Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial.

CONTEXT: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied. OBJECTIVE: To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions. DESIGN: Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge. SETTING: Two urban, academically affiliated hospitals in Philadelphia, Pa. PARTICIPANTS: Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission. INTERVENTION: Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses. MAIN OUTCOME MEASURES: Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction. RESULTS: A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1 % vs 20.3 %; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in post-discharge acute care visits, functional status, depression, or patient satisfaction. CONCLUSIONS: An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs.

Re-examination of the psychometric characteristics of the La Monica-Oberst Patient Satisfaction Scale.

The purpose of this study was to provide further psychometric testing of the 41-item La Monica-Oberst Patient Satisfaction Scale (LOPSS). Data were drawn from three studies designed to study a model of nurse specialist transitional care (n = 307). Previously, the scale had been tested with oncology patients. This study included three groups of nononcologic female patients. Potential scores on the LOPSS range from 41 to 205; actual scores ranged from 93 to 205, with a mean of 175 (SD = 24), indicating a positively skewed distribution. Coefficient alpha for the entire scale was .98. An examination of the individual items indicated that the LOPSS might be shortened without subsequent loss of information. Thirteen items with low item-total correlations or low variability were dropped. The resulting 28-item scale had a mean of 118.7 and a SD of 17.3. Coefficient alpha was .97. The results of a factor analysis of the revised scale were similar to those reported by La Monica, Oberst, Madea, and Wolf (1986). The results indicate that the scale is useful for nononcologic patients. The difficulty remains the positively skewed distribution of scores. More sensitive items need to be developed.

Attention versus avoidance: attributional search and denial after myocardial infarction.

OBJECTIVE: In this study the focus was on two strategies: denial (an avoidant strategy) and causal thinking (an attention strategy) and their relationships to affect after myocardial infarction. DESIGN: Descriptive, correlational. SETTING: Large rural medical center. SAMPLE: The sample comprised 152 recently hospitalized patients with first-time myocardial infarction. MEASURES: A denial scale, a question about causal thinking, and an affect adjective checklist measuring anxiety, hostility, and depression. RESULTS: Denial had a weak but significant negative correlation with anxiety (r = -0.18, p < 0.05). However, denial was not significantly related to either depression or hostility. Regression analysis indicated that both denial (F = 4.84, p = 0.02) and the interaction of denial with causal search (f = 4.77, p = 0.009) were predictors of affect. The interaction indicated that those with high denial who had not searched for a cause were least anxious. A large number of subjects used both attention and avoidant strategies. CONCLUSIONS: The main effect for denial suggests that avoidance is a more effective strategy for reducing anxiety after myocardial infarction than causal search, an attention strategy. However, the fact that many subjects used both strategies suggests that they are not mutually exclusive in the process of adaptation after a heart attack.

A randomized trial of a health care program for first-time adolescent mothers and their infants.

To test the effectiveness of a special health care program for adolescent mothers (17 years old or younger) and their infants, 243 mother-infant pairs were randomly assigned to one of two groups. All of the mothers were unwed, on Medicaid, and black. The control group received routine well-baby care. The experimental group received routine care and services that included rigorous follow-up, discussions with the mother about her plans for return to school and use of family planning methods, and extra health teaching. The dropout rate in the experimental group (60%) was significantly less after 18 months than the control group (82%). In spite of the high dropout rate, 91% of the mothers were located for the 18 month follow-up interview. The repeat pregnancy rate in the experimental group was 12% after 18 months, and 28% in the control group. There was no significant difference in the percentage returning to school. After 12 months, the infants in the experimental group were more likely to be fully immunized (33%) than the infants in the control group (18%). Mothers in the special care program who continued to attend clinic used the emergency room less than the mothers who continued to attend in the control group. These results suggest that a comprehensive health care program is one way to bring about better outcomes for both adolescent mothers and their infants.

PIP: 120 adolescent mothers who delivered at a large teaching hospital in Philadelphia, Pennsylvania, and their infants were assigned to an experimental group who had received special care which included rigorous follow-up, discussions with the mothers about plans to return to school and use of family planning, and additional health education. Another 123 mothers formed the control group and received only routine well-baby care. A nurse practitioner directed the experimental clinic. All the cases and controls were African American, on Medicaid, and unmarried. Mothers in the control group were more likely to return for all well-baby visits (at 2 weeks, 92% vs. 76%; at 18 months, 40% vs. 18%; p = 0.002). At 18 months, the dropout rate was high for both groups, but it was less for the experimental group than the control group (60% vs. 82%). Nevertheless, clinic staff were able to locate 91% of the mothers at 18 months postpartum. At 18 months, mothers in the experimental group had a lower repeat pregnancy rate than did those in the control group (12% vs. 28%; p = 0.003). More than 50% of mothers from both groups returned to school with no significant difference between the 2 groups. Children of mothers in the experimental group were more likely to be fully immunized at 18 months than those in the control group (33% vs. 18%; p 0.02). Experimental group mothers who still attended the clinic at 18 months were less likely to use the emergency room for infant care at least once than control group mothers who still attended the clinic (81% vs. 100%; p 0.03). These findings indicate that a comprehensive health care program improves outcomes for adolescent mothers and their infants. The high dropout rates from clinic attendance suggests a need for more research into developing programs targeting adolescent mothers.

Further analysis of the psychometric properties of the Levine Denial of Illness Scale.

This study contributes cross-validational data with regard to the Levine Denial of Illness Scale from a sample of 152 hospitalized myocardial infarction patients. A factor analysis and subsequent examination of the data yielded four usable factors of denial termed: Cognitive Denial of Illness, Denial of Impact on Future, Denial of Need for Care, and Affective Denial. In an analysis of subscale correlations, these four factor-based scales were related, but distinguishable, thus supporting the idea of the multidimensionality of denial. Furthermore, these factors were not related to demographic variables. Correlating these four scales with standardized measures of affect indicated that it can be useful in research to distinguish between several types of denial of illness in myocardial infarction patients.

Why me? Causal thinking, affect, and expectations in myocardial infarction patients.

This study investigated whether patients who seek an explanation for their heart attack, as compared to those who do not, differ in their affect, in expectations about their future recovery, and in expectations about coping with their future. Forty-two myocardial infarction patients were interviewed, in both the acute and convalescent stages, as to whether they had thought about "Why me?" Approximately half of the patients at each stage reported searching for an answer to that question. The patients remained generally consistent in their self-reported anxiety, depression, and hostility over time; however, patients who had not thought about "Why me?" reported less anxiety than those who had. No significant differences were found in affect in patients who gave a specific cause for their heart attack and in those who could not. Patients were significantly less optimistic about their future recovery at follow-up than when they were in the hospital, but there were no differences in expectations for future recovery or for future coping of those who had and those who had not thought about "Why me?"

A comparison of patient/nurse perceptions about current and future recovery status.

Research comparing patient and caregiver perceptions suggests that caregivers tend to be negatively biased in their assessment of patients. That is, they are more likely to judge the patients' status more negatively than the patients themselves. The data analyses, however, have not always been as informative about the extent of disagreement. Our data on the extent to which patients who had a myocardial infarction and their nurses' assessments differed suggest that, in the case of the patients' current status, there were no differences in the aggregate between patients' and nurses' assessments. Examination of the discrepancies between the pairs, however, suggests that in some cases nurses are more negative in their assessments than their patients. In the case of beliefs about the future, nurses were significantly more negative, in the aggregate, than patients, and the extent of this difference is further elaborated in the examination of the discrepancies. Nevertheless, with respect to both current and future status, the correlations between patients and nurses were low, indicating little, if any, shared variation. Because this study did not examine the relationship between either patients' or nurses' perceptions of recovery status, and the patients' actual recovery status, further research is needed to further determine the implications of this work. The meaning of these results for clinical nurse specialists (CNS) is discussed.

Three sides of the same coin: the analysis of paired data from dyads.

Three types of research questions are commonly asked about data from dyads: (1) What are the overall group differences between the two sets of measurements? (2) What is the association between paired data? and (3) What is the agreement between pairs? These three types of questions about the same dyad dataset lead to different analyses, and the answer to one question does not necessarily help in answering the other questions. The purpose of this article is to highlight the differences among these questions and their respective methods of data analysis. The intent is to stress the necessity for congruence between research questions and the analysis, rather than to present a review of all possible methods of analysis of paired data.

The computer as a classroom participant in teaching statistics.

The versatility, speed, and portability of the personal computer make it a great partner in the classroom for teaching statistics. The computer display from the monitor can be shown as a clear image on a large screen by a projection panel. Commercially available software, easy-to-use and relatively inexpensive, enables an instructor to carry out many classroom demonstrations of basic statistical ideas. The graphics capabilities of the personal computer for plotting and animated effects capture students' interest and promote learning.

On the prevalence of causal search in illness situations.

The prevalence of causal search was examined in two samples, one of chronically ill patients, the other of acutely ill patients. In contrast to the assumption that causal search occurs in important or unexpected life events, the results indicated that such a search was reported by only about half of 296 long-term diabetic, hypertensive, and arthritic patients and 83 newly diagnosed myocardial infarction patients. Moreover, in both samples, affect and expectancies for the future were better for those who had not engaged in causal search. Further research to examine the questions used to elicit causal responses and to test the assumption that causal thinking takes place is suggested.

The designs and methods of published nursing research: 1956-1983.

This study describes the relative frequencies over time of designs and methods used in nursing research articles published in three refereed journals. All articles published in 1956, 1961, 1966, 1971, 1976, 1981, and 1983 were reviewed (N = 434); 83% were research articles. Methodological research comprised 11% and historical research 1% of the 362 research articles. The designs of the remaining 317 research reports were classified as experimental (27%) or observational (73%). Use of experimental designs peaked in the mid-1960s (41%) and appears to be on the decline (20% in 1983). Cross-sectional studies predominated throughout the period (49%). Methods, including types of subjects, sample selection, and data collection instruments, are described and analyzed for time trends. The findings are discussed in light of the designs and methods advocated in nursing texts and literature.

Attributional analysis of chronic illness outcomes.

The Weiner et al. attribution model has generated a great deal of research on attributions for success and failure in academic achievement situations. Studies of success and failure attributions in real-life situations of high personal concern are limited. If the attribution model is to lead to a general theory of motivation, such tests in real-life situations are critical. In this study, causal attributions for success and failure outcomes of chronically ill patients were examined. Results indicated at least partial support for the model. Patients tended to attribute success internally and failure externally, but stability and expectations were not linked in this sample. Moreover, a tendency to respond with no cause to an open-ended measure and to hold little commitment to any causes on a closed-ended measure was characteristic of failure subjects.