VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans.

The U.S. Department of Veterans Affairs' Home-Based Primary Care (HBPC) Interdisciplinary Team (IDT) provides in-home, primary care for medically complex Veterans. This study explores how HBPC and Veterans' caregivers partner to provide care. Interviews, focus groups, and field observations were conducted during eight HBPC site visits. Qualitative thematic analysis was performed. Caregivers/IDT member partnerships are important to care. Effective partnerships include: ease of communication; caregiver-centered support; and when no caregiver is present, IDTs providing more monitoring/services to Veterans and connection to community services. As this model expands, understanding dynamics between IDT members and caregivers will optimize the success of HBPC programs.

Preschool ontology: The role of beliefs about category boundaries in early categorization.

These studies examined the role of ontological beliefs about category boundaries in early categorization. Study 1 found that preschool-age children (N= 48, ages 3-4) have domain-specific beliefs about the meaning of category boundaries; children judged the boundaries of natural kind categories (animal species, human gender) as discrete and strict, but the boundaries of other categories (artifact categories, human race) as more flexible. Study 2 demonstrated that these domain-specific ontological intuitions guide children's learning of new categories; children (N = 28, 3-year-olds) assumed that the boundaries of novel animal categories would be narrower and more strictly defined than novel artifact categories. These data demonstrate that abstract beliefs about the meaning of category boundaries shape early conceptual development.

Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia.

OBJECTIVES: To compare two strategies for implementing guidelines for nursing home-acquired pneumonia (NHAP) and to measure outcomes associated with treatment in accordance with the guidelines. DESIGN: Randomized controlled trial. SETTING: Ten skilled nursing facilities (SNFs) from a single metropolitan area. PARTICIPANTS: Patients with an episode of pneumonia acquired more than 3 days after admission to SNF (N = 350): 226 preintervention episodes of pneumonia and 116 postintervention episodes. INTERVENTIONS: Multi-faceted education intervention including small-group consensus process limited to physicians and a similar intervention that included physicians and nurses within randomly selected SNFs. MEASUREMENTS: Antibiotic use at diagnosis compared with the guidelines, hospital admission, severity of pneumonia, and 30-day mortality. RESULTS: Data were complete for 344 episodes of NHAP. For the preintervention group (n = 226), 62.2% (79/127) of the episodes were treated with parenteral antibiotics (PA) when PA were recommended by the guidelines and 57.6% (57/99) of episodes were treated with oral antibiotics (OA) when OA were indicated by the guidelines. Postintervention, treatment with PA and OA according to the guidelines was not significantly different between the two groups of randomized SNFs. A multivariate analysis comparing PA use pre- and postintervention for all SNFs, adjusted for variation in the frequency and severity of pneumonia, found significantly more of the postintervention episodes were treated with PA in accordance with the guidelines (P < .02). A preintervention significant difference in 30-day mortality observed between episodes with indications for PA (37.8% (48/127)) and episodes with indications for OA (6.1% (6/99)) (P < .001) was not present postintervention (11.5% (6/52); (23.8% (15/64); P = .06). There was no significant difference in 30-day mortality preintervention and postintervention for episodes with guideline indications for OA (P = .35) or for PA (P = .05) (P = .16 for multivariate analysis). The difference in PA use was not associated with significant differences in hospital admissions for episodes on NHAP. CONCLUSION: The increase in the use of PA provides evidence that care within SNFs can be significantly changed using standard quality improvement techniques. Use of the guidelines did not significantly affect mortality. The addition of a practical severity of NHAP model or a change in reimbursement structure may enhance the guidelines' impact on hospitalization for NHAP. The financial benefits available with use of the guidelines will be limited unless the guidelines contribute to a reduction in rates of hospitalization.

Impacting quality: assessment of a hospital-based geriatric acute care unit.

This article describes a preliminary evaluation of the effectiveness of an inpatient geriatric acute care service (GACS) unit specifically designed to care for elderly nursing home residents. The study employed a retrospective, matched-control group design. Two separate control groups were used to provide a more thorough picture of the effectiveness of the GACS. Subjects for the study included a GACS "intervention" group consisting of 334 residents from nineteen nursing homes, an acute care "other hospital" control group consisting of 309 residents from the same nursing homes as the intervention group who were treated at other area hospitals, and an acute care "same hospital" control group, consisting of 74 matched nursing home residents who were hospitalized at the same hospital, but in a different unit than the intervention group. The length of the first hospitalization, the total length of stay during the study period, the number of rehospitalizations of the patients, and mortality were examined. Patients treated at the GACS were less likely to die, had shorter lengths of stay, less rehospitalization, and longer times between hospitalizations than both of the control groups. The GACS unit is a successful answer to the complex acute hospital care needs of the elderly nursing home population.

Delivery of vaccines to adults: correlations with physician knowledge and patient variables.

Our objective was to explore reasons why vaccines are not provided to adult patients receiving primary health care. The study setting was a primary health care clinic in a urban hospital staffed primarily by residents and teaching faculty. The patients were identified as all continuity care patients with a scheduled visit to the clinic during the 4-week study period in April 1995. The providers were all primary care providers for the patients during the study period. The providers were given two surveys before the study: one to assess their knowledge of published preventive health care guidelines and one to assess their perspective of the guidelines. During the study period, the charts of the patients were reviewed for the services they had received. An assessment was placed in each patient's chart for the provider's completion during the visit. The assessment enabled the provider to explain why services had not been provided. The results showed that influenza, pneumococcal, and diphtheria-tetanus vaccines were provided at varying rates. Each vaccine had a different profile as to noncompliance with guidelines. Lack of provider knowledge of the guideline was most apparent with pneumococcal vaccine. Providers' ambivalence regarding the scientific basis and/or clinical importance was most apparent with influenza vaccine. Patient refusal was a prominent cause with influenza vaccine in the elderly. Patient appointment behavior (opportunity for care and compliance) also seemed to play an important role. We conclude that explanations for nondelivery of vaccines to adults seem to be multiple. Lack of physician knowledge and physician perception of the guidelines provide some explanations. Patient-related factors including refusal, decreased opportunity for care, and noncompliance also play important roles in why vaccinations are not provided. Improvement in the rates at which immunizations to adults are provided will require interventions in multiple areas.

Medical practice with nursing home residents: results from the National Physician Professional Activities Census.

OBJECTIVE: The study describes the prevalence of medical nursing home practice. Further, it examines the extent to which physician characteristics and local county health care resources predict nursing home involvement. This information is relevant to evaluating and devising strategies that address the future provision of medical care in institutionalized long-term care. DESIGN: A cross-sectional survey. SETTING: A national sample of all licensed practicing physicians was obtained from a special Professional Activities (PPA) survey conducted by the American Medical Association (AMA) in 1991. PARTICIPANTS: Respondents were 21,578 physicians involved in direct patient care. MEASURES: The typical number of hours spent weekly caring for nursing home patients was obtained from the PPA survey, and physician demographics were obtained from the AMA Masterfile. County health care resources were obtained from the National Institutes of Health Area Resources File. RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients. In all disciplines, a majority of physicians with a nursing home practice spent less than 2 hours per week with patients. Logistic regressions indicted that family practitioners and internists were most likely to have a nursing home practice, but general practitioners were most likely to spend more time in practice. Only 15% of specialists reported having a nursing home practice. Prevalence of practice was greatest among solo practitioners and physicians in partnerships and least among academic and hospital-based physicians and physicians in group practice or employed by the government. Most county of practice resources were not associated or were modestly associated with nursing home practice, but having a nursing home practice became much more likely as the number of nursing home residents increased and hospital beds decreased. A pattern was found for nursing home practice to be slightly less likely as the county's per capita income and the proportion of proprietary nursing facilities increased. CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.

Assessment of preventive health care: design considerations.

OBJECTIVE: To design an instrument to assess the performance of a clinic in the delivery of preventive health services to a general population. METHODS: The study utilized a chart review of services delivered, abstraction of data from electronic databases, and a standardized provider assessment of each eligible patient. The study was conducted in a primary care clinic staffed primarily by internal medicine residents in an urban academic medical center. Patients who were receiving continuity care in the clinic and who were scheduled for an appointment during the 2-week study period were eligible for inclusion. Patients were identified prospectively from the appointment schedule. Charts were reviewed for the delivery of preventive health services prior to the patient's visit. Assessment forms were provided to the primary providers for review and completion. Demographic and appointment information was electronically abstracted from current databases. RESULTS: The rate at which services were provided varied considerably by service and over time. The reasons for nondelivery included disagreement with guidelines, patient resistance/refusal, and lack of priority. CONCLUSIONS: It should be possible to assess a clinic's performance over a range of services over its entire population over time. There may be legitimate reasons for services not being provided to a sizable proportion of the population. These issues are complex and require sensitive detailed investigation.

Assessment of delivery of preventive health services.

Our objective was to design and evaluate an instrument to assess the performance of a clinic in the delivery of preventive health services to a general medical clinic population. The patients were identified prospectively; data were obtained retrospectively with review of the charts. The study was conducted in a primary care clinic staffed primarily by internal medicine residents in an urban academic medical center. Patients who were receiving continuity care in the clinic and who were scheduled for an appointment during the 4-week study period were eligible for inclusion. Patients were identified by the appointment schedule. Charts were reviewed for the delivery of preventive health services. Data were abstracted utilizing a standard instrument. We found that the rate at which services were provided varied considerably by service and over time. The techniques used provided some insight into methods for the evaluation of the delivery of preventive services. It should be possible to assess a clinic's performance over a range of services over its entire population over time. An understanding of this more global performance may provide a better tool for managers and researchers addressing these issues. There may be legitimate reasons for services not being provided. These issues are complex and require sensitive, detailed investigation.

Academics and the nursing home.

Several characteristics of the nursing home justify its new found status as an academic site, including a heterogenous patient population, a rich and varied milieu for teaching, opportunities for faculty development, and more importantly, the nursing home's new found position in the health care continuum. Mandates from a number of professional and accrediting bodies pertaining to primary care training experiences further highlight the nursing home's role in medical education. In addition to education, research in the nursing home has become increasingly recognized and valued. The incorporation of nursing facilities into the academic mainstream will impact positively not only in patient care and age-related clinical investigation but also on the breadth and quality of training for the primary care physician of the future.

The small group consensus process for changing physician practices: influenza vaccination.

OBJECTIVE: To evaluate the effectiveness of a small group consensus process in enhancing compliance with guidelines for influenza vaccination among older HMO members. DESIGN: A controlled study of the practice of primary care physicians, with pre/post comparisons and a 2-year follow-up. SETTING: An 84,000 member prepaid staff model HMO group practice. PARTICIPANTS: Primary care clinicians (N = 36) practicing in a staff model HMO. INTERVENTION: A small-group process, including opinion leader, feedback, and group decision making. MAIN OUTCOME MEASURE: Percentage of patients in a given physician-panel who received influenza immunization. RESULTS: Improvement in vaccination rate from 60.8% to 72.35% (with further increases over 2 successive years), in the intervention group as compared with improvement in the control from 60.7% to 65.93%. CONCLUSION: In this model, the small group consensus process resulted in an alteration in physician practice pattern, yielding a significant improvement in immunization rates above the already-established level of 60%.

Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process.

BACKGROUND: A dissemination intervention to facilitate adoption of a preventive practice guideline (influenza vaccination for older adults) in group practices was developed and evaluated. The intervention, small-group consensus process, started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment (ie, "buy in") to adopt the guideline. METHODS: Thirteen group practices and their primary care physicians (mean size, 5) were assigned randomly to intervention or control arms. In each group practice, physicians in the intervention arm met for 1 hour. Control physicians participated in an unrelated discussion (non-steroidal drug use). Guideline adoption was determined by changes in physicians' vaccination rates that were obtained through prechart and postchart reviews of 51 physicians. Prequestionnaires and postquestionnaires measured influenza knowledge and prevention attitudes. RESULTS: Using analysis of covariance, the small-group consensus process was found to increase physician vaccination rates by 34% compared with the control arm (F (1,48) = 19.49). All intervention arm physicians increased vaccination rates from before to after compared with 54% of control arm physicians. Attitudes and knowledge did not change and were unrelated to increased vaccination rates. CONCLUSIONS: A case is made for the small-group consensus process as an effective utilization-focused dissemination method. Interventions based on group dynamics and sensitive to local practice contexts can be useful in facilitating adoption of guidelines by physicians in group practices.

Resident training in nursing home care: survey of successful educational strategies.

OBJECTIVE: To identify educational strategies for resident training in nursing home care deemed successful by a large number of programs. DESIGN: A mail survey with three follow-up mailings. PARTICIPANTS: Directors of accredited internal medicine and family practice residency programs. MEASUREMENTS: Open- and closed-ended questionnaire eliciting curricular content, instructional strategies, and evaluation techniques from programs offering a nursing home experience. Identification of barriers to implementation of a nursing home curriculum and recommendations for success were requested. MAIN RESULTS: Of the 814 surveys mailed, 537 were returned for a response rate of 66%. Nursing home experiences were required in 86% of family practice residency programs but in only 25% of internal medicine programs. Most geriatric medicine curricular content areas were taught in the nursing home; however, relatively little emphasis was given to rehabilitation, organization, and financing of health care, and coordination of care between acute and chronic settings. Direct patient care, bedside rounds, and lectures were the most common instructional strategies reported. Evaluation approaches included faculty observations, resident attendance, and chart reviews with written and skill-based examinations infrequent. Availability of faculty and conflict with other rotations were identified as the principal barriers to implementation of nursing home rotations. An organized nursing home curriculum supervised by enthusiastic faculty using a longitudinal rotation format with resident involvement in an interdisciplinary team was recommended. CONCLUSIONS: Educational strategies exist for successful implementation of a residency nursing home curriculum. Greater priority must be given to training residents in nursing home care and developing nursing home faculty to substantially increase the number and quality of physicians who practice in this setting.

Physician staffing patterns correlates of nursing home care: an initial inquiry and consideration of policy implications.

BACKGROUND: To determine, post-OBRA 1987, medical organization in nursing facilities (ie, medical director and staff profile, closing of medical staff, use of physician contract); structural correlates of medical organization; and links between medical organization, especially closed staffing, and medical care. METHOD: Mail survey of New York state nursing facility administrators (63% response). Survey consisted of open and closed end items that focused on facility and staff demographics, medical organization, and markers of medical care delivery, ie, physicians' daily presence, average response time to emergency calls, cross coverage for acute conditions and emergencies, attendance at care conferences, and offering of in-services. RESULTS: On average, facilities had 8.6 attending physicians, 32 residents per physician, 70% of residents cared for by non-staff physicians, no daily physician presence (60%), and no cross coverage. Most medical directors were from family (42%) or internal (55%) medicine, had a tenure of 7.5 years, did not have a certificate of added qualification in geriatrics (73%), and attended residents (66%). Forty-three percent of facilities had closed medical staffs, and 12% had physician contracts. Closed staffs were more likely in facilities that were larger, had more Medicaid residents, used physician extenders, and had more residents per nurse. Facilities with closed medical staffs had fewer physicians more residents per physician, and reported medical care practice patterns that would be associated with quality of care. These effects were independent of nursing and facility characteristics. Physician contract was unrelated to care. CONCLUSIONS: Medical organization and practice patterns emerge as important factors in considerations of nursing home quality. Results argue that, as in acute settings, limiting practice privileges in nursing homes may be a useful organizational strategy to improve quality of care.

Oral-surgeon-reported incidence of complications related to simple extractions in adults.

This study examined the incidence of complications related to simple forceps extractions in male and female adults. A total of 413 patients (156 young adults, 150 middle-aged, and 107 older adults) presenting for extraction in the practices of 20 privately practicing oral surgeons was followed prospectively for a 30-day period. A total of 74 patients had complications. No age differences were found in the incidence of operative or postoperative complications. Reasons for extraction, number of teeth extracted, or the time required for extraction did not vary among the age groups. Oral surgeons were more likely to prescribe postoperative analgesic medications to patients already on medications. Tendency to prescribe analgesic medications was unrelated to patient age. Results indicate that among community-dwelling adults, age is not a risk factor for complications resulting from simple extractions.

Gender of physicians and patients and preventive care for community-based older adults.

BACKGROUND: This study was undertaken to determine whether the gender of patients and physicians is a significant factor in deciding which older adults are offered preventive care. METHODS: A survey of medical records of ambulatory patients older than 60 years was performed in the practices of 210 physicians. Documentation of influenza vaccine, rectal examination, fecal occult blood test, Papanicolaou smear, pelvic examination, breast examination, mammogram, and pneumococcal vaccine was recorded, and rates of compliance were evaluated by sex of patient and physician. RESULTS: The medical records of 3327 patients were surveyed. Men were given influenza and pneumococcal vaccines more frequently than women. Among physicians, women physicians were more likely to give influenza vaccine (P = 0.003) and to check for fecal occult blood (P < 0.001). No significant difference was found between men and women physicians in the frequency of doing Papanicolaou smears, breast examinations, rectal examinations, and mammograms. CONCLUSIONS: While a difference in practice patterns was found between men and women physicians, most of the variance in compliance with preventive care guidelines was unexplained by the gender of physicians and patients. Matching of physician and patient by sex did not predict improved preventive care, indicating that other factors are involved in the failure to provide adequate primary preventive care to the ambulatory elderly.

Methicillin-resistant Staphylococcus aureus: a questionnaire survey of 75 long-term care facilities in western New York.

OBJECTIVES: To determine the frequency of recognition of methicillin-resistant Staphylococcus aureus (MRSA) as an infection control problem and its prevalence among long-term care facilities, and to evaluate whether certain long-term care facility characteristics such as bed size, ownership, level of infection control activity, and frequency of resident transfers to acute care hospitals are related to the recognition or prevalence of MRSA in this setting. DESIGN: Questionnaire survey. SETTING: Seventy-five long-term care facilities in the 8 counties of western New York. RESULTS: Seventy-five of 81 (92.6%) long-term care facilities returned a completed questionnaire. Seventy-nine percent were considered to have a "limited" level of infection control activity (part-time infection control practitioner who spent less than 10 hours a week on infection control activities). The larger the long-term care facility, the more time was spent on infection control activities (p = .01). Seventy-two percent of the long-term care facilities screened new admissions for MRSA by reviewing culture reports; 69% of the long-term care facilities had a specific infection control policy for MRSA. Sixteen of the 75 (21%) facilities felt they had an infection control problem with MRSA. By univariate analysis, the only characteristic significantly associated with this recognition was use of nurse practitioners or physician assistants by a facility (p < .05). Eighty-one percent of the 75 long-term care facilities had identified one or more patients with MRSA in the year prior to the survey. By univariate analysis, the only characteristics that were significantly associated with the number of residents with MRSA were the monthly average number of residents transferred to acute care facilities (p = .034) and facility bed size (p = .022); there was also a trend toward increasing intensity of infection control activities (p = .085). However, facility bed size and the average number of resident transfers per month to acute care facilities were strongly associated (p = .0002). By stepwise logistic regression analysis, only bed size was an independent predictor of the number of residents with MRSA. Many long-term care facilities had tried to eradicate MRSA; ciprofloxacin was most commonly used to eradicate MRSA. CONCLUSIONS: The vast majority of the 75 long-term care facilities in the 8 counties of western New York have identified patients with MRSA, although only a minority (21%) of them actually believed that an infection control problem existed. Facility size (a surrogate for the monthly average number of resident transfers to acute care facilities) seems to be an important factor in determining the number of residents with MRSA in long-term care facilities in our geographic region. The major longitudinal studies of MRSA in such facilities have so far been done only in Veterans Affairs facilities. Further studies are needed in freestanding long-term care facilities, the largest group of long-term care facilities in the United States, to determine the epidemiology of MRSA in this setting and to develop practical and valid infection control methods for residents with MRSA.

Patient outcomes in hospital-based respite: a study of potential risks and benefits.

BACKGROUND: Primary care physicians provide increasing care for elderly patients with chronic disabilities. To maintain these individuals in the community, families and other caregivers are supplying more intensive support in the home. Services, such as short-term respite care, can relieve the caregiver burden and allow the patient to continue community living. Whether hospital-based respite can be an effective option for patients is unclear. METHODS: To determine the patient outcomes in hospital-based respite, 15 elderly male respite patients (mean age 71 years) were matched and compared during a 6-month period with 14 elderly acute care control patients and 16 community-based elderly control patients who were chronically ill and were enrolled in a hospital-based home-care program. RESULTS: The average respite stay was 15 days. The respite group did not experience increased risk of mortality or iatrogenesis. Benefits at 6 months included fewer admissions for acute medical care for the respite group (P less than 0.05). Total number of hospital days was equivalent for the respite group and community-based control patients and was fewer than that for the acute care group. CONCLUSION: The results do not indicate any harm and argue that a slight benefit is associated with hospital-based respite for chronically ill older adults. Because of potential complications that can develop for chronically ill geriatric patients, a hospital setting for respite can be a viable respite alternative. A valid concern for physicians, however, remains the potential danger of a greater rate of iatrogenic illness and expectation of more aggressive care based on a tertiary care model.

Oral status and resident well-being in a skilled nursing facility population.

We studied the relationship between oral status and well-being in dentate and edentulous institutionalized residents through interviews with and dental examinations on 58 men and women. Oral status (measured by oral function, dental problem self report, soft tissue anomalies, and dry mouth) and well-being (measured by affect balance, self-esteem, health status, and nurse's ratings) were similar for dentate and edentulous subjects. Multiple regression analyses indicated oral status was significantly related to well-being. Unexpectedly, the extent of caries and plaque was also positively related to well-being, suggesting complex relationships between oral status markers and well-being in institutional settings.

Residency education in the nursing home: a national survey of internal medicine and family practice programs.

OBJECTIVE: To assess the role of the nursing home in postgraduate medical education. DESIGN: A survey questionnaire addressing the following issues: 1) prevalence of nursing home rotations in internal medicine and family practice residency programs, 2) duration and type of rotation, 3) extent of residents' responsibilities, 4) patterns of faculty supervision, 5) program directors' assessments of nursing home experience, and 6) frequently encountered problems. PARTICIPANTS: Directors of accredited internal medicine and family practice residency programs in the United States. MEASUREMENTS AND MAIN RESULTS: A total of 502 surveys were returned for a response rate of 60%. Nursing home rotations were more frequent in family practice programs (87%) compared with internal medicine programs (32%). Rotations in internal medicine were generally optional and limited to a short block of time compared with family practice, where rotations were most often required and longitudinal. Internal medicine residents received more intense supervision, whereas family practice residents had greater clinical responsibilities. Few faculty had formal geriatric training or certification. Reimbursement for physician services was low. Although availability of faculty, resident interest, and conflict with other clinical services were identified as problem areas, program directors in both internal medicine and family practice were supportive of nursing home rotations for their trainees.

A comparison between erythrocyte sedimentation rate (ESR) and selected acute-phase proteins in the elderly.

The erythrocyte sedimentation rate (ESR) and selected acute-phase proteins (APPs) were studied in 101 elderly people (mean age, 72 years) to determine their utility as diagnostic aids in subjects with underlying infections or inflammation. ESR and values for serum immunoglobulin A (IgA), the fourth component of complement (C4), haptoglobin, and alpha-1-antitrypsin (AAT) all correlated with infection or inflammation. C4 was the only test predictive of mortality at six months. Neither ESR nor any of the APPs demonstrated concomitantly high sensitivity, specificity, and positive predictive values. Receiver-operating characteristic curve analysis revealed low true positive to false positive ratios for all of the tests studied. In the elderly, measurement of APPs as a guide to underlying infection or inflammation has limited utility and offers no advantage over the traditional low-cost ESR.