Physician participation in TQM in geriatric medicine.

BACKGROUND: Quality improvement (QI) approaches such as total quality management (TQM) and continuous quality improvement (CQI) have great potential for improving the care provided to older people. Geriatricians have the necessary experience and skills to initiate and lead these QI efforts. A national sample of practicing geriatricians was surveyed in 1998 regarding involvement in, satisfaction with, and insights regarding TQM processes in four care settings. RESULTS: Of 537 questionnaires returned in time for analysis, 497 were included for analysis after omitting questionnaires that were undeliverable or unusable (n = 25) and those from respondents who worked fewer than 20 hours per week (n = 15). More than one-third of the respondents (37.1%) reported no TQM activity at all. For the remainder, the primary site for TQM activity was the nursing home (33.0%), the hospital (22.5%), the office (11.4%), and the patient's home (3.7%). A majority of the respondents spent two hours per week or less on TQM projects. Planning an intervention and acting to maintain it in practice after its evaluation were the two stages of the improvement cycle these respondents engaged in most frequently. DISCUSSION: More geriatricians should be encouraged to participate in TQM training and in specific projects to improve systems of care for older people. Incentives to increase participation should be made available. Rapid-cycle improvement may fit better with physicians' culture of working for outcomes that have relatively short turnaround times.

Communication between the hospitalized older patient and physician.

Much research has shown that how physicians communicate with patients can have profound influence on behavioral, psychosocial, and clinical outcomes of the encounter. Communication with older patients, however, is often compromised by some attributes of the aging process. Communication can also be affected by the setting in which it takes place, and the hospital presents some barriers not found in ambulatory sites. These concerns are often compounded in end-of-life decisions for older patients when discussed in hospital settings.

Do physicians discuss HIV and AIDS with patients? A survey of physician practices.

HIV and AIDS continue to be major concerns to the health care community and the world around them. Preventive efforts and education have been the focus of the fight against AIDS thus far. By the year 2000, 75% of physicians are expected to conduct risk-reduction counseling for patients regularly. Previous studies show that a smaller percentage "routinely" follow this recommendation. The purpose of our study was to assess with what percentage of patients physicians discuss several HIV/ AIDS-related topics, what percentage of their patients are considered at risk for infection, and how comfortable the physicians are with their knowledge level and discussing the subject matter. We sent surveys to the last five graduating classes from St. Louis University School of Medicine and to 169 physician preceptors in the community. The survey asked about patients considered at risk, physician comfort level with HIV/ AIDS, the percentage of patients they discuss various HIV/AIDS topics with, and his or her preparedness for these discussions. Total responses were 464 (53.7%) representing all areas of medicine. Most of the physicians (72.9%) consider 0-25% of their patients at risk for HIV/AIDS. Eighty-one percent claim they are moderately or very comfortable discussing the material with patients and more than 90% feel they have at least adequate knowledge. Most of the respondents discuss the HIV/ AIDS topics with 0-25% of patients. Recent medical school graduates and primary care physicians are more comfortable with HIV/AIDS and discuss the surveyed topics with a higher percentage of patients.

The magic of science and the science of magic: an essay on the process of healing.

The field of medical sociology has developed rapidly in recent years in sophistication of conceptualization and research techniques. Nonetheless, there remains a considerable amount of "unexplained variance" in knowledge about health and illness behaviors. This paper asserts that to grow further, medical sociology should become more interdisciplinary in conceptualization and design of research projects. The application of research findings from the field of psychoneuroimmunology to explain the effects of placebos as a form of magic is used as an illustration.

Inner-city older blacks have high levels of functional disability.

OBJECTIVES: To describe the frequency and severity of functional problems in two groups of noninstitutionalized inner-city blacks aged 70 years and older contrasted with results from appropriate groups of white and black older adults and with the goals of the Healthy People 2000 program. DESIGN: Cross-sectional descriptive study. SETTING: Community-based samples. PARTICIPANTS: A population-based sample of 416 older adults living in a 3.5-square mile catchment area in north St. Louis (NSL), Missouri, and a sample of 197 older residents living in public housing in East St. Louis (ESL), Illinois. MEASUREMENTS: Health status, preventive health activities, health services utilization, and risks for progressive frailty were assessed by self report and observation using well validated, standardized instruments. Whenever possible, comparison data were derived from national datasets, original samples used to validate the measures, and other useful comparison groups. RESULTS: The NSL sample had somewhat better health status and risk for progressive disability than the ESL sample. However, compared with national or regional reference groups using age-gender adjustments, both study groups demonstrated increased levels of dependence in intermediate activities of daily living, restricted activity days, inability to walk one-half mile without assistance, reported poor vision, living alone, and limited income compared with both older whites and blacks, and increased levels of worsening health, inability to perform heavy work around the house, never walking a mile or more, and currently unmarried versus whites with variable decrements versus blacks. Contrasted with other comparison groups, the two samples had increased body fat; consistent decrements in gait speed, timed chair stands, timed one-leg balance, and frequency of preventive exercise; and lower levels of dental care; results relative to physician visits and hospital days were mixed. They also had high levels of measured visual and hearing impairments, unmet needs for home delivered meals, and problems with false teeth. Deficiencies compared with the goals of Healthy People 2000 were large. CONCLUSIONS: The special attributes of inner-city blacks, including poverty and access to and acceptance of remedial programs, will have to be considered if the goals of Healthy People 2000 are to be met in this important and growing segment of older Americans. 44:0000-0000, 1996.

Nutritional risk in inner-city-dwelling older black Americans.

OBJECTIVE: To define the degree of nutritional risk in older inner-city black Americans and to identify important underlying factors associated with high nutritional risk. DESIGN: Cross-sectional descriptive study. SETTING AND PARTICIPANTS: A population-based sample of 400 noninstitutionalized persons older than 69 years of age in north St. Louis (NSL), Missouri, and a community-based sample of 115 residents aged 50 years and older living in public housing in East St. Louis (ESL), Illinois. Both study areas have high levels of poverty. MEASUREMENTS: Nutritional risk was measured using the Nutrition Screening Initiative Checklist. Demographic information, economic status, self-rated health, Geriatric Depression Scale score, and body mass index were assessed using established standardized instruments. MAIN RESULTS: Forty-eight percent of NSL and 66% of ESL subjects scored high on the Checklist. Compared with a mostly white (96%) comparison group from New England, both samples demonstrated particularly high prevalence for limited intake of fruits, vegetables, and milk; tooth and mouth problems; lack of money for food; eating alone; polypharmacy; and inability to shop, cook or feed on their own. High levels of depressive symptoms, fair or poor self-rated health, perceived inadequacy of income, and low income levels were associated with high risk, but even those subjects with no or few such predisposing factors were still high on the Checklist score compared with the New England sample. CONCLUSIONS: If confirmed, these results indicate that inner-city-dwelling older black Americans are at high nutritional risk. Attempts to reduce their nutritional risk should focus on improving nutritional content of their diet, oral health, polypharmacy, depressive symptoms, and poor general health; offering group meals; and providing assistance with shopping and cooking.

Evaluation of a HIV/AIDS education program for adolescents.

The adolescent population has recently been recognized as one of the groups at risk for human immunodeficiency virus (HIV) infection. Statistics are beginning to document the extent of this trend. This study is aimed at determining adolescent sexual behaviors and the efficacy of a medical student-run acquired immune deficiency syndrome (AIDS) education program. Medical students taught 2,169 high school students in the St. Louis area with a pre- and post- intervention questionnaire administered to record levels of HIV/AIDS knowledge and sexual practices. Data revealed that 56.4% of the respondents were sexually active with 70.4% having multiple partners and 61.0% admitting to unprotected sex. These students demonstrated a significant increase in their knowledge about HIV infection after the educational program. The results show that, adolescents are sexually active and more importantly, they are practicing behaviors that put them at risk for HIV/AIDS, a risk which they recognize. Finally, the educational intervention did increase students' knowledge of HIV/AIDS. This may not translate into a change in behaviors, but it is a first step.

Nutritional risk and survival in elderly veterans: a five-year follow-up.

The purpose of this study was to identify predictors of survival over five years in a sample of 377 elderly (age 55+) chronically ill men. Subjects were selected at baseline from consecutive appointments at a geriatric clinic and given extensive medical and psychosocial assessment. Five years later, subjects who could be located were interviewed by telephone. Interviews were completed with 194 (51.4%) subjects, 90 others were confirmed as deceased, 29 subjects could not be interviewed, and 64 more were not located although VA records did not show that any were deceased. The predictor variable of interest was the Nutritional Risk Index (NRI), a 16 item index which measures nutritional dimensions of health status. Other variables included functional health status [Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL)], mental health status [Mini-Mental Status Exam (MMSE), morale], health habits (smoking, alcohol use and exercise), use of health services (physician visits, emergency room (ER) visits, hospital stays), and demographic factors (age, income, marital status and living arrangements). Proportional hazard models showed that the variables with statistically significant direct effects on survival time were younger age, higher functional health status on IADL, non-smoking, moderate alcohol use, and perception of adequate income. Nutritional status was indirectly associated with survival.

Achieving consensus on withdrawing or withholding care for critically ill patients.

OBJECTIVE: To examine the decision-making process to withhold or stop life support. DESIGN: Survey. SETTING: Medical intensive care unit of a tertiary care center. PARTICIPANTS: Physicians and families of 15 critically ill patients; in seven cases patients also participated. MEASUREMENTS: Meetings between physicians and family members concerning a decision to withhold or stop treatment of a critically ill family member were tape-recorded. Transcriptions of the meetings were analyzed for 1) process: how the physician introduced the need for a decision, framed the likely outcomes of options, and closed on a decision; 2) what decision was made; and 3) the outcome; died, discharged home, or discharged to another institution. RESULTS: The concept of "patient's wishes" was a central orientation point for the negotiation of consensus regarding withholding or withdrawing therapy even when the patient was not a participant. Physicians tended to provide a direct and unambiguous introduction, give equal weights to options during decision framing, but narrow the options during decision closure to correspond to their judgments. Not every decision was consistent with the physician's judgment. CONCLUSIONS: Decision making to withhold or withdraw life-support therapy from critically ill persons involves complex, difficult processes. Successful management of the tension among life extension, quality of life, patient autonomy, and social justice requires better understanding of these processes.

Impact on caregivers of supporting urinary function in noninstitutionalized, chronically ill seniors.

In a multivariate study of 148 caregivers of chronically ill older persons, 22% of those caring for a continent senior reported that maintaining continence was a burden, and 75% of caregivers of incontinent seniors reported it as burdensome. The burden of maintaining urinary function was associated with lack of social support, time spent providing care, and care receiver's immobility. Caregivers' depressive symptoms were associated with perceived burden from providing care for urinary function, a confused care receiver, and post-stroke support.

Progress in the development of a nutritional risk index.

The development of a 16-item nutritional risk index (NRI) is chronicled from its inception through its application in three studies designed to assess its reliability and validity. Study I involved a survey of 401 community-dwelling elderly in St. Louis, Missouri who were interviewed at baseline, 4-5 mo later, and 1 yr later. Study II involved a cross-sectional survey of 377 male outpatients attending two clinics at the St. Louis Veterans Administration Medical Center. Study III involved a cross-sectional survey of 424 community-dwelling elderly in Houston, Texas. Internal consistency reliability coefficients ranged between 0.47 and 0.60, and test-retest reliability coefficients ranged between 0.65 and 0.71. Validity was established by using the NRI to predict the use of health services, as well as by correlating it with a variety of anthropometric, laboratory, and clinical markers of nutritional status. The utility of the NRI for future applications is discussed.

Correlates of a measure of coping in older veterans: a preliminary report.

Sense of Coherence (SOC) is a specific measure of perception of coping ability which is examined here in relation to demographic characteristics and measures of physical and mental health status of older veterans (N = 240). Results suggest that the SOC is strongly correlated with measures of subjective health status. It does not uniquely contribute to that dimension but does exhibit appropriate psychometric properties to encourage its use in further research.

Clinical validation of a nutritional risk index.

This research assessed the clinical validity of a nutritional risk index (NRI). Subjects were 377 male veterans, aged 55+, attending general medicine and geriatric outpatient clinics. Data were collected by personal interviews, anthropometric measurements, laboratory assay of nutritional parameters, three-day food records, and medical record reviews. Although the results showed that the NRI correlated significantly with only two nutritional measures (body mass index, total energy intake), critical values or threshold levels of NRI were identified that significantly discriminated low risk from high risk patients on four nutritional parameters (body mass index, total energy intake, laboratory risk, and medications risk). It was concluded that the NRI is a valid measure of health status and contains a nutritional dimension.

Older veterans' future use of VA health care services.

This study is a secondary analysis of the Harris Survey of Aging Veterans (SAV) and is designed to identify variables that may be associated with older veterans' future use of the Veterans Administration (VA) health care system. Using regression and discriminant analysis techniques, the study identifies variables that may predispose older veterans to use the VA health care system in the next 10 years. The results indicate that older veterans may elect to use their health care benefits on objective criteria consistent with their health and financial resources, e.g., past use of veterans benefits, expected health status, and private insurance coverage. These variables suggest that the VA's recently enacted means test and the removal of automatic age eligibility will disenfranchise few older veterans.

Widowhood, sex, labor force participation, and the use of physician services by elderly adults.

This paper investigated the relationships of widowhood, sex, and labor force participation with the use of ambulatory physician services by elderly adults. Data on 18,441 individuals aged 55 and over were taken from the 1978 Health Interview Survey. Hierarchical regression results indicated that although these three factors are related to physician utilization at the zero- and first-partial levels, only sex remained significant when their two- and three-way interactions and other variables from the behavioral model (including living arrangements) were introduced. This suggests that the effects of widowhood and labor force participation are spurious. Widows are simply more likely to live alone and are less likely to work than widowers; those who live alone and do not work are more likely to use health services (and more of them) than those who live with others and are gainfully employed.

PIP: Studies typically report that widowed persons go to the doctor and to the hospital more often than married persons. Using data from the 1978 Health Interview Survey, the researchers studied 18,441 individuals aged 55 and older to clarify the effect of widowhood on physician use. They examined the unadjusted effects of widowhood, sex, and labor force participation on physician contact and the volume of physician visits. Next they adjusted the effect of each of the 3 factors for the other 2 and for the 2- and 3-way interactions among them. Finally, they introduced additional controls typically included in modelling the use of health services among elderly adults. 56% of the sample were women, 23% were widowed, and 34% were gainfully employed. 78% had seen a doctor at least once in the past 12 months. The controls used were taken from Anderson's behavioral model. Ordinary least squares regression analysis was used to obtain the unstandardized (and standardized) coefficients. Results show that although widowhood, sex, and labor force participation are related to physical utilization at the 0 and 1st- partial levels, only sex remained significant when their 2- and 3-way interactions and other variables from the behavioral model (including living arrangements) were introduced. Women are about 4% more likely to have seen a physician during the past year than men. Those who live alone are 5% more likely to have seen a doctor in the past year. Thus, the real effect is living alone, not being a widow. The researchers mention 2 cautions about the data: 1) generalization to other outcomes is tenuous; and, 2) the data do not indicate how long the widowed have been widowed.

Further assessment of the reliability and validity of a Nutritional Risk Index: analysis of a three-wave panel study of elderly adults.

This paper reports on the further assessment of the reliability and validity of a short (16-item), portable method for assessing nutritional risk which is easily administered in the typical social survey setting. Data were obtained from a three-wave panel study of 401 randomly selected, noninstitutionalized elderly persons (age 65 and over) in St. Louis. Reliability was assessed by both internal consistency and test-retest methods. Reliability coefficients (internal consistency) of .603, .544, and .515 were obtained at T-1, T-2, and T-3, respectively. Cross-panel intercorrelations (test-retest) ranged between .67 and .71. Validity was assessed using factor analysis and various outcome measure comparisons for those at risk versus those not at risk. A five-factor orthogonally rotated solution explained 47.9 percent of the variance in the 16 items. Individuals with higher risk scores had significantly poorer health as measured by other standard indexes, and used significantly more health services than those with lower risk scores. These results underscore the potential of the Nutritional Risk Index (NRI) as a screening device for use among the elderly.