Integrative Review of Racial Disparities in Perinatal Outcomes Among Beneficiaries of the Military Health System.

OBJECTIVE: To examine the extent to which racial disparities exist in the perinatal outcomes of beneficiaries of the Military Health System (MHS). DATA SOURCES: We searched the PubMed, CINAHL, and Embase databases. STUDY SELECTION: We selected articles published in English in peer-reviewed journals in which the authors examined race in relation to perinatal outcomes among beneficiaries of the MHS. Date of publication was unrestricted through March 2021. DATA EXTRACTION: Twenty-six articles met the inclusion criteria. We extracted data about study design, purpose, sample, setting, and results. We also assigned quality appraisal ratings to each article. DATA SYNTHESIS: In most of the included articles, researchers observed differences in perinatal outcomes between Black and White women. Compared to White women, Black women had greater rates of cesarean birth, preterm birth, low birth weight, and small for gestational age neonates. White women had greater rates of postpartum depression than Black women. CONCLUSION: Racial disparities in very low birth weight newborns and preterm birth may be smaller in the MHS than in the general population of the United States. The overall rates of preterm birth, cesarean birth, and neonatal mortality were lower for beneficiaries of the MHS than in the general population of the United States.

Advancing Health Services Research to Eliminate Health Care Disparities.

Findings from health services research highlight continuing health care disparities in the United States, especially in the areas of access to health care and quality of care. Although attention to health care disparities has increased, considerable knowledge gaps still exist. A better understanding of how cultural, behavioral, and health system factors converge and contribute to unequal access and differential care is needed. Research-informed approaches for reducing health care disparities that are feasible and capable of sustained implementation are needed to inform policymakers. More important, for health equity to be achieved, it is essential to create a health care system that provides access, removes barriers to care, and provides equally effective treatment to all persons living in the United States.

Long-term health-related quality of life of stroke survivors and their spousal caregivers.

Because treatment for stroke has improved, individuals are living longer with the effects of a stroke. The resulting long-term impairment can affect both stroke survivors' and their caregivers' health-related quality of life (HRQOL). Few studies have examined the HRQOL of stroke survivors and their caregivers greater than 2 years poststroke. The stroke survivors and their spousal caregivers (n = 30 dyads) who had previously completed a 12-month study after discharge from inpatient rehabilitation were assessed at 3-5 years poststroke. The HRQOL and related outcomes were measured for stroke survivors and caregivers. Data from baseline to 12 months were used in conjunction with data from this study. Linear mixed models were used to analyze the change in repeated measures over time. Multiple linear regression was used to analyze the relationship of generic HRQOL to related psychosocial outcomes. The stroke survivors were an average of 4.68 years poststroke. The mean age for stroke survivors and caregivers was 70.8 and 64.9 years, respectively. Most stroke survivors were men (80%) and non-Hispanic White (70%). Among stroke survivors, depression decreased from baseline to 12 months (p = .04) but increased from 12 months to the end of follow-up (p = .003). The caregivers' depression decreased from baseline to all time points (p = .015). Stroke-specific HRQOL showed statistically significant (p < .03) decreases between 12 months and end of follow-up. Increased number of illnesses and older age were associated with caregivers' lower physical HRQOL score (p = .004). Higher depression was associated with lower mental HRQOL score for both caregivers and stroke survivors (p = .003 and p = .011, respectively). Both stroke survivors and caregivers continue to experience negative stroke-related health outcomes for many years after the initial stroke; some of these outcomes even worsen over time. These findings illustrate the need for ongoing psychological and medical evaluation for both long-term stroke survivors and caregivers. Development and testing of targeted behavioral interventions are also warranted.

Cost associated with stroke: outpatient rehabilitative services and medication.

PURPOSE: This study aimed to capture direct costs of outpatient rehabilitative stroke care and medications for a 1-year period after discharge from inpatient rehabilitation. METHODS: Outpatient rehabilitative services and medication costs for 1 year, during the time period of 2001 to 2005, were calculated for 54 first-time stroke survivors. Costs for services were based on Medicare reimbursement rates. Medicaid reimbursement rates and average wholesale price were used to estimate medication costs. RESULTS: Of the 54 stroke survivors, 40 (74.1%) were categorized as independent, 12 (22.2%) had modified dependence, and 2 (3.7%) were dependent at the time of discharge from inpatient rehabilitation. Average cost for outpatient stroke rehabilitation services and medications the first year post inpatient rehabilitation discharge was $17,081. The corresponding average yearly cost of medication was $5,392, while the average cost of yearly rehabilitation service utilization was $11,689. Cost attributed to medication remained relatively constant throughout the groups. Outpatient rehabilitation service utilization constituted a large portion of cost within each group: 69.7% (dependent), 72.5% (modified dependence), and 66.7% (independent). CONCLUSIONS: Stroke survivors continue to incur significant costs associated with their stroke for the first 12 months following discharge from an inpatient rehabilitation setting. Changing public policies affect the cost and availability of care. This study provides a snapshot of outpatient medication and therapy costs prior to the enactment of major changes in federal legislation and serves as a baseline for future studies.

Quality of life measures for patients on hemodialysis: a review of psychometric properties.

This review describes quality of life (QOL) instruments and evaluates evidence of reliability and validity as obtained from articles where QOL was assessed for patients with end stage renal disease. Articles selected for review were based on the construct of QOL measures for adult patients on hemodialysis (HD). Articles reviewed were in English and published between 1982 and 2007 as identified by searches in Medline, PubMed, Pubmed Central, SCOPUS, and CINAHL. Key words included adults, hemodialysis, ESRD, reliability, validity, QOL measures, QOL instruments, and health-related QOL instruments. Of the 146 articles meeting the inclusion criteria, 80 were reviewed. Of these, 38 articles were observational studies, and 34 QOL measures were identified. Analysis permitted sorting the instruments as generic measures (59%), patient-preference measures (15%), and disease-specific measures (26%). Studies using the most commonly used disease-specific instrument, the Kidney Disease Quality of Life Short Form (KDQOL-SF), reported minimal psychometric testing. Within the HD population, multidimensional QOL instruments that are adequately tested, reliable, and valid are needed. Since reliability and validity may vary from one group of participants to another or from one disease population to another, it is beneficial for researchers to take the time and effort to establish psychometric properties for their QOL instruments.

Challenges of patient-reported outcome assessment in hemophilia care­a state of the art review.

INTRODUCTION: One of the recent advances in assessing outcomes of medical care is the inclusion of the patient perspective. The term patient-reported outcome (PRO) is used to reflect the patient perceptions of disease and its consequences as well as of treatment and health-care provision. The development of PRO measures has advanced rapidly, and implementation in clinical research and practice is now underway. From an evaluation perspective, recommendations for the choice of PRO measures and an appraisal of the potential benefits of PRO data collection within specific health conditions are needed. METHODS: Hemophilia is a rare and clinically well-defined health condition with established and cost-intensive treatment strategies, in which PRO assessment is increasingly recognized as important. For this reason, measurement of PROs in hemophilia focusing on health-related quality of life (HRQoL) and patient preferences were reviewed to identify appropriate measures, to make recommendations for their choice, and to critically examine their impact in international hemophilia research and practice. RESULTS: Using literature searches and expert discussion strategies, generic and targeted measures for HRQoL and patient preferences in adults and children with hemophilia were screened, and 20 were reviewed on the basis of their psychometric properties and international availability. Only a few of the 20 measures have been used in clinical settings or research related to persons with hemophilia. CONCLUSION: Consequently, an increased use of these measures is recommended to understand patient views on disease and treatment and to judge the impact of PROs for improvements in health care.

Medications, comorbidities, and medical complications in stroke survivors: the CAReS study.

Stroke survivors enter rehabilitation units with many medical comorbidities and often experience significant complications during their stays. The 97 stroke survivors discharged home in this study received prescriptionsfor a mean of 11.3 medications from 5.4 different drug classifications. There were significant correlations between the number of comorbidities and after stroke complications and the number of different classifications of drugs that were ordered. This article (1) identifies the types of medications prescribed for stroke survivors who are being discharged home from rehabilitation, (2) explores correlations between medication prescriptions and the number of stroke-related comorbidities and medical complications, (3) identifies the cost of medications and the potential effect of medication costs on stroke survivors, and (4) discusses the nurse's role in preparing stroke survivors and their caregivers for medication use after discharge. Rehabilitation nurses bear the major responsibility for teaching stroke survivors and their caregivers about their discharge medications.