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Biomedical subjects

L Z Rubenstein

Publications and source records attributed to L Z Rubenstein.

At least 109 records · Page 6Linked to original sources
PubMed1987

Impact of computerized drug profiles and a consulting pharmacist on outpatient prescribing patterns: a clinical trial.

The effects of computerized drug profiles and clinical pharmacist consultation in the internal medicine clinics at a Veterans Administration hospital were studied. Population included patients (n = 512) and physicians (n = 35) of three internal medicine clinics during an eight-week period. The first four weeks were the preintervention period. The second four weeks were the intervention period in which a clinical pharmacist attended one clinic (A) and provided drug profiles on all patients. Two other clinics (B and C) served as controls. During the intervention, patients in clinic A experienced a significant reduction in prescribing problems as identified by the pharmacist: 49 percent of patients before the intervention versus 9.4 percent after the intervention (p less than 0.001). Patients in clinic B had no significant change in prevalence in the number of problems identified (39 versus 40 percent; NS), and patients in clinic C had a significant but less dramatic decrease (35 versus 22 percent; p less than 0.05). The proportion of patients in clinic A with net decrease in the number of prescribed medications rose from 7.1 to 34.9 percent (p less than 0.001), with a mean decrease of 0.3 medications per patient. No significant differences in number of prescribed medications were noted in clinics B or C. Accuracy of physician medication charting improved for patients in clinic A from 54 percent of charts with accurate drug lists before the intervention to 78.3 percent after the intervention (p less than 0.001). No significant improvements were noted for clinics B and C. These results suggest that computerized drug profiles together with clinical pharmacist consultation can improve prescribing practices in a hospital outpatient department.

Ambulatory Care↗
PubMed1987

Geriatric assessment: an overview of its impacts.

Geriatric assessment programs of various types have become an increasingly important component of the geriatric health care delivery system in the United States. Such programs provide interdisciplinary assessment, treatment planning, case management, and, often, rehabilitation for frail elderly persons and are especially important for those suspected of needing long-term institutional care. A growing body of literature, summarized in this chapter, documents many proven benefits to health care outcomes. Among these benefits are better diagnostic accuracy and treatment planning, more appropriate placement decisions with less referral to nursing homes, improved patient functional and mental status, prolonged patient survival, and lower overall use of costly institutional care services.

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PubMed1987

Geriatric assessment on a subacute hospital ward.

The authors collected data on all patients admitted to the Sepulveda Veterans Administration Geriatric Evaluation Unit (GEU) during its first 6 years of operation. Analysis of these data indicate several beneficial effects associated with this type of specialized geriatric care: improved diagnostic accuracy, reduced use of drugs, improved functional status, and improved placement location. The authors also analyzed additional data from a previously published, randomized controlled trial to compare better process of care between patients randomized to the GEU and those receiving usual services. During their initial hospitalizations, GEU patients received significantly more specialty evaluations than controls (4.9 versus 1.7, p less than .001), had longer lengths of stay (85.1 days versus 44.3 days, p less than .001), had more new diagnoses discovered (2.9 versus 0.6, p less than .001), and had more drugs discontinued from their regimens (4.6 versus 2.3 p less than .001). These process differences were probably related to the previously reported outcome differences: GEU patients were more likely than controls to show improvements in functional status, affect, placement location, use of institutional services, and survival.

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PubMed1986

Organizing an academic nursing home. Impacts on institutionalized elderly.

In March 1984, a program for an academic nursing home was established at the Sepulveda Veterans Administration Medical Center. The program was designed to improve care of nursing home patients, provide interdisciplinary training for medical house staff and allied health students, and stimulate research. Geriatric faculty physicians were appointed, medical house staff were assigned as primary physicians to groups of patients, and geriatric nurse practitioners were hired to provide day-to-day care. A two-phase evaluation of the impact of the academic nursing home on patient care was conducted. Beneficial developments associated with the program in concurrent comparison with the standard nursing home unit included a significant decrease in patient transfers to the acute-care hospital and significant improvements in functional status, patient satisfaction, and morale. A trend toward improved survival was nonsignificant. Longer-term follow-up revealed a significantly increased rate of discharge for patients completing long-term rehabilitation. Overall, the costs of nursing home care were only minimally increased by the program. Results suggest that programs like the academic nursing home can lead to improved process and outcomes of nursing home care.

Academic Medical Centers↗
PubMed1986

Comprehensive health screening of well elderly adults: an analysis of a community program.

We examined the yield of a health screening program in a free-standing community senior citizen center and identified factors associated with patient compliance with referral recommendations. Of elderly individuals screened, 94% had some positive finding requiring advice or intervention, and 54% were referred to a physician for further evaluation. The most prevalent findings were skin disorders (52%), genitourinary disorders (44%), and eye-ear-nose-throat disorders (33%). Of individuals referred to a physician, 70% complied with the referral. Of those who complied, 38% reported receiving treatment for the referred condition--15% of the entire group of clients screened. Factors positively associated with compliance with physician referral included the specific type of referred problem, the perceived seriousness of the problem, and absence of financial barriers to medical care. Though controlled trial data are lacking, this and other published studies indicate that many remediable problems can be identified among apparently healthy elderly individuals in community geriatric screening programs.

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PubMed1986

Medicare capitation and quality of care for the frail elderly.

Previous studies have shown that the quality of care provided in health maintenance organizations (HMO's) is either similar or better than that in fee-for-service settings; however, few studies have included sufficiently large numbers of older persons. Although it is reasonable to believe that healthy older patients will do as well in HMO's as younger people, the outcome for the frail elderly is less certain. This population may not do as well in the conservative medical practice environment of HMO's, and decreased hospitalization may have detrimental effects on their health. On the other hand, this population may benefit from the improved continuity of care and potential for comprehensive assessment in HMO's. The quality of care received by the frail elderly will be an important test of the success of Medicare capitation.

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PubMed1986

Differential prognosis and utilization patterns among clinical subgroups of hospitalized geriatric patients.

While screening elderly inpatients on acute Veterans Administration (VA) hospital wards for a special geriatric program, we prospectively classified all patients age 65 and over, who had been hospitalized at least a week, into five clinical subgroups using specific diagnostic, prognostic, and functional criteria. These five subgroups were "geriatric evaluation unit (GEU) candidate", "severely demented", "medical", "terminal", and "independent". Medical record data from the initial admission and a full year of follow-up were collected from random samples of each subgroup and of nonscreened patients who had been hospitalized for less than a week. Analysis revealed that each subgroup had a distinctive pattern of survival, living location, and use of institutional services during the follow-up period. For one major subgroup ("GEU candidate"), a specific intervention (the GEU) has proved very effective in reducing mortality, increasing patient functioning, improving placement, and decreasing use of institutional services. Moreover, there are specific treatment and intervention strategies appropriate for each of the other subgroups (e.g., hospital-based home care, hospice, respite, and day treatment programs), although these services are not universally available nor clearly proved effective. The process of identifying patient subgroups illustrated in this study may be useful in needs assessment, in planning new intervention programs for frail elderly patients, and for identifying appropriate patients for these programs.

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PubMed1986

Geriatric assessment programs in the United States. Their growing role and impact.

Geriatric assessment programs have become a growing component of the health care delivery system for the elderly in the United States. They generally provide interdisciplinary assessment, treatment planning, case management, and often rehabilitation for frail elderly persons and are especially important for persons suspected of needing long-term institutional care. Their development here stems from long experience with geriatric assessment in the United Kingdom and increasing evidence of their effectiveness in North American settings. Among their demonstrated benefits are better diagnostic accuracy and treatment planning, more appropriate placement decisions with less referral to nursing homes, and improved patient functional status, general well-being, and survival. This article provides, in addition to an overview of geriatric assessment programs and their effectiveness, practical guidelines for their establishment in the hospital setting.

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PubMed1984

Effectiveness of a geriatric evaluation unit. A randomized clinical trial.

We randomly assigned frail elderly inpatients with a high probability of nursing-home placement to an innovative geriatric evaluation unit intended to provide improved diagnostic assessment, therapy, rehabilitation, and placement. Patients randomly assigned to the experimental (n = 63) and control (n = 60) groups were equivalent at entry. At one year, patients who had been assigned to the geriatric unit had much lower mortality than controls (23.8 vs. 48.3 per cent, P less than 0.005) and were less likely to have initially been discharged to a nursing home (12.7 vs. 30.0 per cent, P less than 0.05) or to have spent any time in nursing home during the follow-up period (26.9 vs. 46.7 per cent, P less than 0.05). The control-group patients had substantially more acute-care hospital days, nursing-home days, and acute-care hospital readmissions. Patients in the geriatric unit were significantly more likely to have improvement in functional status and morale than controls (P less than 0.05). Direct costs for institutional care were lower for the experimental group, especially after adjustment for survival. We conclude that geriatric evaluation units can provide substantial benefits at minimal cost for appropriate groups of elderly patients, over and above the benefits of traditional hospital approaches.

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PubMed1984

Systematic biases in functional status assessment of elderly adults: effects of different data sources.

Measuring functional status using specific instruments is an important part of geriatric assessment. These instruments, however, often rely on data sources different from those with which they were originally validated. To study possible biasing effects of different data sources on functional status scores, we examined scores for two widely used instruments (the Lawton Personal Self-Maintenance Scale, PSMS, and Instrumental Activities of Daily Living, IADL, Scale) on a group of hospitalized elderly (n = 61) using three different data sources (the patients themselves, the patients' nurses, and significant others). Analysis showed that PSMS scores derived from patients were significantly higher than scores derived from significant others (p less than .025) and that patient-derived IADL scores were significantly higher than both nurse-derived scores (p less than .001) and significant-other-derived scores (p less than .001). We also compared scores for a group of nursing home patients (n = 68) on the Katz Activities of Daily Living (ADL) Scale, using data obtained from patients and their nurses. Again, the patient-derived scores were significantly higher than those from nurses (p less than .001). We conclude that data sources for determining patient functional ability are not interchangeable and that patients may overstate their functional abilities, whereas significant others may understate them, relative to judgments of skilled nursing personnel.

Activities of Daily Living↗
PubMed1984

The Sepulveda VA Geriatric Evaluation Unit: data on four-year outcomes and predictors of improved patient outcomes.

Data from its first four operating years indicate that the Sepulveda VA Geriatric Evaluation Unit is having consistent beneficial effects on patient care. These benefits include improved diagnostic accuracy, reduced use of drugs, improved functional status, and improved placement location. However, not all patients benefit equally, and differences between patient responses highlight the need to select those who will benefit most from relatively costly Geriatric Evaluation Unit services. Discriminant and regression analyses were performed on 98 consecutive patients to determine which patients admitted to the Geriatric Evaluation Unit would show greatest improvement in terms of placement, functional status, one-year survival, and living location, and which patients would be treated most efficiently in terms of length of stay. Patient characteristics on admission significantly associated with discharge home included a relatively high functional and cognitive status, the absence of an unstable medical problem, and not being expected to need nursing home placement by the referring physician. The latter two factors alone predicted actual placement location on the next 101 patients admitted to the Geriatric Evaluation Unit with high predictive accuracy (88.5 per cent). Factors predictive of patients whose functional status would improve on the Geriatric Evaluation Unit included absence of an unstable medical problem and being over 75 years old (predictive accuracy was 82.5 per cent). Two major factors associated with long patient stays on the Geriatric Evaluation Unit were low functional status scores and not living in own home or with family. These analyses indicate criteria that may be useful in selecting patients for inpatient geriatric evaluation and rehabilitation programs.

Activities of Daily Living↗
PubMed1984

Postural hypotension in the elderly.

Postural hypotension is a common and important clinical disorder in the elderly population. The pathogenesis is multifactorial but is probably often due to changes in the autonomic nervous system, as well as to age-related changes in the cardiovascular and endocrine systems. In addition, the presence of multiple diseases and medications are common contributing factors. Standardized measurement of postural blood pressure and recording of heart rate and assessment of associated symptoms are essential for the clinical diagnosis. Evaluation and management depend on an initial thorough clinical review of problems. Usually elimination of offending medications and treatment of contributing medical disorders are adequate. Occasionally, use of volume expanders and newer experimental agents is indicated. Postural hypotension can be seen as a prototypical clinical disorder of the elderly. It reflects impaired homeostasis; its etiology is multifactorial and due to the effects of both age and disease; it is clinically protean; and it can result in falls, injury, and progressive decline if not recognized and treated early.

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