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1.
J Am Geriatr Soc ; 68(1): 96-102, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31603248

RESUMO

BACKGROUND/OBJECTIVE: Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. Here, we examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization. DESIGN: Retrospective cohort study. SETTING: Fee-for-service Medicare data, 2012 to 2015. PARTICIPANTS: Beneficiaries, aged 65 years and older, hospitalized with HF who were subsequently discharged to SNF and then discharged home. MEASUREMENTS: The primary outcome was unplanned readmission within 30 days of discharge to home from SNF. We compared time to readmission between those with and without HHC services using a Cox model. RESULTS: Of 67 585 HF hospitalizations discharged to SNFs and subsequently discharged home, 13 257 (19.6%) were discharged with HHC, and 54 328 (80.4%) were discharged without HHC. Patients discharged home from SNFs with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%; P < .0001) and a longer time to readmission. In an adjusted model, the hazard for readmission was 0.91 (0.86-0.95) with receipt of HHC. CONCLUSIONS: Recipients of HHC were less likely to be readmitted within 30 days vs those discharged home without HHC. This is unexpected, as patients discharged with HHC likely have more functional impairments. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may particularly benefit from restorative therapy through HHC; however, only approximately 20% received such services. J Am Geriatr Soc 68:96-102, 2019.

2.
BMC Health Serv Res ; 19(1): 818, 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31703682

RESUMO

BACKGROUND: While Medicare is a federal health insurance program, managed Medicare limits access to healthcare services to networks within states or territories. However, if a natural disaster requires evacuation, displaced patients are at risk of losing coverage for their benefits. Previous literature has discussed the quality of managed Medicare plans within Puerto Rico but has not addressed the adequacy of this coverage if residents are displaced to the continental United States. We explore Hurricane Maria's impact on a resident of Puerto Rico with chronic health problems, and the challenges he faces seeking healthcare in New York. CASE PRESENTATION: A 59-year-old male with a history of diabetes mellitus type II, coronary artery disease, peripheral vascular disease status post right foot amputation, and end-stage kidney disease on hemodialysis was admitted in October of 2017 for chest pain and swelling of legs for 5 days. The patient had missed his last three dialysis sessions after Hurricane Maria forced him to leave Puerto Rico. In examining this patient's treatment, we observe the effect of Hurricane Maria on the medical management of Puerto Rican residents and identify challenges managed Medicare may pose to patients who cross state or territory lines. CONCLUSIONS: We employ this patient's narrative to frame a larger discussion of Puerto Rican managed Medicare and provide additional recommendations for healthcare providers. Moreover, we consider this case in the context of disaster-related continuity of care for patients with complex medical conditions or treatment regimens. To address the gaps in the care of these patients, this article proposes (1) developing system-based approaches for screening displaced patients, (2) increasing the awareness of Special Enrollment Periods related to Medicare among healthcare providers, and (3) creating policy solutions to assure access to care for patients with complex medical conditions.


Assuntos
Tempestades Ciclônicas , Assistência à Saúde/normas , Desastres , Medicare/normas , Múltiplas Afecções Crônicas/terapia , Hispano-Americanos , Humanos , Seguro Saúde , Masculino , Turismo Médico , Pessoa de Meia-Idade , Múltiplas Afecções Crônicas/etnologia , Cidade de Nova Iorque , Aceitação pelo Paciente de Cuidados de Saúde , Porto Rico/etnologia , Refugiados , Diálise Renal , Estados Unidos
3.
J Am Med Dir Assoc ; 20(4): 432-437, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30954133

RESUMO

OBJECTIVE: Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. MEASURES: Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge. RESULTS: Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78). CONCLUSIONS/IMPLICATIONS: The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.

5.
PLoS One ; 13(4): e0196479, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29702676

RESUMO

OBJECTIVE: To examine predictors for understanding reason for hospitalization. METHODS: This was a retrospective analysis of a prospective, observational cohort study of patients 65 years or older admitted for acute coronary syndrome, heart failure, or pneumonia and discharged home. Primary outcome was complete understanding of diagnosis, based on post-discharge patient interview. Predictors assessed were the following: jargon on discharge instructions, type of medical team, whether outpatient provider knew if the patient was admitted, and whether the patient reported more than one day notice before discharge. RESULTS: Among 377 patients, 59.8% of patients completely understood their diagnosis. Bivariate analyses demonstrated that outpatient provider being aware of admission and having more than a day notice prior to discharge were not associated with patient understanding diagnosis. Presence of jargon was not associated with increased likelihood of understanding in a multivariable analysis. Patients on housestaff and cardiology teams were more likely to understand diagnosis compared to non-teaching teams (OR 2.45, 95% CI 1.30-4.61, p<0.01 and OR 3.83, 95% CI 1.92-7.63, p<0.01, respectively). CONCLUSIONS: Non-teaching team patients were less likely to understand their diagnosis. Further investigation of how provider-patient interaction differs among teams may aid in development of tools to improve hospital to community transitions.


Assuntos
Síndrome Coronariana Aguda/terapia , Insuficiência Cardíaca/terapia , Hospitalização , Educação de Pacientes como Assunto/métodos , Pneumonia/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde , Alta do Paciente , Estudos Prospectivos , Estudos Retrospectivos
6.
J Pain Symptom Manage ; 54(6): 870-876.e1, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28807706

RESUMO

CONTEXT: Ventricular assist devices (VADs) improve quality of life in advanced heart failure patients, but there are little data exploring psychological symptoms in this population. OBJECTIVE: This study examined the prevalence of psychiatric symptoms and disease over time in VAD patients. METHODS: This prospective multicenter cohort study enrolled patients immediately before or after VAD implant and followed them up to 48 weeks. Depression and anxiety were assessed with Patient-Reported Outcomes Measurement Information System Short Form 8a questionnaires. The panic disorder, acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) modules of the Structured Clinical Interview for the DSM were used. RESULTS: Eighty-seven patients were enrolled. After implant, depression and anxiety scores decreased significantly over time (P = 0.03 and P < 0.001, respectively). Two patients met criteria for panic disorder early after implantation, but symptoms resolved over time. None met criteria for ASD or PTSD. CONCLUSIONS: Our study suggests VADs do not cause serious psychological harms and may have a positive impact on depression and anxiety. Furthermore, VADs did not induce PTSD, panic disorder, or ASD in this cohort.


Assuntos
Ansiedade , Procedimentos Cirúrgicos Cardíacos , Depressão , Coração Auxiliar , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Transtorno de Pânico , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Fatores Socioeconômicos , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento
7.
J Pain Symptom Manage ; 52(4): 483-490.e1, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27401516

RESUMO

CONTEXT: Ventricular assist devices (VADs) have been shown to improve survival and overall quality of life, but there are limited data on pain control and functional status in this patient population. OBJECTIVES: This study examined changes in pain, functional status, and quality of life over time in VAD patients. METHODS: Patients were enrolled in this prospective cohort study before or as early after VAD implant as possible and then followed for up to 48 weeks. The Brief Pain Inventory was used to assess pain. The Katz Independent Activities of Daily Living questionnaire was used to assess functional status. The Kansas City Cardiomyopathy Questionnaire, a 23-item questionnaire covering five domains (physical function, symptoms, social function, self-efficacy, and quality of life), was used to assess quality of life and health status. RESULTS: Eighty-seven patients were enrolled at four medical centers. The median Brief Pain Inventory severity score was 2.8 (interquartile range 0.5-5.0) before implantation and 0.0 (interquartile range 0.0-5.3) 48 weeks after implantation (P = 0.0009). Katz Independent Activities of Daily Living summary scores also demonstrated significant improvement over time (P < 0.0001). Kansas City Cardiomyopathy Questionnaire summary scales demonstrated significant improvement with time (P < 0.0016). CONCLUSION: This study demonstrated that patients with VADs experienced improved pain, functional status, and quality of life over time. These data may be useful to help patients make decisions when they are considering undergoing VAD implantation.


Assuntos
Coração Auxiliar , Dor/epidemiologia , Feminino , Nível de Saúde , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Qualidade de Vida , Autoeficácia , Inquéritos e Questionários , Resultado do Tratamento
8.
Soc Work Health Care ; 54(6): 485-98, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26186421

RESUMO

Evidence of care coordination programs to reduce readmissions is limited. We examined whether a social work transitional care model reduced hospital utilization and costs with a retrospective cohort study conducted from 9/3/2010-8/31/2012. Patients enrolled in the Preventable Admissions Care Team (PACT) program were matched to controls. PACT patients received follow-up from a social worker to address psychosocial strain. PACT reduced thirty-day readmission rate by 34% (p = <0.001), Sixty-day hospitalization rate by 22% (p = 0.004); ninety-day hospitalization rate by 19% (p = 0.006), and but not 180-day hospitalization rate. Inpatient costs thirty days post-index were $2.7 million for PACT patients and $3.6 million for controls.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Hospitalização/estatística & dados numéricos , Serviço Social/organização & administração , Idoso , Continuidade da Assistência ao Paciente/economia , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Serviço Social/economia , Fatores Socioeconômicos , Cuidado Transicional
9.
Am J Emerg Med ; 33(9): 1246-8, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26022752

RESUMO

Optimal evidence-based management of patients with uncomplicated community-acquired pneumonia in the emergency department (ED) setting remains a topic of discussion. This discussion was recently revitalized by a 2014 study published in JAMA Internal Medicine by Makam et al showing an increase in the use of blood cultures for patients with community-acquired pneumonia during ED visits from 29.4% of patients in 2002 to 51.1% in 2010. As the authors acknowledge, one of the most likely explanations could be the former pneumonia core measures required by the Centers for Medicaid & Medicare Services and the Joint Commission, potentially encouraging both ED and inpatient providers to reflexively order cultures. As these measures were the subject of fierce debate in the emergency medicine literature almost a decade ago, with recent policy changes affecting practicing clinicians, we aimed to briefly revisit the developments and concerning guidelines and discuss some important potentials for research in this setting.


Assuntos
Infecções Comunitárias Adquiridas/microbiologia , Serviço Hospitalar de Emergência , Técnicas Microbiológicas , Pneumonia/microbiologia , Sepse/diagnóstico , Sepse/microbiologia , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/terapia , Política de Saúde , Humanos , Pneumonia/diagnóstico , Pneumonia/terapia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Estados Unidos
10.
J Med Pract Manage ; 30(3): 203-7, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25807626

RESUMO

This is a prospective intervention study conducted between 2007 and 2011 to evaluate whether an electronic alert can influence provider practice in treatment of skin and soft tissue infections (SSTIs). A best-practice alert (BPA) was programmed to appear for intervention ICD-9 SSTI diagnoses. Controls were patients who had other SSTI ICD-9 codes where the BPA was not programmed to fire. Rate of culture taken in patients was compared between patients in the intervention and control groups. We found that cultures were taken among 13.5% of the intervention group and 5.4% of the control group (p <.0001). A logistic regression analysis controlling for covariates showed the odds of the intervention group having a culture taken was 2.6 times that of the control group. The results of this study support the use of BPAs for improving the management of SSTIs.


Assuntos
Atenção Primária à Saúde/organização & administração , Sistemas de Alerta , Dermatopatias Infecciosas/terapia , Infecções dos Tecidos Moles/terapia , Adulto , Técnicas de Apoio para a Decisão , Feminino , Humanos , Classificação Internacional de Doenças , Masculino , New York , Estudos Prospectivos
11.
Int J Med Inform ; 82(2): 73-9, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22494855

RESUMO

BACKGROUND: Electronic order-sets increasingly ask clinicians to answer questions or follow algorithms. Cooperation with such requests has not been studied. SETTING: Internal Medicine service of an academic medical center. OBJECTIVE: We studied the accuracy of clinician responses to questions embedded in electronic admission and discharge order-sets. Embedded questions asked whether any of three "core" diagnoses was present; a response was required to submit orders. Endorsement of any diagnosis made available best-practice ordering screens for that diagnosis. DESIGN: Three reviewers examined 180 electronic records (8% of discharges), drawn equally (for each core diagnosis) from possible combinations of Yes/No responses on admission and discharge. In addition to noting responses, we identified whether the core diagnosis was coded, determined from notes whether the admitting clinician believed that diagnosis present, and sought clinical evidence of disease on admission. We also surveyed participating clinicians anonymously about practices in answering embedded questions. MEASUREMENTS: We measured occurrence of six admission and five discharge scenarios relating medical record evidence of disease to clinician responses about its presence. RESULTS: The commonest discordant pattern between response and evidence was a negative response to disease presence on admission despite both early clinical evidence and documentation. Survey of study clinicians found that 75% endorsed some intentional inaccuracy; the commonest reason given was that questions were sometimes irrelevant to the clinical situation at the point asked. CONCLUSION: Through faults in order-set design, limitations of software, and/or because of an inherent tendency to resist directed behavior, clinicians may often ignore questions embedded in order-sets.


Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Relações Interprofissionais , Sistemas de Registro de Ordens Médicas/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Coleta de Dados , Humanos , New York/epidemiologia
12.
J Neurosci ; 22(17): 7746-53, 2002 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-12196598

RESUMO

We demonstrated recently that uninjured C-fiber nociceptors in the L4 spinal nerve develop spontaneous activity after transection of the L5 spinal nerve. We postulated that Wallerian degeneration leads to an alteration in the properties of the neighboring, uninjured afferents from adjacent spinal nerves. To explore the role of degeneration of myelinated versus unmyelinated fibers, we investigated the effects of an L5 ventral rhizotomy in rat. This lesion leads to degeneration predominantly in myelinated fibers. Mechanical paw-withdrawal thresholds were assessed with von Frey hairs, and teased-fiber techniques were used to record from single C-fiber afferents in the L4 spinal nerve. Behavioral and electrophysiological data were collected in a blinded manner. Seven days after surgery, a marked decrease in withdrawal thresholds was observed after the ventral rhizotomy but not after the sham operation. Single fiber recordings revealed low-frequency spontaneous activity in 25% of the C-fiber afferents 8-10 d after the lesion compared with only 11% after sham operation. Paw-withdrawal thresholds were inversely correlated with the incidence of spontaneous activity in high-threshold C-fiber afferents. In normal animals, low-frequency electrocutaneous stimulation at C-fiber, but not A-fiber, strength produced behavioral signs of secondary mechanical hyperalgesia on the paw. These results suggest that degeneration in myelinated efferent fibers is sufficient to induce spontaneous activity in C-fiber afferents and behavioral signs of mechanical hyperalgesia. Ectopic spontaneous activity from injured afferents was not required for the development of the neuropathic pain behavior. These results provide additional evidence for a role of Wallerian degeneration in neuropathic pain.


Assuntos
Fibras Nervosas Mielinizadas , Fibras Nervosas , Neurônios Aferentes , Neurônios Eferentes , Degeneração Walleriana/fisiopatologia , Potenciais de Ação , Animais , Comportamento Animal , Estimulação Elétrica , Hiperalgesia/etiologia , Hiperalgesia/fisiopatologia , Região Lombossacral , Masculino , Fibras Nervosas/fisiologia , Fibras Nervosas Mielinizadas/patologia , Fibras Nervosas Mielinizadas/fisiologia , Neurônios Aferentes/fisiologia , Neurônios Eferentes/fisiologia , Medição da Dor , Ratos , Rizotomia , Nervo Isquiático/fisiologia , Nervos Espinhais/fisiopatologia
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