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J G Ouslander

Publications and source records attributed to J G Ouslander.

At least 19 recordsLinked to original sources
PubMed2001

Prompted voiding for nighttime incontinence in nursing homes: is it effective?

OBJECTIVES: To determine whether prompted voiding (PV) is effective for nighttime urinary incontinence in nursing home (NH) residents and whether residents who respond well to daytime PV also respond well at night. DESIGN: Prospective case series. SETTING: Four community NHs. PARTICIPANTS: Sixty-one long-stay incontinent NH residents of mean age 88 years, 75% female. MEASUREMENTS: The percentage of hourly checks for wetness and the appropriate toileting rate (continent voids divided by total voids) were measured during 3 days (7 a.m.-7 p.m.) of PV, and for an average of 5 nights (7 p.m.-7 a.m.), during which a modified PV protocol, designed to be minimally disruptive to sleep, was carried out. RESULTS: Fourteen residents (23%) responded well to daytime PV, with average wetness and appropriate toileting rates of 5% and 73%, respectively. In the group as a whole, nighttime PV was not effective, with wetness and appropriate toileting rates of 49% and 18%, respectively. Among those who responded well to daytime PV, wetness rates during nighttime PV remained significantly higher than during the day (24% vs. 5%; P = .000), and nighttime appropriate toileting rates were significantly lower (39% vs. 73%; P = .002). The poor response rate at night was primarily observed between 10 p.m. and 6 a.m. CONCLUSIONS: In this sample of incontinent NH residents, nighttime PV, even when carried out so as to minimize sleep disruption, was not an effective intervention. Although residents who responded well to daytime PV responded better to nighttime PV than those who did not respond to daytime PV, their wetness rates remained relatively high and their appropriate toileting rates were low. These data suggest that routine nighttime toileting programs should not be carried out for the majority of incontinent NH residents. Instead, individualized care based on resident's preferences, willingness to toilet at night, and sleep patterns should be emphasized.

Activities of Daily Living↗
PubMed2001

Urinary incontinence treatment preferences in long-term care.

OBJECTIVE: To elicit preferences for different urinary incontinence (UI) treatments in long-term care (LTC) from groups likely to serve as proxy decision makers for LTC residents. DESIGN: A descriptive, comparative study of preference for UI treatments of frail older adults, family members of nursing home (NH) residents, and LTC nursing staff. Surveys were mailed to families and self-administered by staff. Older adults were interviewed. SETTING: Four LTC facilities and two residential-care facilities in Los Angeles. PARTICIPANTS: Four hundred and three family members of incontinent NH residents were mailed surveys. Sixty-six nursing staff caring for these incontinent residents and 79 older adult residents of care facilities (nine cognitively intact NH respondents and 70 residential care residents) answered surveys. MEASUREMENTS: Preference rankings between seven paired combinations of five different UI treatments were measured on an 11-point visual analog scale, with the verbal anchors "definitely prefer" this treatment, "probably prefer" this treatment, and "uncertain." Respondents gave open-ended comments as well. RESULTS: Forty-two percent of family members (171/ 403) returned the mailed survey. Of all respondents, 85% "definitely" or "probably" preferred diapers, and 77% "definitely" or "probably" preferred prompted voiding (PV) to indwelling catheterization. Respondent groups occasionally differed significantly in their preferences. In choosing between treatment pairs using a visual analogue scale, nurses preferred PV to diapers significantly more than did older adults or families (both of whom preferred diapers) (F (2,295) = 13.11, P < .0001). Older adults, compared with family and nurse respondents, showed a significantly stronger preference for medications over diapers (F (2,296) = 41.54, P < .0001). In open-ended responses, older adults stated that they would choose a UI treatment based in part upon criteria of feeling dry, being natural, not causing embarrassment, being easy, and not resulting in dependence. Nurses said that they would base their choice of UI treatment upon increasing self-esteem and avoiding infection. CONCLUSIONS: Although there was wide variation within and between groups about preferred UI treatment, most respondents preferred noninvasive strategies (diapers and PV) to invasive strategies (indwelling catheters and electrical stimulation). Older adults preferred to a greater degree medications and electrical stimulation, therapies directed at the underlying cause of UI. Despite data documenting that diapering is a less time intensive way to manage UI and that toileting programs are difficult to maintain in LTC, nurses viewed PV as "natural" and strongly preferred it to diapering. Several family members and older adults viewed PV as "embarrassing" and "fostering dependence." These data highlight the need to elicit preferences for UI treatment among LTC residents and their families.

Activities of Daily Living↗
PubMed2001

Effects of oral estrogen and progestin on the lower urinary tract among female nursing home residents.

OBJECTIVE: To examine the effects of oral estrogen/progestin on incontinence and related lower urinary tract conditions among female nursing home (NH) residents. DESIGN: Randomized placebo-controlled trial. SETTING: Five NHs. PARTICIPANTS: Thirty-two incontinent female residents of average age 88. MEASUREMENTS: Subjects were randomized to receive either oral estrogen (0.625 mg) combined with progesterone (2.5 mg) or placebo, daily for 6 months. Measures of incontinence severity, the clinical appearance of the vagina, vaginal and urethral cytology, and urine and vaginal cultures were made at baseline, 3 months, and 6 months. In addition to active drug or placebo, all subjects received regular toileting assistance (prompted voiding) by trained research aides during 3-day data-collection periods to compensate for mobility and cognitive impairments. RESULTS: At 3 and 6 months there were no significant differences between the groups in the severity of incontinence, the prevalence of bacteriuria, or the results of vaginal cultures. Several clinical findings associated with atrophic vaginitis improved more in the active than the placebo group and vaginal pH and vaginal and urethral cytology exhibited a partial estrogenic effect. CONCLUSIONS: Our results must be interpreted with caution because of the size and the select nature of our subject sample. Up to 6 months of oral estrogen had only a partial estrogenic effect on vaginal and urethral epithelium and no clinical effects in this patient population. We believe that future studies of estrogen for urinary incontinence in frail NH residents should utilize a topical preparation and consider targeting urinary tract infection as an additional outcome measure.

Activities of Daily Living↗
PubMed2000

Managed care and multilevel long-term care providers: reluctant partners.

Managed care is reshaping our health care system, although long-term care is only beginning to feel its effects. We report on the managed care involvement of 492 multilevel, long-term care facilities (MLFs; including skilled nursing and assisted/independent living) nationally. Organizational structure and culture and especially environmental characteristics are associated with whether facilities have contracts with managed care organizations (MCOs), plan to have contracts, are only gathering information on MCOs, or intend to do nothing in the near future. Resource dependence theory best explains MCO contracting patterns with MLFs appearing to be responding more to survival than to growth.

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PubMed2000

Intractable incontinence in the elderly.

The number of people living into extreme old age is rising exponentially in the USA, Europe and other developed countries. Urinary incontinence is prevalent in this population. While many very old (age > 75 years) incontinent individuals are relatively healthy and respond well to various treatments, a substantial proportion has impaired cognitive function and impaired mobility. These impairments make urinary incontinence much more difficult to assess, manage and cure than in younger populations. Irrespective of age and disability, a basic assessment of incontinence should be carried out to identify potentially reversible causes and indications for further evaluation. The outcome of such an assessment may not be cure or improvement of incontinence, but better quality of life and the prevention of morbid and expensive medical conditions that may result from poorly managed incontinence. Incontinence in this population should generally not be considered 'intractable' until a trial of noninvasive therapy (i.e. behavioural and/or pharmacological) has been undertaken. Some very frail elderly respond well to a toileting programme such as prompted voiding, and a small but significant proportion benefit from the careful addition of a bladder relaxant drug to the toileting programme. Others, depending on their ability and willingness to toilet and their preferences for further treatment, may be candidates for surgical intervention. Pads and garments should not be used so that they foster dependency, or as a primary treatment until other specific interventions have been tried. Indwelling catheters should be used only for specific and well-documented indications, because of the risks of urinary tract infection and sepsis associated with their long-term use. The dictionary defines 'intractable' as 'not easily relieved or cured'. In the elderly, cure for incontinence, and most other chronic conditions, is the exception rather than rule. Relief (or amelioration), improvement in function and quality of life, and the exclusion of treatable medical conditions that cause morbidity and expense when undiagnosed, are generally achievable and more important goals than complete cure.

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PubMed2000

Health care utilization by old-old long-term care facility residents: how do Medicare fee-for-service and capitation rates compare?

OBJECTIVE: To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. SETTING: A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. PARTICIPANTS: Residents (n = 700) living in the community between September 1995 and February 1996. METHODS: Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. RESULTS: Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. CONCLUSIONS: Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.

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PubMed2000

Overactive bladder: special considerations in the geriatric population.

Overactive bladder (OAB) is a highly prevalent condition among older patients, and its presence is associated with the use of substantial healthcare resources and economic costs. Within the next 30 years, it is expected that the demand for services related to OAB will increase dramatically. Treatment of OAB is challenging and depends on several factors, including the age of the patient, cognitive functioning, and the degree of mobility. Pharmacotherapy, such as the use of tolterodine and oxybutynin, is a viable option for the treatment of OAB, and muscarinic antagonists are commonly used. The efficacy of an agent may differ in older patients compared with younger ones. In addition, certain side effects can be particularly troublesome in the geriatric population. A retrospective analysis of a large managed care database showed an age-related increase in the number of women seeking care for OAB. Caring for incontinent patients in the long-term care setting was shown to result in substantial additional costs, which were higher in those with more frequent incontinent episodes. Prompted voiding may be effective in reducing the number of incontinent episodes for those in institutionalized care; however, this practice is labor intensive and generally is only effective in 40% of cases. Moreover, assistance with prompted voiding must be maintained continuously. Future research should focus on defining the most cost-effective methods of treating OAB in the long-term care setting.

Adult↗
PubMed1999

Urinary incontinence in the older man.

Older men experience UI less often than older women, but the disruption and bother they experience because of UI is significant. Several anatomic differences between men and women account for different pathophysiology of incontinence. In men, overflow incontinence and detrusor instability predominate; stress incontinence is seen only in cases in which men have had prostate surgery. Reported symptoms of urgency and urge incontinence may be particularly difficult to interpret clinically in men because they might indicate detrusor instability or bladder outlet obstruction causing uninhibited contractions. The medical evaluation of UI is similar for men and women; men being evaluated for UI need a postvoid residual. Noninvasive measurement of urine flow may add to the diagnostic accuracy of detecting bladder outlet obstruction, but the results may not agree with results obtained by pressure-flow studies. Prostate surgery can result in UI, and biofeedback can be an effective treatment. Near-continual leakage after prostate surgery seems to be most responsive to artificial sphincter implantation. Male nursing home patients with UI present a different challenge in that mental and physical dysfunction must be addressed. Staff-dependent interventions are the most appropriate.

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PubMed1999

Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group.

OBJECTIVE: To determine the prevalence of stress, urge, and mixed urinary incontinence and associated risk factors in postmenopausal women. METHODS: Before enrollment in a 4-year, randomized trial of combination hormone therapy to prevent coronary heart disease, 2763 participants completed questionnaires on prevalence and type of incontinence. We measured factors potentially associated with incontinence including demographics, reproductive and medical histories, height, weight, and waist-to-hip circumference ratio. We used multivariate logistic models to determine independent associations between those factors and weekly incontinence by type. RESULTS: The mean (+/- standard deviation [SD]) age of the participants was 67+/-7 years; 89% were white and 8% were black. Fifty-six percent reported weekly incontinence. In multivariate analyses, the prevalence of weekly stress incontinence was higher in white than black women (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.6, 5.1), in women with higher body-mass index (BMI) (OR 1.1 per 5 units, 95% CI 1.0, 1.3), and higher waist-to-hip ratio (OR 1.2 per 0.1 unit, 95% CI 1.0, 1.4). The prevalence of weekly urge incontinence was higher in older women (OR 1.2 per 5 years, 95% CI 1.1, 1.3), diabetic women (OR 1.5, 95% CI 1.1, 2.0) and women who had reported two or more urinary tract infections in the prior year (OR 2.0, 95% CI 1.1, 3.6). CONCLUSION: Stress and urge incontinence are common in postmenopausal women and have different risk factors, suggesting that approaches to risk-factor modification and prevention also might differ and should be specific to types of incontinence.

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PubMed1999

Objective and subjective measures of the quality of managed care in nursing homes.

BACKGROUND: The number of nursing home (NH) residents enrolled in managed care plans (HMO) will increase, and there is concern that the quality of their medical care may be compromised by cost-containment pressures. In this study, we evaluated the medical care of residents enrolled in 3 health maintenance organizations (HMO) that developed specific long-term care programs. OBJECTIVES: To compare the medical care received by NH residents enrolled in HMO and Fee-for-Service (FFS) plans with both objective process of care and consumer perception (subjective) measures. To describe the relationship between the objective and subjective measures. MEASURES: Number of primary care visits per month; process of medical care for 2 geriatric tracer conditions (falls, fevers); family and residents' perceptions of the adequacy of sickness episode management; and the frequency of primary provider visits. DESIGN: Quasi-experimental. RESULTS: HMO residents received more timely and appropriate responses to falls and fevers than did FFS residents. HMO residents also received more frequent routine visits by a primary care provider team consisting of a physician and nurse practitioner. Consumer perceptions of quality did not differ between the HMO and FFS groups. Families within both groups were significantly more positive than were residents about the frequency of visits by both physicians and nurse practitioners. Within the HMO group, both families and residents were more positive about the frequency of nurse practitioner visits than were physician visits even when the frequency of visits by the 2 providers were similar. CONCLUSIONS: Although the medical care received by HMO residents was better on most objective process measures than that received by FFS residents, consumer perceptions of care did not detect those differences. NH residents and families have different perceptions about the adequacy of visits by physicians and nurse practitioners, and both families and residents appear to have different expectations concerning how often they want physicians to visit as compared with nurse practitioners.

Fee-for-Service Plans↗
PubMed1999

Life-sustaining treatment decisions for nursing home residents: who discusses, who decides and what is decided?

OBJECTIVE: To evaluate whether nursing home residents and their families reported discussions about life-sustaining treatment with their physicians, the relationship between such discussions and orders to limit therapy, and predictors of physician-patient communication about life-sustaining treatment. DESIGN: Cross-sectional interviews and retrospective chart abstraction. SETTING: Three regions: West Coast, New England, Western. SAMPLE: A total of 413 nursing home residents, 363 family/surrogate interviews, and 192 resident interviews. MAIN OUTCOME MEASURES: Measured were (1) physician-resident communication about life-sustaining treatment and (2) presence of an advance directive or do not resuscitate (DNR) order in resident's chart. RESULTS: Seventy-four percent of residents had DNR orders, and 32% had advance directives; only 29% of residents reported discussions about life-sustaining treatment. Of residents with DNR orders who could have participated in discussions about life-sustaining treatment, nearly half reported they had not discussed CPR with their caregivers. Older age, longer duration of time living in nursing home, location in a New England nursing home, physician-family member discussion, and the presence of an advance directive in the medical chart were positively associated with having DNR orders. Physician-resident discussion was not associated with having a DNR order. For the subsample of interviewed residents, age and a diagnosis of cognitive impairment were negatively associated with a physician-resident discussion about life-sustaining treatment, whereas the likelihood of having a discussion increased with increasing numbers of medical diagnoses. CONCLUSIONS: Chart orders to limit therapy are common, but physician-resident discussions about life-sustaining treatments are not. Far more family members than residents report such discussions with the resident's physicians.

Adult↗
PubMed1999

Primary care of long-stay nursing home residents: approaches of three health maintenance organizations.

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.

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PubMed1999

Use of primary care teams by HMOS for care of long-stay nursing home residents.

OBJECTIVE: To characterize the use of formal primary care programs by health maintenance organizations (HMOs) for their members who are long-stay residents of nursing homes. DESIGN: Using mail survey techniques, 34 Medicare risk-contracting HMOs with the largest Medicare beneficiary enrollments were asked to complete a written questionnaire. HMOs were asked how they evaluate care in nursing home settings and whether they operate a formal primary care program for members who are long-stay nursing home residents. Those reporting they had programs were asked about the program features, participation in the program, roles performed by clinical practitioners, and clinical caseloads. Surveys were completed by 21 (61.8%) of the HMOs. PARTICIPANTS: HMO management personnel who know the primary care programs the HMOs operate in affiliated nursing homes. MEASUREMENTS: Descriptive summaries of the HMOs' responses to the survey questions were generated. For HMOs with primary care programs, caseloads of physicians and nurse practitioners were estimated using survey data reported by the HMOs. RESULTS: Eight (38.1%) of the responding HMOs operate formal primary care programs in affiliated nursing homes. HMOs with programs consider more factors than non-program HMOs in evaluating care for nursing home residents. Reasons cited most frequently for not having a program are costs and too few nursing home residents. The most common primary care program features are designated physicians and use of physician extenders. CONCLUSIONS: Survey findings point to the potential importance of formal HMO primary care programs for long-term nursing home residents, which may expand with growth in the older population and Medicare-managed care. Program adoption, however, may depend on sufficient resident participation to be financially feasible.

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