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Biomedical subjects

R L Kane

Publications and source records attributed to R L Kane.

At least 55 records · Page 3Linked to original sources
PubMed1999

Innovative healthcare for chronically ill older persons: results of a national survey.

OBJECTIVE: To describe the origin, scope, operations, funding, and outcomes of innovative healthcare programs for chronically ill older persons. STUDY DESIGN: Cross-sectional survey. METHODS: A national expert panel nominated chronic illness programs they believed to be innovative and field tested. The directors of the 31 eligible programs provided descriptive information in 60-minute semistructured telephone interviews. RESULTS: The innovative programs we surveyed tended to target their services to high-risk patients, use teams of providers to deliver care, designate providers to coordinate multiple components of complex care plans, and shift care from higher- to lower-cost environments and/or redesign the delivery of primary care. CONCLUSIONS: Recent innovations in healthcare programs hold considerable promise for improving the outcomes of chronic care, but most have yet to be rigorously evaluated.

Aged↗
PubMed1999

Neuropsychological correlates of domestic violence.

Neuropsychological functioning was assessed in 39 males who had committed domestic violence (batterers) and compared to 63 nonviolent (both maritally discordant and satisfied) subjects recruited by advertisement. Subjects were subsequently divided into two groups (head injured, nonhead injured) and these groups were also contrasted as a function of batterer status. Tests were administered to assess for cognitive and behavioral functions, including executive dysfunction, hypothesized to be a factor contributing to propensity for violence. Questionnaires and structured clinical interviews were used to assess marital discord, emotional distress, and violent behaviors. Batterers differed from nonbatterers across several cognitive domains: executive, learning, memory, and verbal functioning. Batterers were reliably discriminated from nonbatterers based on three neuropsychological tasks: Digit Symbol, Recognition Memory Test-Words, Wisconsin Card Sorting Test. Neuropsychological performance was the strongest correlate of domestic violence of all clinical variables measured. However, the inclusion of two other variables, severity of emotional distress and history of head injury, together with the neuropsychological indices provided the strongest correlation with batterers status. Among batterers, neuropsychological performance did not vary as a function of head injury status, indicating that while prior head injury was correlated with batterer status, it was not the sole basis for their impairments. The findings suggest that current cognitive status, prior brain injury, childhood academic problems, as well as psychosocial influences, contribute along with coexisting emotional distress to a propensity for domestic violence.

Achievement↗
PubMed1998

Differences in valuation of functional status components among consumers and professionals in Europe and the United States.

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor-patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

Activities of Daily Living↗
PubMed1998

Outpatient geriatric evaluation and management.

OBJECTIVE: To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high-risk, community-dwelling older adults. PARTICIPANTS: Community-dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (P(ra) > .40) in the future (n = 248). INTERVENTION: Outpatient GEM. MEASUREMENTS: Demographic, clinical, and use-of-hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians. RESULTS: At enrollment, the average patient was 78.7 years old, took 5.0 long-term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated. CONCLUSIONS: This model of outpatient GEM provided 6 months of targeted intensive care at a reasonable cost. The satisfaction ratings of patients and their primary physicians were high.

Activities of Daily Living↗
PubMed1998

Functional outcomes of posthospital care for stroke and hip fracture patients under medicare.

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

Activities of Daily Living↗
PubMed1998

Managed care as a vehicle for delivering more effective chronic care for older persons.

Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition.

Aged↗
PubMed1998

The relationship between nursing staffing levels and nursing home outcomes.

This study examined the effects of selected Minnesota nursing home attributes (size, ownership, noncompliance with a state correction order, and licensed and nonlicensed nursing hours) on specific outcomes (functional ability, discharge home, and death) for residents ages 65 and older, controlling for residents' age and previous functional ability. The functional outcome was operationalized by calculating the resident's Total Dependence Score (TDS), the total score on the assessment of eight activities of daily living (score range: 0-33). Ordinary least squares regression analysis was used to estimate the effects of facility attributes, admission TDS, and age on resident outcomes, and nonlinear probability analyses were used to estimate the effects of facility attributes, admission TDS, and age on the probability of death or discharge home. In the year after admission, licensed (but not nonlicensed) nursing homes were significantly related to improved functional ability, increased probability of discharge home, and decreased probability of death, but when limited to chronic residents, the role of professional nursing hours virtually disappears. Overall, the findings support greater use of licensed nurses in the nursing home setting.

Activities of Daily Living↗
PubMed1998

Variation in state spending for long-term care: factors associated with more balanced systems.

Pressures to turn over responsibility for long-term care to the states will exacerbate the already sizable difference in such efforts. This article describes the nature of the interstate variation in the types and amounts of long-term care provided under Medicaid. The average Medicaid long-term care expenditure on persons sixty-five years and older varies from $2,720 in New York to $380 in Arizona. Likewise, payments for home and community-based services (HCBS) vary from $1,180 in New York to $29 in Mississippi. Only a modest portion (28 percent) of the variance in total long-term care expenditures appears to be related to differences in population characteristics, and even less (7 percent) appears to be related to differences in HCBS expenditures. When supply factors (e.g., nursing home beds) are added, the explained variance increases to 52 percent and 17 percent, respectively. Medicare replaces some--but not most--of the difference in Medicaid home and community-based services payments.

Aged↗
PubMed1998

Effects of post-hospital Medicare home health and informal care on patient functional status.

OBJECTIVE: To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures. STUDY SETTING/DATA SOURCES: Consecutive patients enrolled in the study between March 1988 and February 1989 prior to discharge from one of 52 hospitals in three cities. Data sources included patient interviews, medical records, and the Medicare Automated Data Retrieval System (MADRS). ANALYSIS: The effect of the two types of care on patients' subsequent functional status was estimated using a selectivity corrected least squares regression of functional status six weeks post-discharge on hours of informal care, Medicare home health expenditures, and patient prior functional and cognitive status. DATA COLLECTION/EXTRACTION METHODS: Patients were interviewed before hospital discharge and six weeks later. The patient's primary caregiver was interviewed by telephone six weeks post-discharge. Patient data included demographic characteristics, illness severity, cognitive status, functional status at discharge and six weeks later, post-discharge expenditures for Medicare home health, and hours of informal care. PRINCIPAL FINDINGS: More informal care after discharge was associated with greater patient functional impairment six weeks later. The amount of Medicare home health that patients used had a nonsignificant effect on subsequent functional status. CONCLUSIONS: Post-acute home care may maintain the patient at home and compensate for functional limitations, rather than promote restoration of function. Future studies are needed to examine the effects of specific types of care, services, and providers as well as factors that mediate their effects on patient functional outcomes.

Activities of Daily Living↗
PubMed1997

Peer review of the quality of care. Reliability and sources of variability for outcome and process assessments.

CONTEXT: Peer assessments have traditionally been used to judge the quality of care, but a major drawback has been poor interrater reliability. OBJECTIVES: To compare the interrater reliability for outcome and process assessments in a population of frail older adults and to identify systematic sources of variability that contribute to poor reliability. SETTING: Eight sites participating in a managed care program that integrates acute and long-term care for frail older adults. PATIENTS: A total of 313 frail older adults. DESIGN: Retrospective review of the medical record with 180 charts randomly assigned to 2 geriatricians, 2 geriatric nurse practitioners, or 1 geriatrician and 1 geriatric nurse practitioner and 133 charts randomly assigned to either a geriatrician or a geriatric nurse practitioner. MAIN OUTCOME MEASURES: Interrater reliabilities for structured implicit judgments about process and outcomes for overall care and care for each of 8 tracer conditions (eg, arthritis). RESULTS: Outcome measures had higher interrater reliability than process measures. Five outcome measures achieved fair to good reliability (more than 0.40), while none of the process measures achieved reliabilities more than 0.40. Three factors contributed to poorer reliabilities for process measures: (1) an inability of reviewers to differentiate among cases with respect to the quality of management, (2) systematic bias from individual reviewers, and (3) systematic bias related to the professional training of the reviewer (ie, physician or nurse practitioner). CONCLUSIONS: Peer assessments can play an important role in characterizing the quality of care for complex patients with multiple interrelated chronic conditions, but reliability can be poor. Strategies to achieve adequate reliability for these assessments should be applied. These strategies include emphasizing outcomes measurement, providing more structured assessments to identify true differences in patient management, adjusting systematic bias resulting from the individual reviewer and their professional background, and averaging scores from multiple reviewers. Future research on the reliability of peer assessments should focus on improving the ability of process measures to differentiate among cases with respect to the quality of management and on identifying additional sources of systematic bias for both process and outcome measures. Explicit recognition of factors influencing reliability will strengthen efforts to develop sound measures for quality assurance.

Aged↗
PubMed1997

Does scoliosis have a psychological impact and does gender make a difference?

STUDY DESIGN: A population-based case-control study, we identified adolescents with and without scoliosis in Minnesota who were 12 through 18 years of age. Matched control subjects were randomly selected from school children who did not have scoliosis or any other condition. Information on scoliosis was obtained by a self-administered questionnaire, the Adolescent Health Survey. Collected on more than 75,000 school age adolescents, with established validity and reliability, a secondary analysis of adolescents with scoliosis was performed as compared with a normative peer group. OBJECTIVE: To describe and characterize the psychosocial impact of scoliosis on the areas of peer relations, body image, and health-compromising behavior, such as suicidal thought and alcohol consumption. SUMMARY OF BACKGROUND DATA: The impact of adolescent idiopathic scoliosis has not been assessed using generic health status measures appropriate for adolescents. Previous studies have concentrated on the health status of adults by measuring work status, marriage status, and other adult measures. The purpose of this study was to study the health status of patients with adolescent idiopathic scoliosis, using the Adolescent Health Survey, a generic health status measure with established validity and reliability. METHODS: Body image, peer relations, social and high-risk behavior, and comparative health were assessed to determine if scoliosis was an independent risk factor and to determine if scoliosis was associated with these psychosocial issues. RESULTS: Six hundred eighty-five cases of scoliosis were identified from the 34,706 adolescents. The prevalence was 1.97%. Of the 685 adolescents with scoliosis and their control subjects, the adjusted odds ratio for having suicidal thought among adolescent with scoliosis, compared to adolescents without scoliosis, was 1.40 (P value of 0.04) after adjustment for race, gender, socioeconomic status, and age. The adjusted odds ratio for having feelings about poor body development among adolescents with scoliosis was 1.82 (P value 0.001) compared with adolescents without scoliosis after adjustment for race, gender, socioeconomic status, and age. Scoliosis was an independent risk factor for suicidal thought, worry and concern over body development, and peer interactions after adjustment. CONCLUSION: Scoliosis is a significant risk factor for psychosocial issues and health-compromising behavior. Gender differences exist in male and female adolescents with scoliosis.

Adolescent↗
PubMed1997

Variations in the performance of hip fracture procedures.

OBJECTIVES: Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures. METHODS: The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities. RESULTS: The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%; P = 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%; P = 0.0001), and no variation among those with displaced fractures (P = 0.72). Other factors associated with hip replacement are history of hip fracture (P = 0.003) and cerebrovascular disease (P < or = 0.10), APACHE II-APS score (P = 0.09), and impacted fracture (P = 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P > 0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P < 0.001). CONCLUSIONS: Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

APACHE↗
PubMed1997

Improving outcomes in rehabilitation. A call to arms (and legs).

In rehabilitation, assessment of outcomes requires refinement of existing measurement and analysis tools. A suitable taxonomy of outcomes, risk factors, and treatment modalities must be developed to reflect the field's complexity and the multiplicity of care providers. The goal of outcomes studies is to distinguish the effects of treatment from improvement resulting from the natural course of illness. Outcomes researchers must adjust for casemix and be alert to possible selection effects. A common set of outcome measures is needed to measure disability. Those currently in use reflect both nursing home and rehabilitation care. They rely on provider information and measure patients' performance, but they do not record patients' perceptions of important components of outcomes. Current techniques for describing treatment are inadequate. Outcomes assessment must include adjustment for prognostic factors and must be measured against baseline information at the onset of treatment. Although patients' perception of care is recognized as important to outcomes assessment, patients should also play a central role in decision-making about care and in weighting the importance of the various outcomes. In an era of managed care, the major challenge for rehabilitation care is to demonstrate its cost-effectiveness. Clear and precise analysis of the salient issues and a dynamic model of outcomes measurement will facilitate this goal and will permit incorporation of new learning in this field.

Aged↗
PubMed1997

The relationship of patient satisfaction with care and clinical outcomes.

OBJECTIVES: The authors examine the relationship between three dimensions of patient satisfaction (quality of care, hospital care, and physician time) and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status). METHODS: A total of 2,116 patients undergoing cholecystectomy were interviewed before surgery and again at 6 months. The baseline interview addressed health status (general functioning and specific symptoms) and risk factors. The follow-up interview included health status and a series of satisfaction questions. Outcomes included both overall health status and specific symptoms. Potential confounding factors, in addition to baseline status, such as demographics, casemix, and procedure type, were accounted for in the analysis. RESULTS: Each of the outcomes was related significantly to each of the satisfaction scales; however, the relative outcomes were related more strongly to satisfaction than were the absolute versions. Although the regression coefficients were highly significant, none of the outcomes measures accounted for more than 8% of the explained variance in the several satisfaction scores. CONCLUSIONS: Although outcomes and satisfaction are related, more goes into satisfaction than just outcomes. When determining their satisfaction with the care they have received, patients are more likely to focus on their present state of health than to consider the extent of improvement they have enjoyed.

Adult↗
PubMed1997

The substitutability of adult foster care for nursing home care in Oregon.

OBJECTIVES: This study investigates the degree of substitutability of adult foster care for nursing home care in Oregon. METHODS: Using three tests, the authors determined (1) the extent to which an additional adult foster care resident in a county reduces the number of nursing home residents in that county, (2) which characteristics of residents and facilities are important in sorting residents into either nursing homes or adult foster care facilities, and (3) the price elasticity of demand for adult foster care, using the county as the unit of observation. RESULTS: It was found that for every additional foster care resident in a county, a nursing home loses 0.85 residents-almost a one-to-one substitution ratio. CONCLUSIONS: Despite the high degree of substitutability, residents perceive important differences in the characteristics of the two forms of care. Indeed, private residents are, on average, willing to pay twice as much for nursing home care as for adult foster care, suggesting that these differences are important. Finally, private consumers are sensitive to price differences among adult foster care facilities. The implications for policy are discussed.

Adult↗
PubMed1997

Outcomes for older men and women with congestive heart failure.

OBJECTIVES: To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF). DESIGN: Prospective cohort study. PARTICIPANTS: A total of 519 patients, aged > or = 65, who were discharged alive after a hospitalization for CHF (DRG = 127). MEASUREMENTS: Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge. RESULTS: The 205 men were, on average, younger (77 +/- 7 vs 80 +/- 8, P < .001), wealthier (46% vs 21% earned > or = $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values > or = .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0-6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge. CONCLUSIONS: Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).

Activities of Daily Living↗