the result of a national competition to establish an HSR&D field program in each of the VA regions. The goals of the Medical District 17 Field Program are to improve the health care of veterans by conducting relevant research on the processes and outcomes of patient care; to provide comprehensive technical research assistance; and to educate VA managers, planners, and clinicians, as well as the general medical community, about advances in health care delivery. The field program's commitment to excellence is strengthened by its multidisciplinary approach, which enables physicians, nurses, social workers, psychologists, sociologists, economists, statisticians, administrators, and individuals in various related disciplines to cooperate in efforts to address a wide range of topical issues. These collaborations are a major strength of the field program. Primary research priorities of the field program are cost effectiveness of VA services (e.g., patient care technologies, delivery systems), long-term care, and rehabilitation. Investigators, however, are not limited to these topics and explore many other health services research issues of particular interest to them.

Threats to internal validity in worksite health promotion program research: common problems and possible solutions.

Reviews of the research on worksite health promotion programs reveal that most studies are limited in their ability to draw clear inferences about program effects because the studies employed flawed research designs and/or analyses. Conclusions are often drawn about program effectiveness with little consideration given to alternative explanations for the findings. In an effort to promote improved research, this article uses the Cook and Campbell delineation of threats to valid causal inference to illustrate how the threats can operate in worksite health promotion program research as well as how they can be examined and controlled. Researchers, even those attempting to conduct true experiments, must consider the existence of all plausible threats to validity and control or rule them out before valid causal inferences can be drawn. The theoretical and design issues involved in worksite health promotion program research are presented, followed by a discussion of threats to internal validity.

An agency-based representative payee program and improved community tenure of persons with mental illness.

OBJECTIVE: Representative payee programs help severely mentally ill individuals manage money from their Social Security payments to cover expenses for necessities and to avoid homelessness and rehospitalization. This study examined a representative payee program operated by a community mental health center to determine the criteria used by clinicians and ease managers to refer clients to the program and to learn whether participation in the program was associated with reductions in hospitalization. METHODS: The retrospective study included 56 individuals with severe mental illness who were enrolled in the representative payee program at Community Counseling Centers of Chicago for one year and who also had received services from the agency for at least one year before enrollment. Criteria used to refer clients to the representative payee program were determined through chart reviews. Data on state hospitalizations before and after enrollment were available for the entire sample; additional data on Medicaid-funded private hospitalizations were available for a subset of 33 clients. RESULTS: The most common criteria for enrollment in the representative payee program were comorbid substance abuse or dependence (49 percent), a history of homelessness (33 percent), and frequent hospitalizations (32 percent). During the year of participation in the representative payee program, the mean number of days spent in state hospitals decreased markedly compared with the year before enrollment, from 68 days to seven days. A similar reduction was noted in the number of days spent in state and private hospitals, from 97 days to 15 days. CONCLUSIONS: Findings from this pre- and postintervention retrospective study are tentative in the absence of a more rigorous design. However, the results suggest that the representative payee program is quite effective in reducing hospital stays.

Characteristics of persons with mental illness in a representative payee program.

This study compared the characteristics of 56 clients with severe mental illness in a community mental health agency's representative payeeship program with those of 54 clients who did not participate in the program. Based on data from a two-year period, participants in the representative payee program were characterized by disability or financial distress, indicated by a diagnosis of schizophrenia, homelessness, lack of rent money, and lack of financial skills; long-term dependence on income from Social Security and services provided by the mental health system, evidenced by receipt of Supplemental Security Income and frequent hospitalizations; and lack of financial independence, as reflected by inability to earn income from employment and lack of financial support from family.

Patient education resources related to biotherapy and the immune system.

PURPOSE/OBJECTIVES: To provide cancer care professionals with insight into available patient education resources related to biotherapy. DATA SOURCES: Literature from pharmaceutical companies, national organizations, the National Cancer Institute, and individual cancer centers. DATA SYNTHESIS: Comprehensive, but not all-inclusive, list of booklets, videotapes, and fact sheets currently available to inform and instruct patients and families regarding biotherapy, injection techniques, the immune system, and reimbursement strategies. CONCLUSIONS: Using available materials eliminates the need to develop new products and standardizes patient instruction. IMPLICATIONS FOR NURSING PRACTICE: These products facilitate patient and family education to promote understanding of the disease and treatment plan. Increased understanding can lead to independence and confidence in self-care.

Assessing the influence of adult day care on client satisfaction.

Using data collected from 74 adult day care centers, this study measured various program characteristics from four different categories of respondents--clients, caregivers, staff members, and administrators. The perceptions of these respondents were examined for their associations with each other and with client satisfaction. Three program characteristics, as perceived by clients, were significantly associated with client satisfaction (staff caring, general morale, and interior environment). The caregivers', staff members' and administrators' perceptions were not significantly associated with client satisfaction. In addition, most of these program component ratings were not significantly associated among clients, caregivers, staff members, and administrators.

Evaluation of a prospective payment system for VA contract nursing homes.

An evaluation of a pilot program for community nursing home care reimbursement by Department of Veterans Affairs Medical Centers (VAMCs) was undertaken. Eight VAMCs began using the Enhanced Prospective Payment System (EPPS) in 1992. These sites were compared to eight customary payment sites in a pretest/posttest quasi-experimental design. Outcomes included access to care, administrative workload, quality of care, and cost. As expected, per diem costs were significantly higher for EPPS than customary reimbursement patients ($106 vs. $87). However, EPPS sites placed veterans more quickly (81 days vs. 113 days; p < .01) than comparison sites and reduced administrative workload associated with placement. EPPS sites also increased the number of Medicare-certified homes under contract (76% vs. 54%) and placed significantly more veterans who received therapy (20% vs. < 1%). Savings in hospital days more than offset the increased cost of nursing home placement. Because the findings were attributed largely to a few veterans with long lengths of hospital stay, the early success of EPPS may diminish as the backlog of these long-stay patients decreases.

Gene therapy of cancer.

OBJECTIVE: To provide a review of the basic concepts and terminology of human genetics, the clinical application and risks of gene therapy, and ethical and societal issues. DATA SOURCES: Review articles, research studies, and book chapters related to genetics and human gene therapy. CONCLUSIONS: The genetic changes that play a role in the development of cancer have begun to be elucidated, and these discoveries have led to strategies to destroy cancers by correcting genetic defects or manipulating genes to induce tumoricidal activities. Gene therapy is a novel investigational intervention that is constantly evolving. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses will need an increased understanding of cellular biology, genetics, and genetics engineering. Major considerations for nursing practice include patient and family education, informed consent, side effects, and ethical and societal issues.

Can foot orthoses prevent hallux valgus deformity in rheumatoid arthritis? A randomized clinical trial.

Hallux valgus deformity is the most commonly observed forefoot deformity in patients with rheumatoid arthritis. This 5-year, double-blind, randomized clinical trial compared treatment orthoses with placebo orthoses for the prevention of hallux valgus deformity in the rheumatoid arthritic foot.One hundred and two subjects with active rheumatoid arthritis and with foot pain and minimal radiographic changes of the feet participated in the study. They were recruited from five arthritis clinics in the Chicago metropolitan area that are affiliated with or are teaching clinics of area medical schools. Patients were followed for 3 years.Eighty-one subjects completed the study. In a logistic regression analysis, the treatment group was 73% less likely to develop hallux valgus deformity compared with the control group (adjusted odds ratio 0.27, 95% confidence interval 0.078, 0.916 p = .04). These findings suggest that foot orthoses can prevent or slow the progression of hallux valgus deformity.

A short-term, three-year epidemiological study of median nerve sensitivity in practicing dental hygienists.

PURPOSE: Hand-intensive, repetitive motion procedures such as those performed by dental hygienists can lead to median nerve dysfunction which, left untreated, can degenerate into clinical carpal tunnel syndrome (CTS). Vibrometry has been used as a method for early detection of sensory nerve impairment. METHODS: A cohort of 16 university-educated dental hygienists was evaluated by means of programmed frequency stimuli for median nerve dysfunction at graduation and at one, two, and three years postgraduation. RESULTS: The results indicate that median nerve dysfunction was not detected in this cohort. However, further analysis suggests that a significant loss of median nerve sensitivity, or permanent "threshold shift," has occurred in the three years since graduation. CONCLUSION: Whether this is a harbinger of future events is unknown at this time.

A short-term epidemiological study of median nerve dysfunction in practicing dental hygienists.

The purpose of this study was to assess over time changes in median nerve function in a group of 20 students who entered the University of Minnesota dental hygiene program in 1986. This is a follow-up report on 16 of the 20 students who were evaluated two years postgraduation in 1990. Comparisons were made with prior evaluations of the subjects completed at graduation in 1988, and one year postgraduation in 1989. Digital vibrometry was used to evaluate median nerve sensibility threshold at each of the time periods studied. Analysis revealed that after one year of clinical practice, there was a mean sensibility threshold shift of 11.04% in the left median nerve and 8.42% in the right median nerve as measured by digital vibrometry. Results at two years postgraduation indicated that the threshold shift observed in an earlier study had been arrested. The reasons appeared to be twofold: (1) a period of work hardening with a concept of neuromuscular ligamentous tissue hypertrophy or adaptation to the rigors of dental hygiene practice, and/or (2) the practicing dental hygienist had learned to become more efficient in the provision of hygiene procedures. There were no reported symptoms of median nerve dysfunction and none of the subjects had been diagnosed as having CTS at any time during the two years since graduation. Continued evaluations will be necessary to determine whether the observations noted during the second year postgraduation evaluation indicated temporary or permanent slowing of the conditions necessary for the development of CTS.

Peripheral nerve dysfunction in practicing dental hygienists.

Hand-intensive repetitive procedures such as those performed by dental hygienists can lead to cumulative trauma disorders of the upper extremity. One such disorder is median nerve dysfunction leading to carpal tunnel syndrome (CTS). Vibrometry has been used in industrial settings as a method of early detection of sensory nerve impairment. This technique uses vibratory stimuli to assess the level of sensory perception in the fingertips. Using programmed frequency stimuli, 58 practicing dental hygienists were evaluated bilaterally for median nerve dysfunction. Results indicated that 15 (25.9%) of the dental hygienists reported the presence of CTS symptoms, while 7 (12.0%) tested positive for mild median nerve dysfunction. The findings suggest that vibrometry testing could aid in the early detection of CTS, thereby reducing its effects on clinical practice and facilitating early treatment.