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Biomedical subjects

B J Naughton

Publications and source records attributed to B J Naughton.

At least 19 recordsLinked to original sources
PubMed2001

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.

Administration, Oral↗
PubMed2000

Validity of an artificial neural network in predicting discharge destination from a postacute geriatric rehabilitation unit.

OBJECTIVE: To develop an artificial neural network (ANN) designed to predict discharge destination from postacute geriatric rehabilitation units. DESIGN: Nonconcurrent prospective study. SETTING: Postacute geriatric rehabilitation units: a 20-bed unit in a nonproprietary skilled nursing facility and a 40-bed unit in a suburban private facility. PATIENTS: Consecutive sample of 661 patients admitted between January 1995 and February 1999, including a derivation group of 452 patients and a validation group of 209 patients. INTERVENTIONS: A feed-forward, back-propagation neural network to predict discharge destination. MAIN OUTCOME MEASURE: Discharge destination from postacute geriatric rehabilitation. RESULTS: An ANN was trained on clinical pattern set derived from 452 patients and validated prospectively on 209 consecutive patients admitted to postacute geriatric rehabilitation units. The neural network achieved a sensitivity of 85.7% (95% confidence interval [CI], 83.7-89.4) and specificity of 94.1% (95% CI, 84.4-99.1) in identifying discharge destination with a corresponding area under the curve of 95.7% (95% CI, 92.1-98.3). CONCLUSION: An ANN can predict discharge to the community postacute rehabilitation with a high degree of accuracy. It could have particular value to predict return to the community for older adults with multiple comorbidities after an acute hospitalization.

Activities of Daily Living↗
PubMed2000

Outcome of nursing home-acquired pneumonia: derivation and application of a practical model to predict 30 day mortality.

OBJECTIVES: To derive a prediction model of 30 day mortality for nursing home-acquired pneumonia (NHAP) based on factors that can be readily identified by nursing home staff at the time of diagnosis and to apply the model to management issues related to NHAP including clarifying the importance of prepneumonia functional status as a predictor of outcome of NHAP. DESIGN: This was a retrospective chart review of 378 episodes of NHAP treated in the nursing home or hospital during two periods: November 1997 to April 1998 and November 1998 to April 1999. SETTING: Eleven nursing homes in the greater Buffalo, NY region. PARTICIPANTS: Nursing home residents with radiographically proven pneumonia who had at least one of the following signs/symptoms: cough, fever, purulent sputum, respiratory rate > or =25 breaths/minute, localized auscultatory findings, or pleuritic pain. MEASUREMENTS: Status (alive or dead) of each resident at 30 days (30 day mortality) after diagnosis of NHAP was the dependent variable. Factors predicting 30 day mortality were identified by logistic regression analysis. A scoring system was developed based on the results of the logistic model. Each episode of NHAP in the derivation cohort was scored using the model and the cohort was stratified by the model score into six categories or risk for mortality (0-5). The predictability of the model in the derivation cohort was measured using receiver operator characteristics curve analysis. RESULTS: Of 378 episodes of NHAP, 74% were treated initially in the nursing home and 26% were hospitalized initially for treatment. The overall 30 day mortality was 21.4%; however, the mortality rate was significantly higher for those treated initially in the hospital (29.6% vs 16.6%; P = .012). Logistic regression analysis identified four predictors of 30 day mortality: (1) respiratory rate >30 breaths/minute (2 points), (2) pulse > 125 beats/minute (1 point), (3) altered mental status (1 point), and (4) a history of dementia (1 point). Applying the scoring system to each episode in the derivation cohort demonstrated increasing mortality with increasing score. The c statistic for the model in the derivation cohort was .74. Based on the severity of NHAP, model episodes treated initially in the hospital were more acutely ill than those who were treated initially in the nursing home, and episodes treated with a parenteral antibiotic in the nursing home were more acutely ill than those who were treated with an oral agent. Functional status was not a predictor of 30 day mortality although there was a trend of higher mortality in the most dependent group (P = .065). The severity of NHAP model was able to define low and high risk mortality groups within a functional status category. CONCLUSIONS: A severity of NHAP model was derived from a large cohort of episodes in multiple facilities. The model had reasonable discriminatory power in the derivation cohort. The model may aid clinicians in making treatment decisions in the nursing home setting and in making hospitalization decisions. Although prepneumonia functional status provides a reasonable estimate of NHAP severity and prognosis, the severity of NHAP model permitted further refinement of these estimates. The severity of NHAP model requires validation before it can be recommended for general use.

Activities of Daily Living↗
PubMed2000

Treatment guideline for nursing home-acquired pneumonia based on community practice.

OBJECTIVES: To describe the findings of a retrospective study of the treatment of nursing home-acquired pneumonia (NHAP) in 11 nursing homes in one community and the development of a treatment guideline for NHAP using data from the retrospective study. DESIGN: A retrospective chart review of 239 episodes of NHAP occurring between November 1, 1997, and April 30, 1998, was performed. Data regarding antibiotic treatment of NHAP were used to revise a treatment guideline developed by the authors. Further refinements of the guideline were made based on small group discussions with physicians and nurse practitioners caring for the study population. SETTING: Residents with NHAP were identified among the populations of 11 nursing homes in the metropolitan Buffalo, New York area (Erie county). These 11 nursing homes had a total of 2375 beds, comprising nearly one-third of all nursing home beds in the county. PARTICIPANTS: Nursing home residents with chest X-rays showing infiltrates and signs and symptoms of pneumonia. MEASUREMENTS: Antibiotic treatment (drug used, route of administration, and duration of treatment), location of initial treatment (nursing home or hospital), and status (alive or dead) of each resident were recorded 30 days after diagnosis of NHAP. RESULTS: Of the 239 episodes of NHAP, 171 (72%) were initially treated in nursing homes. Of these 171 patients, 105 (61%) were treated only with an oral regimen, whereas 66 (39%) were treated initially with an intramuscular antibiotic and subsequently with an oral regimen. There was no significant difference in 30-day mortality rates between those initially treated in nursing homes (22%) and those initially treated in hospitals (31%; P = .15) or between those initially treated with an oral regimen in nursing homes (21%) and those initially treated with an intramuscular antibiotic in nursing homes (25%; P = .56). There was no consistency in how physicians made the choice to use intramuscular antibiotics in nursing homes, and a logistic model for predicting this approach could explain very little. The frequency of the prescription of various antibiotic agents in nursing homes and in hospitals was tabulated as well as the duration of treatment; specific attention was paid to the timing of the switch to an oral agent among episodes initially treated with a parenteral agent. These data were used in the guideline to make specific recommendations regarding which agent to prescribe, the duration of parenteral therapy, the timing of the switch to an oral regimen, and the duration of treatment. In the setting of informal small groups, the guideline was discussed with physicians who cared for residents with NHAP in the study nursing homes. Revisions made to the guideline were based on these discussions. CONCLUSIONS: A treatment guideline for NHAP was developed primarily on the basis of the practices of geriatricians in one community. These treatment practices were similar to those reported in the literature in terms of the proportion of patients treated in nursing homes and the antibiotics prescribed. The guideline also provided specific recommendations for timing of the switch to an oral agent after parenteral therapy and for duration of treatment. Studies are in progress to determine if use of this guideline will reduce some of the variation observed in the treatment of NHAP.

Administration, Oral↗
PubMed2000

Treatment of verbal agitation with a selective serotonin reuptake inhibitor.

The objective of this study was to examine the safety and efficacy of paroxetine as an alternative to neuroleptic medications for the treatment of verbal agitation in demented patients. An open case series design was used, and the setting included two nursing homes and an outpatient geriatric clinic. Participants were eight consecutive nursing home residents and seven community-dwelling older adults diagnosed with dementia who exhibited verbal agitation in the form of repetitive questions or unwarranted request for attention. Patients received paroxetine orally in doses of 10 mg to 40 mg per day. The Cohen-Mansfield Agitation Inventory (CMAI) was used to rate the frequency of verbal agitation. A baseline score was obtained before starting paroxetine. Six scores were then obtained at 2-week intervals over a period of 3 months. All patients had reduction (2-4 points per item) in the CMAI scores at the end of the first month of treatment with paroxetine. Scores were further reduced (up to 5 points per item, 67%-71% reduction from baseline) in five patients at the end of the third month of treatment. Most patients tolerated paroxetine well. In this report, the use of paroxetine was associated with reduction in verbal agitation. This finding supports the possibility that verbal agitation in demented patients could be a manifestation of underlying depression.

Aged↗
PubMed1999

Using admission characteristics to predict return to the community from a post-acute geriatric evaluation and management unit.

OBJECTIVE: To compare the Cumulative Illness Rating Scale (CIRS) and the Nursing Severity Index (NSI) as independent predictors of discharge outcome from a post-acute GEM unit and to define a multivariate model for predicting the same outcome. DESIGN: Retrospective chart review for the entire sample. The sample was split into two cohorts, a derivation cohort (n = 298) and a validation cohort (n = 154). SETTING: A 20-bed, post-acute GEM unit in a nonproprietary skilled nursing facility. PARTICIPANTS: All 452 patients admitted to the GEM from the unit's inception in December 1994 until January 1998. MEASUREMENT: Demographics, CIRS, NSI, functional status, and social support variables were measured using data available on admission to the GEM unit. The discharge outcome was dichotomized as return to the community or not. RESULTS: A total of 99.7% of the individuals in the derivation cohort were living in the community before the index hospitalization; 75.8% of patients in the derivation cohort returned to the community. The NSI, individual "severe" items from the CIRS, age, and social support were in the final logistic regression model fitted to the derivation cohort. A total of 87.7% of the observed discharge outcomes were predicted when the model was applied to the validation cohort and the calculated probability of return to the community. CONCLUSIONS: Variables for severity of illness, function, social support, and age combined into a logistic regression equation that predicted more than 80% of the dichotomized discharge outcome in the derivation cohort. The proportion of discharge outcomes that were predicted with the validation cohort remained high at 87.7%. The NSI and CIRS were each important to a model that is anticipated to refine the selection of geriatric patients for post-acute services.

Age Factors↗
PubMed1997

Computed tomography scanning and delirium in elder patients.

OBJECTIVE: 1) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions. METHODS: This was a 2-part study. Part 1 was a prospective, observational study of 560 adults > 70 years of age evaluated at 3 separate EDs using a 200-hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records (n = 279) for patients > 70 years of age in the prospective sample (n = 79) and from a sample (n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan. RESULTS: Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, impaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned (p < 0.001). Part 2: Of 279 CT scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space-occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED. CONCLUSIONS: Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population.

Acute Disease↗
PubMed1995

Delirium and other cognitive impairment in older adults in an emergency department.

STUDY OBJECTIVE: To determine the prevalence of delirium and other alterations in mental status in older adults in the emergency department setting. DESIGN: Prospective, cross-sectional study. SETTING: Private, nonprofit, academic medical center in a densely populated urban area. PARTICIPANTS: One hundred eighty-eight adults 70 years or older who presented to the ED. INTERVENTIONS: None. RESULTS: Delirium and other alterations in mental status were present in 39.9% of the patients studied; 24% of these patients had delirium. Age and severity of illness were positively correlated with alteration in mental status. Patients with alterations in mental status were more likely to be admitted to an inpatient unit. Among those admitted from home, alterations in mental status in the ED were associated with a higher likelihood of institutionalization at discharge. CONCLUSION: Alterations in mental status are prevalent in ED patients. Older adults with alterations in mental status, particularly alterations in consciousness and delirium, are at high risk for admission to an inpatient unit and institutionalization after discharge. Standardized mental status testing identified high-risk older adults in the ED.

APACHE↗
PubMed1994

Predicting stroke inpatient rehabilitation outcome using a classification tree approach.

A classification tree, a nonparametric statistical analysis, was used to develop decision rules to predict a favorable inpatient stroke rehabilitation outcome. Descriptive and functional status data collected on admission from 225 patients were the predictor variables. Favorable outcome was defined as having met three criteria: discharged to community, survival greater than 3 months postdischarge, and no more than minimal physical assistance required in functional activities on discharge. The classification tree correctly classified 88% of the sample using only four of the predictor variables (level of independence in Toilet Management, Bladder Management, and Toilet Transfer, and adequacy of Financial Resources). The cross validation error rate was 18%. The advantages of the classification tree approach over parametric methods are that it is desirable for ordinal data, it readily identifies the interactions among predictor variables, the results are easily communicated, and it provides additional insights into the factors that predict outcome.

Activities of Daily Living↗
PubMed1994

Stroke inpatient rehabilitation: a comparison across age groups.

OBJECTIVE: To examine and compare the inpatient stroke rehabilitation experience of older adults (> or = 75 years) with that of young adults (< 65 years) and young-old adults (65-74 years). DESIGN: Cross-sectional descriptive study. SETTING: A large university-affiliated free-standing rehabilitation hospital. PARTICIPANTS: 260 adults who were admitted to inpatient stroke rehabilitation with a primary diagnosis of recent (< 120 days) stroke (ICD9 430-436). VARIABLES: Demographic data, diagnosis, time between stroke onset and rehabilitation admission, discharge disposition, and functional status on admission and discharge were obtained from the patient's medical record. Treatment intensity and type, length of stay, and primary payment source data were obtained from the patient's billing record. Three-month mortality data were available from the hospital's routine follow-up survey. MAIN RESULTS: Compared with the younger adults (< 65 yrs and 65-75 years), the older adults (> or = 75 years) were admitted to rehabilitation earlier and with comparable cognitive but poorer motor function. Rehabilitation treatment intensity (per day) and type were similar across age groups, but the older adults (> or = 75 years) had significantly shorter rehabilitation stays. Three-month survival was comparable across age groups, but the older adults (> or = 75 years) had poorer motor function at discharge and were more often discharged to a nursing home or required a paid caregiver. CONCLUSIONS: Age-associated factors may influence inpatient stroke rehabilitation referral, treatment, and outcome, particularly for patients over age 75. The cumulative effects of frailty and co-morbid disease upon stroke disability and treatment are possible explanations for the findings. The study provides evidence of a need for further investigation of stroke rehabilitation strategies for adults over 75 years old.

Activities of Daily Living↗
PubMed1994

Reducing hospital costs for the geriatric patient admitted from the emergency department: a randomized trial.

OBJECTIVE: To test the impact of a geriatric evaluation and management model on the costs of acute hospital management of emergently admitted older adults. DESIGN: Randomized controlled trial. Patients were followed in the acute hospital from admission through discharge. Results based on both univariate and multiple regression analyses. SETTING: Private, nonprofit, academic medical center in a densely populated urban area. PATIENTS: Adults 70 years of age and older admitted from the Emergency Department to the medicine service (non-ICU admission) who did not have an internist on staff at the admitting hospital. Of 141 randomized patients, 111 (78.7%) met eligibility criteria. INTERVENTION: Assignment of a geriatrician and a social worker as the primary managing team during the hospital stay. MAIN OUTCOME MEASURES: Length of stay, total cost of acute hospital care, cost of laboratory, pharmacy, and rehabilitation services. RESULTS: Patients in the intervention group had 2.1 fewer days of hospitalization, but this shorter length of stay was not statistically significant (P = 0.108). There were no differences in mortality or discharge disposition. In risk-adjusted, multiple regression analysis the intervention group had a statistically significant lower predicted total cost per patient than the usual care group (-$2,544, P = 0.029); assignment to the intervention group was associated with a lower predicted cost per patient for laboratory (including cardiology graphics) services (P = 0.007) and pharmacy costs (P = 0.047). CONCLUSIONS: When controlled for important predictors of expected resource use, care provided by a geriatric management team resulted in a significant reduction in the cost of hospitalization. A reduction in the cost of laboratory, cardiographic, and pharmacy services is consistent with the team's philosophy of defining the services needed based on goals related to functional outcomes.

Academic Medical Centers↗
PubMed1992

Self-reported functional status predicts change in level of care in independent living residents of a continuing care retirement community.

OBJECTIVE: To test the hypothesis that self-reported functional status predicts change in level of care from independent to dependent in residents of a continuing care retirement community (CCRC). DESIGN: Two-year longitudinal descriptive study of change in level of care and survival. SUBJECTS: One hundred fifty-two residents in the independent-living unit of a non-profit CCRC. Mean age at initial evaluation was 82.3 years, SD 6.2. MEASUREMENT: Predictor variables assessed at baseline were age, sex, physician estimate of functionally significant disease, self-reported functional status, and performance-based hand function. Criterion variables collected at 2-year follow-up were level of care (independent/dependent) and survival (alive/dead). MAIN RESULTS: Self-reported functional status (P less than 0.01) and age (P less than 0.05) were significant predictors of change in level of care in a logistic regression analysis containing all predictor variables. No variable predicted survival. CONCLUSIONS: Self-reported functional status may help to predict dependency in older adults in good health who have few markers of dependency risk.

Activities of Daily Living↗
PubMed1991

Self report and performance-based hand function tests as correlates of dependency in the elderly.

Preventing or minimizing functional dependency in older adults rests, in part, upon the ability to predict who is at risk. The purpose of this study was to compare the ability of five tests of hand function to discriminate the degree of dependency in older adults. Seven hundred sixty four subjects were assessed for hand function on performance-based (Williams Test of Hand Function, a test of Williams Board items only, Jebsen Test of Hand Function, grip strength), and self-reported (Dexterity Scale of the Geriatrics-Arthritis Impact Measurement Scale (GERI-AIMS] measures of hand function, and self-reported multidimensional functional status (GERI-AIMS). A trichotomous variable representing a continuum of dependency based upon living site (independent living, home-bound, institutional) was used as the measure of dependency. Sixty-two cases were dropped for incomplete data. Discriminant function analyses of the 702 subjects (age X = 76.78 years, SD = 8.79) showed that basic demographic variables explain 40.8% of the variance in dependency; all hand function tests significantly correlated with dependency; the Williams Board correlated best (additional 12.5% variance explained). However, a multidimensional functional status measure explains substantially more variance in dependency (16.9%) after controlling for demographic variables and performance on the Williams Board. This comparison of methods and tests available for measuring hand function was made to provide criteria for selecting an instrument for a given setting.

Activities of Daily Living↗
PubMed1977

Measurement of cardiac output using improved chromatographic analysis of sulfur hexafluoride (SF6).

A constant current variable frequency pulsed electron capture detector has been incorporated into the gas chromatographic analysis of trace amounts of sulfur hexafluoride (SF6) in water and blood. The resulting system offers a broader effective operating range than more conventional electron capture units and has been utilized for measurements of cardiac output employing constant-rate infusion of dissolved SF6. The SF6 technique has been validated against direct volumetric measurements of cardiac output in a canine right-heart bypass preparation and used subsequently for rapidly repeated measurements in conscious animals and man.

Animals↗
PubMedDate not supplied

Patterns of syphilis testing in the elderly.

OBJECTIVE: To evaluate the frequency of inconsistencies in the use of laboratory tests for syphilis among the elderly in an acute care setting. DESIGN: Retrospective medical record review. SETTING: Academic medical center. PATIENTS/PARTICIPANTS: All patients 60 years of age and older who had: 1) positive tests for syphilis and no lumbar puncture performed (n = 71), 2) lumbar punctures performed and no positive test for syphilis (n = 68), and 3) positive tests for syphilis and lumbar punctures performed (n = 8). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The chronology and results of syphilis tests were abstracted from the medical records. Documentation of signs and symptoms of neurosyphilis, including dementia and depression, were abstracted from the medical records by a second reviewer. Most patients had inadequate evaluations; 51 had no follow-up of positive syphilis tests and 43 had cerebrospinal fluid syphilis tests in the absence of positive blood tests for syphilis or signs and symptoms of neurosyphilis. CONCLUSIONS: The inconsistent pattern of serologic testing in this study suggests that the testing was done as a routine procedure and not for a specific purpose. For a majority of the tested individuals, the results did not provide a public health benefit or contribute to the individual's well-being.

Aged↗