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D R Berlowitz

Publications and source records attributed to D R Berlowitz.

33 records · Page 2Linked to original sources
PubMed1996

Variations in the management of acute myocardial infarction. Importance of clinical measures of disease severity.

OBJECTIVE: To determine the extent to which resource use for patients hospitalized with acute myocardial infarction varies with clinical status, and to see if an observed difference in resource use between two states can be explained by clinically detailed risk adjustment. DESIGN: Retrospective review of the clinical characteristics and resource use of 342 patients hospitalised in two states with acute myocardial infarction. DATA SOURCES: Merged data from three sources: a large, existing research database used in developing the Medicare Mortality Predictor Score, clinical data abstracted from medical charts specifically for this study, and Medicare Parts A and B claims records. PATIENTS: A probability sample of Medicare patients hospitalized in 1986 with a diagnosis of acute myocardial infarction and residing in either Wisconsin or Washington state; patients dying within 30 days are oversampled. MEASUREMENTS AND MAIN RESULTS: Although patients were clinically similar in the two states, there were systematic differences in resource use. Patients in Wisconsin spent more than one extra day in the intensive care unit (ICU) (2.8 vs 1.7) as well as more than one extra non-ICU day in the hospital (8.0 vs 6.5) than patients in Washington. Patients in Wisconsin were also more likely to receive an echocardiogram (35.6% vs 15.8%), nuclear ventriculogram (12.8% vs 4.1%), exercise tolerance test (21.5% vs 3.4), and Holter monitoring (5.4% vs 0%). (All p < .01.) Differences in utilization were greater for patients at lower risk of dying. The average cost of care was 20.8% higher in Wisconsin (p = .01); risk adjustment for clinical and other factors reduced this difference to 11.8%, but did not eliminate it (p = .04). CONCLUSIONS: Patients with acute myocardial infarction vary in resource use as a function of clinical factors present at admission and occurring during the hospital stay; comparisons that do not take account of these factors may not discriminate well between providers who care for sicker patients and those who are inefficient. The greater use of resources for patients in Wisconsin is at least partially explained by differences in clinical characteristics that are not presently captured in administrative data.

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PubMed1996

Evaluating pressure ulcer occurrence in long-term care: pitfalls in interpreting administrative data.

Administrative databases for long-term care frequently collect information on fixed dates of the calendar year, rather than for entire episodes of care. Patients discharged or dying prior to an evaluation date are lost to follow-up. We used one such database, the VA Patient Assessment File, to examine pressure ulcer occurrence in long-term care. Clinical studies have established that most pressure ulcers develop during the first several weeks following admission. In these data, however, pressure ulcer development was less common in patients assessed within 2 months following admission, as compared to those examined at 3 to 6 months. This finding appears to be related to the selective discharge of patients, which makes these patient populations noncomparable. These results highlight that care must be exercised when interpreting results obtained from such administrative data.

Aged↗
PubMed1994

The limited value of routine laboratory assessments in severely impaired nursing home residents.

OBJECTIVE: To determine the usefulness of a routine, comprehensive battery of laboratory tests in a severely impaired elderly nursing home population. DESIGN: Prospective observational survey. SETTING: Skilled nursing facility wards of a geriatric and extended care veterans hospital. PATIENTS: Consecutive sample of 108 veterans with severe cognitive and functional impairments, who had been hospitalized at least 6 months. MAIN OUTCOME MEASURES: Proportions of tests categorized as screening, monitoring, follow-up, or diagnostic; frequency of abnormal test results, interventions warranted and performed on the basis of these abnormalities, and beneficial or adverse effects. RESULTS: Of 6771 individual nondiagnostic tests performed, 17.2% yielded abnormal results; of these, 33.3% were new. However, only 0.2% of tests resulted in patient benefit. Of 989 panels performed, 31.0% contained at least one abnormality, but only 1.0% of panels (10 patients) yielded any benefit. Overall usefulness was related to the purpose of the testing, with 31.5% of screening tests yielding abnormalities, compared with 45.5%, 78.2%, and 68.7% of monitoring, follow-up, and diagnostic panels, respectively (P < .05 for each compared with screening panels). None of the screening panels detected an abnormality that led to patient benefit, compared with 1.0%, 1.4%, and 3.0% of monitoring, follow-up, and diagnostic panels. CONCLUSIONS: Routine comprehensive laboratory panels may not be warranted in the most severely impaired elderly patients in long-term care settings. Discontinuing true screening tests and limiting testing strictly to monitoring, follow-up, or diagnostic purposes could minimize the costs of laboratory assessment without losing its potential benefits.

Activities of Daily Living↗
PubMed1991

Pressure ulcers.

Explore the source record for details and available documents.

Humans↗
PubMed1991

Do-not-resuscitate orders at a chronic care hospital.

Do-not-resuscitate (DNR) orders have become an accepted part of medical practice. While these orders have been extensively evaluated in acute care hospitals, little is known about their use in the long-term care setting. We reviewed the medical records of all admissions to a chronic care hospital over a 13-month period, collecting data on selected patient characteristics, use of DNR orders, and patient outcomes during the 6-week period following admission. Fifty-eight of the 301 patients (19.3%) had a DNR order written. Patients' families were involved predominantly in the DNR decision in 73% of the cases while patients themselves were involved in only 18%. Physicians made the decision unilaterally in 6% of the cases. Patients' functional status rather than specific diagnoses predicted the use of DNR orders. Patients with DNR orders were twice as likely to receive new intravenous therapies than patients without those orders (71% vs 33%, P less than 0.01) and four times as likely to die (38% vs 9%, P less than 0.01). They were no more likely to be transferred emergently to an acute care hospital (5% vs 9%, P greater than 0.2). We conclude that DNR orders are not infrequently used, and physicians rarely make the decision unilaterally. Patients with DNR orders have a high likelihood of dying and are infrequently transferred to acute care facilities.

Activities of Daily Living↗
PubMed1990

The short-term outcome of pressure sores.

Patients with pressure sores have been observed to have a poor prognosis. The short-term outcome of pressure sores at a long-term care hospital was therefore evaluated. Medical records on the 301 admissions to this hospital over a 13-month period were reviewed. One hundred patients (33%) had a pressure sore present on admission. Using ordinary therapies, 79% of these pressure sores improved and 40% completely healed during the 6-week follow-up period. Remaining bed- or chair-bound was the sole patient characteristic associated with a failure of the pressure sore to improve. Mortality rates were significantly increased in patients with a pressure sore present on admission (relative risk [RR] = 1.9), in patients who developed a new sore (RR = 3.1), and in patients in whom the pressure sore failed to improve (RR = 3.3). However, the pressure sores did not appear to be the direct cause of this increased mortality. These data suggest that the majority of pressure sores encountered at a long-term care hospital can be successfully managed in this setting. Although patients with pressure sores have an increased mortality rate, this is most likely due to coexisting medical conditions.

Activities of Daily Living↗
PubMed1989

Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data.

The purpose of this study was to identify prospectively risk factors for pressure sores and to compare these results with a cross-sectional analysis in the same population. Medical records on all admissions to a chronic care hospital over a 13-month period were reviewed. Data on potential risk factors were abstracted from the initial history, physical examination, nursing assessment, and laboratory studies. Pressure sore status on admission and at three weeks was determined from a standardized from completed on all patients with a score. The cross-sectional analysis was performed by comparing patients with and without a pressure sore at the time of admission. The cohort analysis used patients initially without a pressure sore and monitored for a new sore at three weeks. Factors associated with pressure sores on univariate testing were entered into a stepwise logistic regression model. One hundred of the 301 admissions presented with a pressure sore. Factors significantly associated with the presence of a sore were altered level of consciousness (OR = 4.1), bed- or chair-bound (OR = 2.4), impaired nutritional intake (OR = 1.9), and hypoalbuminemia (OR = 1.8 for 10 mg/mL decrease). Of the 185 patients without a pressure sore, 20 (10.8%) developed a sore. Factors significantly associated with the development of a new pressure sore were a history of cerebrovascular accident (OR = 5.0), bed- or chair-bound (OR = 3.8), and impaired nutritional intake (OR = 2.8). Neither urinary nor fecal incontinence, nor the presence of hypoalbuminemia, was associated with sore development. We have prospectively identified risk factors for pressure sores.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

The use of follow-up chest roentgenograms among hospitalized patients.

Follow-up chest roentgenograms are a commonly performed test. We prospectively evaluated their diagnostic and therapeutic influence at a tertiary care teaching hospital. When a follow-up chest roentgenogram was ordered, physicians indicated their reason for ordering the test, the likelihood that the roentgenogram would show changes, and expected alterations in therapy. After the roentgenogram was obtained, physicians described the help provided by the roentgenogram and what changes in therapy were performed. Using receiver operating characteristic curves, we have shown that physicians have difficulty in predicting which roentgenograms will show important changes. Unexpected findings are frequent (25.4%) and highly valued by the physician. Fifty-seven percent of these roentgenograms had a definite or possible influence on patient treatment. Further studies are indicated to define when follow-up chest roentgenograms are likely to be of benefit.

Adult↗
PubMedDate not supplied

Are pressure ulcers preventable? A survey of experts.

OBJECTIVE: There is considerable debate regarding whether pressure ulcers can truly be prevented in nursing homes. New pressure ulcers are often taken as a sign of negligence that can lead to a lawsuit. This study sought to determine expert opinion regarding the preventability of pressure ulcers, the resources available to nursing homes for prevention, and the role of negligence lawsuits in pressure ulcer care. DESIGN: Survey mailed to a convenience sample of 98 experts in the field of pressure ulcer care. The survey contained 36 questions, most based on a 5-point Likert scale from "strongly agree"to"strongly disagree." Several questions asked respondents to rank items. RESULTS: Sixty-five of 92 surveys were completed (6 were returned but not completed) for a response rate of 71%. Sixty-two percent of respondents disagreed with the statement that all pressure ulcers are preventable. Only 5% said that nursing homes have adequate resources to prevent all pressure ulcers. Although most respondents disagreed that pressure ulcers are necessarily a sign of neglect and that nursing homes should be sued when a resident develops a pressure ulcer, 38% agreed with the concept that lawsuits are an appropriate way to stimulate improvement in nursing home care. CONCLUSION: The results of this survey demonstrated divergent expert opinion on whether pressure ulcers are preventable. The role of regulations and litigation in pressure ulcer prevention needs to be further defined.

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PubMedDate not supplied

Clinical practice guidelines in the nursing home.

Clinical practice guidelines are an important tool for improving quality of care. This study determined whether and how guidelines are being used in nursing homes. We surveyed staff at 36 Department of Veterans Affairs (VA) nursing homes. Employees were asked whether they were familiar with guidelines as well as whether 5 specific guidelines had been read, were available, and had been adopted. Among 1065 respondents (60% of those surveyed), 79% reported familiarity with guidelines. The proportion of staff at a facility reporting adoption was generally less than 50%. Those nursing homes in which a high percentage of the staff reported adoption of one guideline were more likely to have adopted other guidelines. However, staff were not more likely to report adoption of a specific guideline when the nurse manager stated that it was adopted. We conclude that staff at VA nursing homes are familiar with guidelines. Guideline adoption at individual nursing homes, however, is not a systematic process involving the entire staff.

Diffusion of Innovation↗
PubMedDate not supplied

Pressure ulcer development in the VA: characteristics of nursing homes providing best care.

This study identifies structural characteristics of VA nursing homes that are associated with the best patient outcomes. We evaluated risk-adjusted rates of pressure ulcer development in VA nursing homes and related these rates to facility size, staffing patterns, teaching nursing home status, and rural versus urban locale. Higher rates of pressure ulcer development were seen among urban teaching nursing homes and among nursing homes associated with both larger and smaller VA hospitals. Staffing patterns had a complex association with pressure ulcer development, and smaller nursing home staffs were not clearly associated with higher rates. For multivariate modeling, only hospital size and staffing remained significant independent predictors of pressure ulcer development. These results emphasize that while structural characteristics of VA nursing homes can provide insights about care, improving the quality of care in this setting will require a much greater understanding of how nursing homes are organized to meet patient needs.

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PubMedDate not supplied

Pressure ulcers: the Minimum Data Set and the Resident Assessment Protocol.

As Americans age and live longer with chronic disabilities, more elderly citizens will reside in nursing homes. The nationally mandated Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) were designed to help plan for the care of the frail elderly residing in nursing homes. One of the areas specifically targeted was pressure ulcers. This study was designed to describe the prevalence, incidence, and current management practices relating to pressure ulcers in nursing homes based on MDS data. In addition, a cross-sectional investigation was performed to examine the MDS items found in the pressure ulcer RAP. The MDS data for 2,011 nursing home residents, aged 60 or older, who lived in 270 facilities from 10 states were evaluated. The results found a prevalence of 11.2% for Stage II-IV lesions and a 6-month incidence of 6.2%. Logistic regression analysis determined that dependence in transfer or mobility, being bedfast, having diabetes mellitus, and having had a pressure ulcer in the past were significantly associated with a Stage II-IV pressure ulcer. The MDS and its associated RAP for pressure ulcers provide the data to begin devising a care plan for patients with pressure ulcers.

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