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Vick JB, Golden BP, Cantrell S, Harris-Gersten ML, Selmanoff MR, Hastings SN, Oyesanya TO, Goldstein KM, Van Houtven C. Family Involvement in the Care of Hospitalized Older Adults: Protocol for a Qualitative Evidence Synthesis. JMIR Res Protoc 2024; 13:e53255. [PMID: 38457771 DOI: 10.2196/53255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Older adults are frequently hospitalized. Family involvement during these hospitalizations is incompletely characterized in the literature. OBJECTIVE This study aimed to better understand how families are involved in the care of hospitalized older adults and develop a conceptual model describing the phenomenon of family involvement in the care of hospitalized older adults. METHODS We describe the protocol of a qualitative evidence synthesis (QES), a systematic review of qualitative studies. We chose to focus on qualitative studies given the complexity and multifaceted nature of family involvement in care, a type of topic best understood through qualitative inquiry. The protocol describes our process of developing a research question and eligibility criteria for inclusion in our QES based on the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) tool. It describes the development of our search strategy, which was used to search MEDLINE (via Ovid), Embase (via Elsevier), PsycINFO (via Ovid), and CINAHL Complete (via EBSCO). Title and abstract screening and full-text screening will occur sequentially. Purposive sampling may be used depending on the volume of studies identified as eligible for inclusion during our screening process. Descriptive data regarding included individual studies will be extracted and summarized in tables. The results from included studies will be synthesized using qualitative methods and used to develop a conceptual model. The conceptual model will be presented to community members via engagement panels for further refinement. RESULTS As of September 2023, we have assembled a multidisciplinary team including physicians, nurses, health services researchers, a librarian, a social worker, and a health economist. We have finalized our search strategy and executed the search, yielding 8862 total citations. We are currently screening titles and abstracts and anticipate that full-text screening, data extraction, quality appraisal, and synthesis will be completed by summer of 2024. Conceptual model development will then take place with community engagement panels. We anticipate submitting our manuscript for publication in the fall of 2024. CONCLUSIONS This paper describes the protocol for a QES of family involvement in the care of hospitalized older adults. We will use identified themes to create a conceptual model to inform further intervention development and policy change. TRIAL REGISTRATION PROSPERO 465617; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023465617. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/53255.
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Affiliation(s)
- Judith B Vick
- Durham VA Health Care System, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- National Clinician Scholars Program, Duke Clinical and Translational Science Institute, Durham, NC, United States
| | - Blair P Golden
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Sarah Cantrell
- Medical Center Library and Archives, Duke University School of Medicine, Durham, NC, United States
| | | | - Mollie R Selmanoff
- Department of Care Management, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Susan Nicole Hastings
- Durham VA Health Care System, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Tolu O Oyesanya
- Duke University School of Nursing, Durham, NC, United States
| | - Karen M Goldstein
- Durham VA Health Care System, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Courtney Van Houtven
- Durham VA Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
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Perfect CR, Lindquist J, Smith VA, Stanwyck C, Seidenfeld J, Van Houtven CH, Hastings SN. Are Geriatrics-Focused Primary Care Clinics Better at Diagnosing Dementia Than Traditional Clinics? A Matched Cohort Study. J Gen Intern Med 2023; 38:2710-2717. [PMID: 36941424 PMCID: PMC10506971 DOI: 10.1007/s11606-023-08136-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/01/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Dementia and mild cognitive impairment (MCI) are prevalent but underdiagnosed. OBJECTIVE To compare new dementia/MCI diagnosis rates in geriatrics-focused primary care clinics and traditional primary care clinics. DESIGN Secondary analysis of a prospective matched cohort study that spanned 2017-2021. PARTICIPANTS Community-dwelling Veterans over 65 receiving primary care in a geriatrics-focused medical home (GeriPACT) or traditional primary care home (PACT) at one of 57 Veterans Affairs sites. We excluded individuals with a documented diagnosis of dementia or MCI in the year prior to enrollment. MAIN MEASURES Diagnoses obtained from EHR. Cognitive status was assessed using modified Telephone Interview for Cognitive Status (mTICS) tool. KEY RESULTS The 470 participants included in this analysis were predominantly white, non-Hispanic males with an average age of 80.3 years. 9.4% of participants received a diagnosis of dementia/MCI after 24 months: 11.5% in GeriPACT and 7.2% in PACT. Adjusted OR for dementia/MCI diagnosis based on GeriPACT exposure was 1.47 (95% CI 0.65-3.29). Low mTICS score (≤ 27) (OR 4.89, 95% CI 2.36-10.13) and marital status (married/partnered) (OR 1.89, CI 0.99-3.59) were independent predictors of dementia/MCI diagnosis. When stratified by cognitive status: diagnosis rates were 20.8% in GeriPACT and 16.7% in PACT among those who scored lower on the cognitive assessment (mTICS ≤ 27); 7.4% in GeriPACT and 3.6% in PACT among those who scored higher (mTICS > 27). The OR for new dementia/MCI diagnosis in GeriPACT was 1.19 (95% CI 0.49-2.91) among those with a low mTICS score and 1.85 (95% CI 0.70-4.88) among those with a higher mTICS score. CONCLUSIONS Observed rates of new dementia/MCI diagnosis were higher in GeriPACT, but with considerable uncertainty around estimates. Geriatrics-focused primary care clinics may be a promising avenue for improving the detection of dementia in older adults, but further larger studies are needed to confirm this relationship.
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Affiliation(s)
- Chelsea R Perfect
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - J Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - V A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of General Internal Medicine, Duke University, Durham, NC, USA
| | - C Stanwyck
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
| | - J Seidenfeld
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Emergency Medicine, Durham VA Health Care System, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - C H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - S N Hastings
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research Education and Clinical Center (GRECC), Durham Veterans Affairs Health Care System, Durham, NC, USA
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Jacobs JC, Bowling CB, Brown T, Smith VA, Decosimo K, Wilson SM, Hastings SN, Shepherd-Banigan M, Allen K, Van Houtven C. Racial inequality in functional trajectories between Black and White U.S. veterans. J Am Geriatr Soc 2023; 71:1081-1092. [PMID: 36519710 PMCID: PMC10089950 DOI: 10.1111/jgs.18169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Racial inequality in functional trajectories has been well documented in the U.S. civilian population but has not been explored among Veterans. Our objectives were to: (1) assess how functional trajectories differed for Black and White Veterans aged ≥50 and (2) explore how socioeconomic, psychosocial, and health-related factors altered the relationship between race and function. METHODS We conducted a prospective, longitudinal analysis using the 2006-2016 Health and Retirement Study. The study cohort included 3700 Veterans who self-identified as Black or White, responded to baseline psychosocial questionnaires, and were community-dwelling on first observation. We used stepwise and stratified linear mixed effects models of biannually assessed functional limitations. The outcome measure was as a count of functional limitations. Race was measured as respondent self-identification as Black or White. Demographic measures included gender and age. Socioeconomic resources included partnership status, education, income, and wealth. Psychosocial stressors included exposure to day-to-day and major discrimination, traumatic life events, stressful life events, and financial strain. Health measures included chronic and mental health diagnoses, smoking, rurality, and use of Veterans Affairs services. RESULTS Black Veterans developed functional limitations at earlier ages and experienced faster functional decline than White Veterans between the ages of 50 and 70, with convergence occurring at age 85. Once we accounted for economic resources and psychosocial stressors in multivariable analyses, the association between race and the number of functional limitations was no longer statistically significant. Lower wealth, greater financial strain, and traumatic life events were significantly associated with functional decline. CONCLUSIONS Health systems should consider how to track Veterans' function earlier in the life course to ensure that Black Veterans are able to get timely access to services that may slow premature functional decline. Providers may benefit from training about the role of economic resources and psychosocial stressors in physical health outcomes.
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Affiliation(s)
- Josephine C Jacobs
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Health Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Christopher Barrett Bowling
- Durham Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Tyson Brown
- Department of Sociology, Duke University, Durham, North Carolina, USA
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kasey Decosimo
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
| | - Sarah M Wilson
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Susan Nicole Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Division of Geriatrics, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Megan Shepherd-Banigan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Kelli Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Division of Rheumatology, Allergy, and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Courtney Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
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Hughes JM, Bartle JT, Choate AL, Mahanna EP, Meyer CL, Tucker MC, Wang V, Allen KD, Van Houtven CH, Hastings SN. Walking All over COVID-19: The Rapid Development of STRIDE in Your Room, an Innovative Approach to Enhance a Hospital-Based Walking Program during the Pandemic. Geriatrics (Basel) 2021; 6:109. [PMID: 34842733 PMCID: PMC8628728 DOI: 10.3390/geriatrics6040109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 11/16/2022] Open
Abstract
Hospitalization is common among older adults. Prolonged time in bed during hospitalization can lead to deconditioning and functional impairments. Our team is currently working with Department of Veterans Affairs (VA) medical centers across the United States to implement STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans), a hospital-based walking program designed to mitigate the risks of immobility during hospitalization. However, the COVID-19 pandemic made in-person, or face-to-face, walking challenging due to social distancing recommendations and infection control concerns. In response, our team applied principles of implementation science, including stakeholder engagement, prototype development and refinement, and rapid dissemination and feedback, to create STRIDE in Your Room (SiYR). Consisting of self-guided exercises, light exercise equipment (e.g., TheraBands, stress ball, foam blocks, pedometer), the SiYR program provided safe alternative activities when face-to-face walking was not available during the pandemic. We describe the methods used in developing the SiYR program; present feedback from participating sites; and share initial implementation experiences, lessons learned, and future directions.
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Affiliation(s)
- Jaime M. Hughes
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
- Section on Gerontology and Geriatric Medicine, Division of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
| | - John T. Bartle
- Physical Medicine & Rehabilitation Service, Durham VA Health Care System, Durham, NC 27705, USA;
| | - Ashley L. Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
| | - Elizabeth P. Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
| | - Cassie L. Meyer
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
| | - Matthew C. Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27705, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC 27705, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27705, USA
| | - Kelli D. Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
- Department of Medicine and Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27705, USA
| | - Courtney H. Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27705, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27705, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC 27705, USA
| | - Susan Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (C.L.M.); (M.C.T.); (V.W.); (K.D.A.); (C.H.V.H.); (S.N.H.)
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27705, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC 27705, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC 27705, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC 27705, USA
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Kuo M, Schroeder R, Barbeito A, Pieper CF, Krishnamoorthy V, Wellman S, Hastings SN, Raghunathan K. Preoperative Care Assessment of Need Scores Are Associated With Postoperative Mortality and Length of Stay in Veterans Undergoing Knee Replacement. Fed Pract 2021; 38:316-324. [PMID: 34733081 DOI: 10.12788/fp.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Care Assessment of Need (CAN) scores predicting 90-day mortality and hospitalization are automatically computed each week for patients receiving care at Veterans Health Administration facilities. While currently used only by primary care teams for care coordination, we explored their value as a perioperative risk stratification tool before major elective surgery. Methods We collected relevant demographic and perioperative data along with perioperative CAN scores for veterans who underwent total knee replacement between July 2014 and December 2015. We examined score distribution, relationships of preoperative CAN 1-year mortality scores with 1-year postoperative mortality and index hospital length of stay (LOS), and patterns of mortality. Results Among 8206 patients, 1-year mortality was 1.4% (110 patients), and CAN scores exhibited near-normal distribution. Median scores among survivors were significantly higher than those of in nonsurvivors (45 vs 75; P < .001). The Kaplan-Meier curves showed an approximately 4-fold higher rate of death at 1 year in the highest tercile for 1-year mortality CAN scores compared with those with lower scores (2.0% vs 0.5% respectively; P < .001). Locally estimated scatterplot smoothing curves revealed a significant and nonlinear increase in hospital LOS across preoperative CAN scores. Conclusions Although designed for ambulatory care use, CAN scores can identify patients at high risk for mortality and extended hospital LOS in an elective surgery population. The CAN scores may prove valuable in supporting informed decision making and preoperative planning in high-risk and vulnerable populations. Further study is needed to confirm the validity of CAN scores and compare them to other more widely used surgical risk calculators.
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Affiliation(s)
- Marissa Kuo
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
| | - Rebecca Schroeder
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
| | - Atilio Barbeito
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
| | - Carl F Pieper
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
| | - Vijay Krishnamoorthy
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
| | - Samuel Wellman
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
| | - Susan Nicole Hastings
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
| | - Karthik Raghunathan
- is a Medical Student at Emory University School of Medicine in Atlanta, Georgia. is a Staff Physician at the Anesthesia Service, Durham Veterans Affairs Health Care System (DVAHCS) in North Carolina and an Associate Professor, Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center (DUMC). is a Staff Physician at the DVAHCS Anesthesia Service and Associate Professor CAPER Unit, DUMC. is an Associate Professor of Biostatistics and Bioinformatics at Duke University Center for Aging and Duke University Department of Medicine and is a Senior Researcher at the Geriatrics Research Education and Clinical Center (GRECC) and Health Services Research and Development, DVAHCS. is an Assistant Professor CAPER Unit DUMC. is Chief, Orthopedic Service, DVAHCS and an Associate Professor, Department of Orthopedic Surgery, Duke University Health System (DUHS). is a Senior Researcher Duke University Center for Aging and Duke University Department of Medicine and is Director of the Center of Innovation to Accelerate Discovery and Practice Transformation; Senior Researcher GRECC and Health Services Research and Development, DVAHCS, and Professor, Department of Medicine and Department of Population Health DUHS. is a Staff Physician Anesthesia Service, DVAHCS and an Associate Professor with Tenure, and Codirector CAPER Unit, Department of Anesthesiology, DUMC
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Boucher NA, Zullig LL, Shepherd-Banigan M, Decosimo KP, Dadolf J, Choate A, Mahanna EP, Sperber NR, Wang V, Allen KA, Hastings SN, Van Houtven CH. Replicating an effective VA program to train and support family caregivers: a hybrid type III effectiveness-implementation design. BMC Health Serv Res 2021; 21:430. [PMID: 33952263 PMCID: PMC8099701 DOI: 10.1186/s12913-021-06448-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 04/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Caring for a growing aging population using existing long-term care resources while simultaneously supporting and educating family caregivers, is a public health challenge. We describe the application of the Replicating Effective Programs (REP) framework, developed by the Centers for Disease Control Prevention and used in public health program implementation, to scale up an evidence-based family caregiver training intervention in the Veterans Affairs (VA) healthcare system. METHODS From 2018 to 2020, clinicians at eight VA medical centers received REP-guided implementation including facilitation, technical assistance, and implementation tools to deliver the training program. The project team used the REP framework to develop activities across four distinct phases - (1) pre-conditions, (2) pre-implementation, (3) implementation, and (4) maintenance and evolution - and systematically tracked implementation facilitators, barriers, and adaptations. RESULTS Within the REP framework, results describe how each medical center adapted implementation approaches to fit local needs. We highlight examples of how sites balanced adaptations and intervention fidelity. CONCLUSIONS The REP framework shows promise for national expansion of the caregiver training intervention, including to non-VA systems of care, because it allows sites to adapt while maintaining intervention fidelity. TRIAL REGISTRATION NCT03474380 . Date registered: March 22, 2018.
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Affiliation(s)
- N A Boucher
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA.
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Durham, NC, 27701, USA.
- Sanford School of Public Policy, Duke University, Durham, NC, 27710, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, 27710, USA.
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, 27710, USA.
| | - L L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Durham, NC, 27701, USA
| | - M Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Durham, NC, 27701, USA
| | - K P Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
| | - J Dadolf
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
| | - A Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
| | - E P Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
| | - N R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Durham, NC, 27701, USA
| | - V Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Durham, NC, 27701, USA
- Department of Medicine, Duke University Medical Center, 300 Morris Street, Durham, NC, 27701, USA
| | - K A Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - S N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, 27710, USA
- Department of Medicine, Duke University Medical Center, 300 Morris Street, Durham, NC, 27701, USA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, 27705, USA
| | - C H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street (Mailcode 152), Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, 27710, USA
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Ramos K, Shepherd-Banigan ME, Stechuchak KM, Coffman C, Oddone EZ, Van Houtven C, Hendrix CC, Mahanna EP, Hastings SN. Psychological distress among medically complex veterans with a recent emergency department visit. Psychol Serv 2021; 19:353-359. [PMID: 33793285 PMCID: PMC8484334 DOI: 10.1037/ser0000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Medical complexity and psychological distress are associated with frequent emergency department (ED) use. Despite this known association, our understanding is limited about which patients are at risk for persistent psychological distress and what patterns of distress emerge over time. A secondary data analysis was used to examine self-reported psychological distress (defined as ≥14 unhealthy days due to poor mental health in the past month) at 30 and 180 days following enrollment in a randomized control trial of 513 medically complex Veterans after a nonpsychiatric ED visit. We used a multivariable ordered logistic regression model to examine the association of a priori factors [baseline psychological distress, age, race, income, health literacy, deficits in activities of daily living (ADL), and deficits in instrumental activities of daily living] with three psychological distress classifications (no/low, intermittent, and persistent). Among 513 Veterans, 40% reported at baseline that they had experienced high psychological distress in the previous month. Older age was associated with lower odds of high psychological distress (OR = 0.95; 95% CI: 0.94-0.97). Baseline factors associated with significantly higher odds of persistent psychological distress at 30 and 180 days assessments, included having the inadequate income (OR = 1.61; 95% CI: 1.02-2.55), having low health literacy (OR = 1.63; 95% CI: 1.01-2.62), and reporting at least one ADL deficit (OR = 1.94; 95% CI: 1.13-3.33). Psychological distress at follow-up was common among medically complex Veterans with a recent ED visit. Future research should explore interventions that integrate distress information into treatment plans and/or link to mental health referral services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Katherine Ramos
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Megan E Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Cynthia Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Courtney Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Cristina C Hendrix
- Geriatric Research, Education, and Clinical Center (GRECC), Durham VA Health Care System
| | - Elizabeth P Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Susan Nicole Hastings
- Geriatric Research, Education, and Clinical Center (GRECC), Durham VA Health Care System
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Van Houtven CH, Smith VA, Sperber NR, Coffman CJ, Hastings SN. Advancing the science of population-based measures of home-time. Healthc (Amst) 2020; 8:100463. [PMID: 32992111 DOI: 10.1016/j.hjdsi.2020.100463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/22/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
The "home time" measure is gaining appeal in evaluating outcomes for multiple patient populations including post-surgery or intervention and the last 6 months of life. Advancing the science of home time measures will require obtaining the perspectives of patients and caregivers to arrive at a population-based measure of quality of life. Additionally, measure development requires considerations of what care settings denote time away from home, observation period, and thresholds that are clinically significant. We explore examples and challenges from current research and our own experience. Being able to advance such measures could also inform payment models and policy design.
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Affiliation(s)
- Courtney Harold Van Houtven
- Durham VA Health Care System, Durham, NC; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA; Duke University, Margolis Center for Health Policy, Durham, NC, USA.
| | - Valerie A Smith
- Durham VA Health Care System, Durham, NC; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA; Duke University School of Medicine, Department of Medicine, Division of General Internal Medicine, Durham, NC, USA
| | - Nina R Sperber
- Durham VA Health Care System, Durham, NC; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA
| | - Cynthia J Coffman
- Durham VA Health Care System, Durham, NC; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, NC, USA
| | - Susan Nicole Hastings
- Durham VA Health Care System, Durham, NC; 508 Fulton Street (152), Durham, NC, 27705, USA; Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA; Duke University School of Medicine, Department of Medicine, Division of Geriatrics, Durham, NC, USA; Duke University School of Medicine, Center for the Study of Aging, Durham, NC, USA
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Van Houtven CH, Smith VA, Lindquist JH, Chapman JG, Hendrix C, Hastings SN, Oddone EZ, King HA, Shepherd-Banigan M, Weinberger M. Family Caregiver Skills Training to Improve Experiences of Care: a Randomized Clinical Trial. J Gen Intern Med 2019; 34:2114-2122. [PMID: 31388914 PMCID: PMC6816649 DOI: 10.1007/s11606-019-05209-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 04/03/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES), a skills training program for caregivers of persons with functional or cognitive impairments. DESIGN A two-arm RCT. SETTING Single Veterans Affairs Medical Center. PARTICIPANTS Patients and their primary caregivers referred in the past 6 months to home and community-based services or geriatrics clinic. INTERVENTION All caregivers received usual care. Caregivers in HI-FIVES also received five training calls and four group training sessions. MAIN MEASURES Cumulative patient days at home 12 months post-randomization, defined as days not in an emergency department, inpatient hospital, or post-acute facility. Secondary outcomes included patients' total VA health care costs, caregiver and patient rating of the patient's experience of VA health care, and caregiver depressive symptoms. RESULTS Of 241 dyads, caregivers' (patients') mean age was 61 (73) years, 54% (53%) Black and 89% (4%) female. HI-FIVES was associated with a not statistically significant 9% increase in the rate of days at home (95% CI 0.72, 1.65; mean difference 1 day over 12 months). No significant differences were observed in health care costs or caregiver depressive symptoms. Model-estimated mean baseline patient experience of VA care (scale of 0-10) was 8.43 (95% CI 8.16, 8.70); the modeled mean difference between HI-FIVES and controls at 3 months was 0.29 (p = .27), 0.31 (p = 0.26) at 6 months, and 0.48 (p = 0.03) at 12 months. For caregivers, it was 8.34 (95% CI 8.10, 8.57); the modeled mean difference at 3 months was 0.28 (p = .18), 0.53 (p < .01) at 6 months, and 0.46 (p = 0.054) at 12 months. CONCLUSIONS HI-FIVES did not increase patients' days at home; it showed sustained improvements in caregivers' and patients' experience of VA care at clinically significant levels, nearly 0.5 points. The training holds promise in increasing an important metric of care quality-reported experience with care.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA.
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
| | - Jennifer G Chapman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
| | - Cristina Hendrix
- School of Nursing, Duke University Medical Center, 307 Trent Drive, Box 102400, Durham, NC, 27710, USA
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | - Susan Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1101A McGavran-Greenberg Hall, Campus Box 7411, Chapel Hill, NC, 27599, USA
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Deardorff WJ, Liu PL, Sloane R, Van Houtven C, Pieper CF, Hastings SN, Cohen HJ, Whitson HE. Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults. J Am Geriatr Soc 2019; 67:1617-1624. [PMID: 30924932 PMCID: PMC6684393 DOI: 10.1111/jgs.15891] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To examine the association between self-reported vision impairment (VI), hearing impairment (HI), and dual-sensory impairment (DSI), stratified by dementia status, on hospital admissions, hospice use, and healthcare costs. DESIGN Retrospective analysis. SETTING Medicare Current Beneficiary Survey from 1999 to 2006. PARTICIPANTS Rotating panel of community-dwelling Medicare beneficiaries, aged 65 years and older (N = 24 009). MEASUREMENTS VI and HI were ascertained by self-report. Dementia status was determined by self-report or diagnosis codes in claims data. Primary outcomes included any inpatient admission over a 2-year period, hospice use over a 2-year period, annual Medicare fee-for-service costs, and total healthcare costs (which included information from Medicare claims data and other self-reported payments). RESULTS Self-reported DSI was present in 30.2% (n = 263/871) of participants with dementia and 17.8% (n = 4112/23 138) of participants without dementia. In multivariable logistic regression models, HI, VI, or DSI was generally associated with increased odds of hospitalization and hospice use regardless of dementia status. In a generalized linear model adjusted for demographics, annual total healthcare costs were greater for those with DSI and dementia compared to those with DSI without dementia ($28 875 vs $3340, respectively). Presence of any sensory impairment was generally associated with higher healthcare costs. In a model adjusted for demographics, Medicaid status, and chronic medical conditions, DSI compared with no sensory impairment was associated with a small, but statistically significant, difference in total healthcare spending in those without dementia ($1151 vs $1056; P < .001) but not in those with dementia ($11 303 vs $10 466; P = .395). CONCLUSION Older adults with sensory and cognitive impairments constitute a particularly prevalent and vulnerable population who are at increased risk of hospitalization and contribute to higher healthcare spending. J Am Geriatr Soc 67:1617-1624, 2019.
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Affiliation(s)
| | - Phillip L. Liu
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Richard Sloane
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
| | - Courtney Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Carl F. Pieper
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
| | - Susan Nicole Hastings
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Geriatrics Research Education and Clinical Center, Durham VA Health Care System, Durham, NC
| | - Harvey J. Cohen
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
| | - Heather E. Whitson
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC
- Geriatrics Research Education and Clinical Center, Durham VA Health Care System, Durham, NC
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC
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Van Houtven CH, Smith VA, Stechuchak KM, Shepherd-Banigan M, Hastings SN, Maciejewski ML, Wieland GD, Olsen MK, Miller KEM, Kabat M, Henius J, Campbell-Kotler M, Oddone EZ. Comprehensive Support for Family Caregivers: Impact on Veteran Health Care Utilization and Costs. Med Care Res Rev 2019; 76:89-114. [PMID: 29148338 PMCID: PMC5726944 DOI: 10.1177/1077558717697015] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This study aimed to examine the early impact of the Program of Comprehensive Assistance for Family Caregivers (PCAFC) on Veteran health care utilization and costs. A pre-post cohort design including a nonequivalent control group was used to understand how Veterans' use of Veteran Affairs health care and total health care costs changed in 6-month intervals up to 3 years after PCAFC enrollment. The control group was an inverse probability of treatment weighted sample of Veterans whose caregivers applied for, but were not accepted into, PCAFC. Veterans in PCAFC had similar acute care utilization postenrollment when compared with those in the control group, but significantly greater primary, specialty, and mental health outpatient care use at least 30, and up to 36, months postenrollment. Estimated total health care costs for PCAFC Veterans were $1,500 to $3,400 higher per 6-month interval than for control group Veterans. PCAFC may have increased Veterans' access to care.
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Affiliation(s)
| | - Valerie A. Smith
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | | | | | - Susan Nicole Hastings
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
- Duke University, Durham, NC, USA
| | - Matthew L. Maciejewski
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | | | - Maren K. Olsen
- Durham VA Medical Center, Durham, NC, USA
- Duke University, Durham, NC, USA
| | | | | | | | | | - Eugene Z. Oddone
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
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Shepherd-Banigan M, Smith VA, Maciejewski ML, Stechuchak KM, Hastings SN, Wieland GD, Miller KEM, Kabat M, Henius J, Campbell-Kotler M, Van Houtven CH. The Effect of Support and Training for Family Members on Access to Outpatient Services for Veterans with Posttraumatic Stress Disorder (PTSD). Adm Policy Ment Health 2018; 45:550-564. [PMID: 29374821 PMCID: PMC6688617 DOI: 10.1007/s10488-017-0844-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides landmark support for family caregivers of post-9/11 veterans. This study examines PCAFC support for veterans with and without PTSD and assesses whether program effect differs by PTSD status using a pre-post, non-equivalent, propensity score weighted comparison group design (n = 24,280). Veterans with and without PTSD in PCAFC accessed more mental health, primary, and specialty care services than weighted comparisons. PCAFC participation had stronger effects on access to primary care for veterans with PTSD than for veterans without PTSD. For veterans with PTSD, PCAFC support might enhance health service use.
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Affiliation(s)
- Megan Shepherd-Banigan
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA.
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA.
| | - Valerie A Smith
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Matthew L Maciejewski
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
| | - Susan Nicole Hastings
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - G Darryl Wieland
- Social Sciences Research Institute, Duke University, Durham, NC, USA
| | - Katherine E M Miller
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
| | - Margaret Kabat
- Caregiver Support Program, VA Central Office, Washington, DC, USA
| | - Jennifer Henius
- Caregiver Support Program, VA Central Office, Washington, DC, USA
| | | | - Courtney Harold Van Houtven
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
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13
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Shepherd-Banigan M, Smith VA, Stechuchak KM, Miller KEM, Hastings SN, Wieland GD, Olsen MK, Kabat M, Henius J, Campbell-Kotler M, Van Houtven CH. Comprehensive Support for Family Caregivers of Post-9/11 Veterans Increases Veteran Utilization of Long-term Services and Supports: A Propensity Score Analysis. Inquiry 2018; 55:46958018762914. [PMID: 29591540 PMCID: PMC5882048 DOI: 10.1177/0046958018762914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 01/28/2018] [Accepted: 02/07/2018] [Indexed: 11/16/2022]
Abstract
Family caregivers are an important component of the long-term services and supports (LTSS) system. However, caregiving may have negative consequences for caregiver physical and emotional health. Connecting caregivers to formal short-term home- and community-based services (HCBS), through information resources and referrals, might alleviate family caregiver burden and delay nursing home entry for the patient. The aim of this study was to evaluate the early impact of the Program of Comprehensive Assistance for Family Caregivers (PCAFC) (established by P.L. 111-163 for family caregivers of seriously injured post-9/11 Veterans) on Veteran use of LTSS. A two-cohort pre-post design with a nonequivalent comparison group (treated n = 15 650; comparison n = 8339) was used to (1) examine the association between caregiver enrollment in PCAFC and any VA-purchased or VA-provided LTSS use among Veterans and (2) describe program-related trends in HCBS and institutional LTSS use. The comparison group was an inverse-propensity-score weighted sample of Veterans whose caregivers applied for, but were not accepted into, the program. From baseline through 24 months post application, use of any LTSS ranged from 13.1% to 17.8% for Veterans whose caregivers were enrolled in PCAFC versus from 3.8% to 5.3% for Veterans in the comparison group. Participation in PCAFC was associated with a statistically significant increased use of any LTSS from 1 to 24 months post application (over time odds ratios ranged from 2.71 [95% confidence interval: 2.31-3.17] to 4.86 [3.93-6.02]). Support for family caregivers may enhance utilization of LTSS for Veterans with physical, emotional, and/or cognitive conditions.
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Affiliation(s)
| | - Valerie A. Smith
- Durham VA Medical Center, NC, USA
- Duke University, Durham, NC, USA
| | | | | | | | | | - Maren K. Olsen
- Durham VA Medical Center, NC, USA
- Duke University, Durham, NC, USA
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14
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Moss JM, Bryan WE, Wilkerson LM, King HA, Jackson GL, Owenby RK, Van Houtven CH, Stevens MB, Powers J, Vaughan CP, Hung WW, Hwang U, Markland AD, Sloane R, Knaack W, Hastings SN. An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department. J Pharm Pract 2017; 32:167-174. [PMID: 29277130 DOI: 10.1177/0897190017747424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). METHODS This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. RESULTS Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). CONCLUSION Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.
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Affiliation(s)
- Jason M Moss
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,2 Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - William E Bryan
- 3 Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Loren M Wilkerson
- 4 Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Heather A King
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - George L Jackson
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - Ryan K Owenby
- 3 Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney H Van Houtven
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - Melissa B Stevens
- 7 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA.,8 Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - James Powers
- 9 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, TN, USA.,10 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Camille P Vaughan
- 7 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA.,8 Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - William W Hung
- 11 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA.,12 Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Ula Hwang
- 11 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA.,12 Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | | | - Richard Sloane
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,14 Department of Duke Aging Center, Duke University Medical Center, Durham, NC, USA
| | - William Knaack
- 15 Division of General Internal Medicine, Veterans Affairs Health Care System, Durham, NC, USA
| | - Susan Nicole Hastings
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
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15
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Duan-Porter W, Van Houtven CH, Mahanna EP, Chapman JG, Stechuchak KM, Coffman CJ, Hastings SN. Internet Use and Technology-Related Attitudes of Veterans and Informal Caregivers of Veterans. Telemed J E Health 2017; 24:471-480. [PMID: 29252110 DOI: 10.1089/tmj.2017.0015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Healthcare systems are interested in technology-enhanced interventions to improve patient access and outcomes. However, there is uncertainty about feasibility and acceptability for groups who may benefit but are at risk for disparities in technology use. Thus, we sought to describe characteristics of Internet use and technology-related attitudes for two such groups: (1) Veterans with multi-morbidity and high acute care utilization and (2) informal caregivers of Veterans with substantial care needs at home. MATERIALS AND METHODS We used survey data from two ongoing trials, for 423 Veteran and 169 caregiver participants, respectively. Questions examined Internet use in the past year, willingness to communicate via videoconferencing, and comfort with new technology devices. RESULTS Most participants used Internet in the past year (81% of Veterans, 82% of caregivers); the majority of users (83% of Veterans, 92% of caregivers) accessed Internet at least a few times a week, and used a private laptop or computer (81% of Veterans, 89% of caregivers). Most were willing to use videoconferencing via private devices (77-83%). A majority of participants were comfortable attempting to use new devices with in-person assistance (80% of Veterans, 85% of caregivers), whereas lower proportions were comfortable "on your own" (58-59% for Veterans and caregivers). Internet use was associated with comfort with new technology devices (odds ratio 2.76, 95% confidence interval 1.70-4.53). CONCLUSIONS Findings suggest that technology-enhanced healthcare interventions are feasible and acceptable for Veterans with multi-morbidity and high healthcare utilization, and informal caregivers of Veterans. In-person assistance may be important for those with no recent Internet use.
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Affiliation(s)
- Wei Duan-Porter
- 1 Center for Chronic Disease Outcomes Research and Section of General Internal Medicine , Minneapolis VA Health Care System, Minneapolis, Minnesota.,2 Department of Medicine, University of Minnesota , Minneapolis, Minnesota
| | - Courtney H Van Houtven
- 3 Center for Health Services Research in Primary Care , Durham VA Health Care System, Durham, North Carolina.,4 Department of Medicine, Duke University School of Medicine , Durham, North Carolina.,5 Center for the Study of Aging and Human Development, Duke University , Durham, North Carolina
| | - Elizabeth P Mahanna
- 3 Center for Health Services Research in Primary Care , Durham VA Health Care System, Durham, North Carolina
| | - Jennifer G Chapman
- 3 Center for Health Services Research in Primary Care , Durham VA Health Care System, Durham, North Carolina
| | - Karen M Stechuchak
- 3 Center for Health Services Research in Primary Care , Durham VA Health Care System, Durham, North Carolina
| | - Cynthia J Coffman
- 3 Center for Health Services Research in Primary Care , Durham VA Health Care System, Durham, North Carolina.,6 Department of Biostatistics and Bioinformatics, Duke University Medical Center , Durham, North Carolina
| | - Susan Nicole Hastings
- 3 Center for Health Services Research in Primary Care , Durham VA Health Care System, Durham, North Carolina.,4 Department of Medicine, Duke University School of Medicine , Durham, North Carolina.,5 Center for the Study of Aging and Human Development, Duke University , Durham, North Carolina.,7 Geriatrics Research, Education and Clinical Center , Durham VA Health Care System, Durham, North Carolina
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16
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Miller KEM, Duan-Porter W, Stechuchak KM, Mahanna E, Coffman CJ, Weinberger M, Van Houtven CH, Oddone EZ, Morris K, Schmader KE, Hendrix CC, Kessler C, Hastings SN. Risk stratification for return emergency department visits among high-risk patients. Am J Manag Care 2017; 23:e275-e279. [PMID: 29087151 PMCID: PMC6415920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare 2 methods of identifying patients at high-risk of repeat emergency department (ED) use: high Care Assessment Need (CAN) score (≥90), derived from a model using Veterans Health Administration (VHA) data, and "Super User" status, defined as more than 3 ED visits within 6 months of the index ED visit. STUDY DESIGN Retrospective cohort study. METHODS Using McNemar's test, we compared rates of high-risk classification between CAN score and Super User status. We examined differences in patient characteristics and healthcare utilization across 4 levels of risk classification: high CAN and Super User status (n = 198), CAN <90 and non-Super User (n = 622), high CAN and non-Super User (n = 616), or Super User and CAN score <90 (n = 106). We used logistic regression to identify associations between risk classification and any ED visit within 90 days. RESULTS Of 1542 veterans, 52.8% (n = 814) had a CAN score ≥90 and 19.7% (n = 304) were Super Users (P <.0001), indicating discrepant rates of high-risk classification. However, we found no differences in patient characteristics. Rates of subsequent ED use were high: 63.1% of patients had 1 or more ED visits. No levels of risk classification were associated with subsequent ED use within 90 days (P = .25). CONCLUSIONS Among the VHA users with multimorbidity and 3 or more prior ED visits or hospitalizations, subsequent ED use was high. Although CAN scores have demonstrated utility for predicting hospitalizations and deaths, prior utilization and multimorbidity without further risk classification identified a high-risk group for repeat ED use.
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Duan-Porter W, Hastings SN, Neelon B, Van Houtven CH. Control beliefs and risk for 4-year mortality in older adults: a prospective cohort study. BMC Geriatr 2017; 17:13. [PMID: 28077089 PMCID: PMC5225633 DOI: 10.1186/s12877-016-0390-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Control beliefs are important psychological factors that likely contribute to heterogeneity in health outcomes for older adults. We evaluated whether control beliefs are associated with risk for 4-year mortality, after accounting for established "classic" biomedical risk factors. We also determined if an enhanced risk model with control beliefs improved identification of individuals with low vs. high mortality risk. METHODS We used nationally representative data from the Health and Retirement Study (2006-2012) for adults 50 years or older in 2006 (n = 7313) or 2008 (n = 6301). We assessed baseline perceived global control (measured as 2 dimensions-"constraints" and "mastery"), and health-specific control. We also obtained baseline data for 12 established biomedical risk factors of 4-year mortality: age, sex, 4 medical conditions (diabetes mellitus, cancer, lung disease and heart failure), body mass index less than 25 kg/m2, smoking, and 4 functional difficulties (with bathing, managing finances, walking several blocks and pushing or pulling heavy objects). Deaths within 4 years of follow-up were determined through interviews with respondents' family and the National Death Index. RESULTS After accounting for classic biomedical risk factors, perceived constraints were significantly associated with higher mortality risk (third quartile scores odds ratio [OR] 1.37, 95% CI 1.03-1.81; fourth quartile scores OR 1.45, 95% CI, 1.09-1.92), while health-specific control was significantly associated with lower risk (OR 0.69-0.78 for scores above first quartile). Higher perceived mastery scores were not consistently associated with decreased risk. The enhanced model with control beliefs found an additional 3.5% of participants (n = 222) with low predicted risk of 4-year mortality (i.e., 4% or less); observed mortality for these individuals was 1.8% during follow-up. Compared with participants predicted to have low mortality risk only by the classic biomedical model, individuals identified by only the enhanced model were older, had higher educational status, higher income, and higher prevalence of diabetes mellitus and cancer. CONCLUSION Control beliefs were significantly associated with risk for 4-year mortality; accounting for these factors improved identification of low-risk individuals. More work is needed to determine how assessment of control beliefs could enable targeting of clinical interventions to support at-risk older adults.
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Affiliation(s)
- Wei Duan-Porter
- Minneapolis VA Health Services Research and Development, One Veterans Dr, Minneapolis, MN 55417 USA
| | - Susan Nicole Hastings
- Durham VA Health Services Research and Development, Durham, NC USA
- Durham VA Geriatrics Resarch, Education, and Clinical Center, Durham, NC USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC USA
- Duke University Center for the Study of Aging and Human Development, Durham, NC USA
| | - Brian Neelon
- Department of Public Health Sciences,Medical University of South Carolina, Charleston, SC USA
| | - Courtney Harold Van Houtven
- Durham VA Geriatrics Resarch, Education, and Clinical Center, Durham, NC USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC USA
- Duke University Center for the Study of Aging and Human Development, Durham, NC USA
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18
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Moss JM, Bryan WE, Wilkerson LM, Jackson GL, Owenby RK, Van Houtven C, Stevens MB, Powers JS, Vaughan CP, Hung WW, Hwang U, Markland AD, McGwin G, Hastings SN. Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department. J Manag Care Spec Pharm 2016; 22:74-80. [PMID: 27015054 PMCID: PMC10397930 DOI: 10.18553/jmcp.2016.22.1.74] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population. OBJECTIVES To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative. METHODS Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time. RESULTS At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period. CONCLUSIONS This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.
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Stevens MB, Hastings SN, Powers J, Vandenberg AE, Echt KV, Bryan WE, Peggs K, Markland AD, Hwang U, Hung WW, Schmidt AJ, McGwin G, Ikpe-Ekpo E, Clevenger C, Johnson TM, Vaughan CP. Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel. J Am Geriatr Soc 2015; 63:1025-9. [DOI: 10.1111/jgs.13404] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Melissa B. Stevens
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
| | - Susan Nicole Hastings
- Department of Veterans Affairs Geriatric Research, Education, and Clinical Center; Durham North Carolina
- Health Services Research and Development Center; Durham North Carolina
- Durham Veterans Affairs Medical Center; Durham North Carolina
- Department of Medicine; Duke University; Durham North Carolina
| | - James Powers
- Department of Veterans Affairs Geriatric Research, Education, and Clinical Center; Nashville Tennessee
- Tennessee Valley Veterans Affairs Health System; Nashville Tennessee
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| | | | - Katharina V. Echt
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
| | | | - Kiffany Peggs
- Tennessee Valley Veterans Affairs Health System; Nashville Tennessee
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| | - Alayne D. Markland
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Department of Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Ula Hwang
- Department of Veterans Affairs, Geriatric Research, Education, and Clinical Center; Bronx New York
- Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York New York
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - William W. Hung
- Department of Veterans Affairs, Geriatric Research, Education, and Clinical Center; Bronx New York
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | | | - Gerald McGwin
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Department of Epidemiology; University of Alabama at Birmingham; Birmingham Alabama
| | - Edidiong Ikpe-Ekpo
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Emergency Medicine; Emory University; Atlanta Georgia
| | - Carolyn Clevenger
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- School of Nursing; Emory University; Atlanta Georgia
| | - Theodore M. Johnson
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
| | - Camille P. Vaughan
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
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20
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Hastings SN, Betts E, Schmader KE, Weinberger M, Van Houtven CH, Hendrix CC, Coffman CJ, Stechuchak KM, Weiner M, Morris K, Kessler C, Oddone EZ. Discharge information and support for veterans Receiving Outpatient Care in the Emergency Department: study design and methods. Contemp Clin Trials 2014; 39:342-50. [PMID: 25445314 DOI: 10.1016/j.cct.2014.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/24/2014] [Accepted: 10/26/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND An explicit goal of Patient Aligned Care Teams (PACTs) within the Veterans Health Administration is to promote continuity of care in primary care clinics and thereby reduce Emergency Department (ED) utilization; however, there has been little research to guide PACTs on how to accomplish this. OBJECTIVES The overall goal of this study is to examine the impact of a primary care-based nurse telephone support program [DISPO ED] on Veterans treated and released from the ED who are at high risk for repeat visits. METHODS This study is a two group randomized, controlled trial to evaluate DISPO ED for Veterans treated and released from the ED who are at high risk for repeat visits. We define high risk as those who have had an ED visit or hospitalization during the 6 month period before the index ED visit and have ≥2 chronic conditions. Veterans are randomized to nurse telephone support or usual care. The primary outcome is repeat ED use within 30 days; secondary outcomes are patient satisfaction with care and total costs. DISCUSSION The results of this randomized, controlled trial with an Effectiveness-Implementation Type I Hybrid design will be directly relevant to the care of more than 500,000 high risk patients seen in Veterans' Affairs Medical Center (VAMC) EDs annually. Results will also be informative to health systems outside VA aiming to reduce ED use through accountable care organizations.
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Affiliation(s)
- Susan Nicole Hastings
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA.
| | - Elizabeth Betts
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Kenneth E Schmader
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Morris Weinberger
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney Harold Van Houtven
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Cristina C Hendrix
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA; Duke University School of Nursing, Durham, NC, USA
| | - Cynthia J Coffman
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Madeline Weiner
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Katina Morris
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Chad Kessler
- Ambulatory Care Service, Durham VA Medical Center, Durham, NC, USA
| | - Eugene Z Oddone
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA
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21
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Hendrix C, Tepfer S, Forest S, Ziegler K, Fox V, Stein J, McConnell ES, Hastings SN, Schmader K, Colon-Emeric C. Transitional Care Partners: a hospital-to-home support for older adults and their caregivers. J Am Assoc Nurse Pract 2013; 25:407-414. [PMID: 24170636 DOI: 10.1111/j.1745-7599.2012.00803.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the development, implementation, and preliminary results of the Transitional Care (TLC) Partners, a clinical demonstration program that supports the transition from hospital to home of older veterans. DATA SOURCES Hospital records of TLC patients to track their hospital and emergency department visits before and after the TLC Partners enrollment. Caregivers of patients completed Preparedness in Caregiving and the Short Form Zarit Burden Scale during the first week of the TLC Partners enrollment and on the week when the services ended. CONCLUSIONS The proportion of patients with one or more emergency department visits and rehospitalization is consistently lower among TLC patients compared to non-TLC patients at 30 and 60 days of hospital discharge. The mean preparedness and burden scores before and after the program essentially remained the same. IMPLICATIONS FOR PRACTICE The description of the implementation of the TLC Partners offers an example of how nurse practitioner-led interprofessional care models can be adapted to the needs of specific healthcare systems, and how they can be monitored to evaluate their reach, effectiveness, and fidelity to the core components of proved care models.
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Affiliation(s)
- Cristina Hendrix
- (Nurse Investigator), (Social Worker), (Physician), Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina (Nurse Investigator), Duke University School of Nursing, Durham, North Carolina (Nurse Investigator), (Physician), Duke University Center for the Study of Aging and Human Development, Durham, North Carolina (Nurse Practitioner), (Occupational Therapist), (Physician), Ambulatory Care, Veterans Affairs Medical Center, Durham, North Carolina (Physician), Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina (Physician), Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
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22
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Hastings SN, Smith VA, Weinberger M, Oddone EZ, Olsen MK, Schmader KE. Health services use of older veterans treated and released from veterans affairs medical center emergency departments. J Am Geriatr Soc 2013; 61:1515-21. [PMID: 24004193 DOI: 10.1111/jgs.12417] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine predictors of repeat health service use in older veterans treated and released from the emergency department (ED). DESIGN Retrospective cohort study. SETTING Veterans Affairs Medical Center (VAMC) EDs. PARTICIPANTS Nationally representative sample of veterans aged 65 and older treated and released from one of 102 VAMC EDs between October 1, 2007, and June 30, 2008. MEASUREMENTS Logistic regression models were used to examine the association between independent variables and primary outcomes (30-day repeat ED visits and hospital admissions). RESULTS In 31,206 older veterans, ED diagnoses were commonly related to chronic conditions (22.5%), injuries and acute musculoskeletal conditions (19%), and infections (13.5%). Within 30 days, 22% of older veterans had returned to the ED (n = 4,779) or been hospitalized (n = 2,005). In adjusted models, factors associated with greater odds of repeat ED visits than injury were homelessness (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.1), previous ED visits (OR = 1.7, 95% CI = 1.6-1.8), previous hospitalization (OR = 1.3, 95% CI = 1.2-1.4), and index ED visit related to infection (1.2, 95% CI = 1.1-1.3). Odds of subsequent hospital admission were higher in veterans with previous hospitalization (OR = 2.5, 95% CI = 2.2-2.8), who were homeless (OR = 1.5, 95% CI = 1.1-2.0), who had aid and attendance benefits (OR = 1.5, 95% CI = 1.2-1.8), who were unmarried (OR = 1.2, 95% CI = 1.1-1.3), and who had an ED visit related to a chronic condition (OR = 1.4, 95% CI = 1.2-1.6) than in those with injury. CONCLUSION A substantial proportion of older veterans treated and released from a VAMC ED returned to the ED or were hospitalized within 30 days. Intervening with high-risk older veterans after an ED visit may reduce unscheduled healthcare use.
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Affiliation(s)
- Susan Nicole Hastings
- Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina; Geriatrics Research, Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina; Division of Geriatrics, Department of Medicine, Duke University, Durham, North Carolina; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
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Martins SB, Lai S, Tu S, Shankar R, Hastings SN, Hoffman BB, Dipilla N, Goldstein MK. Offline testing of the ATHENA Hypertension decision support system knowledge base to improve the accuracy of recommendations. AMIA Annu Symp Proc 2006; 2006:539-43. [PMID: 17238399 PMCID: PMC1839611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
ATHENA-HTN is a clinical decision support system (CDSS) that delivers guideline-based patient-specific recommendations about hypertension management at the time of clinical decision-making. The ATHENA-HTN knowledge is stored in a knowledge-base (KB). Changes in best-practice recommendations require updates to the KB. We describe a method of offline testing to evaluate the accuracy of recommendations generated from the KB. A physician reviewed 100 test cases and made drug recommendations based on guidelines and the "Rules" (descriptions of encoded knowledge). These drug recommendations were compared to those generated by ATHENA-HTN. Nineteen drug-recommendation discrepancies were identified: ATHENA-HTN was more complete in generating recommendations (15); ambiguities in the Rules misled the physician (3); and content in the Rules was not encoded (1). Three new boundaries were identified. Three updates were made to the KB based on the results. The offline testing method was successful in identifying areas for KB improvement and led to improved accuracy of guideline-based recommendations.
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Affiliation(s)
- S B Martins
- GRECC, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Hastings SN, Thompson-Heisterman A, Farrell SP. Identifying and treating agitated behaviors in the long-term care setting. Lippincotts Prim Care Pract 1999; 3:204-15. [PMID: 10426066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
This article provides information on identification, assessment, and intervention techniques for agitated behaviors in the long-term care setting. Although the emphasis is on prevention and management of agitation, the article offers suggestions to assist health care providers in differentiating between delirium, psychosis, depression, anxiety, and dementia, which may place a resident at risk for agitation. Basic treatment approaches for each of these disorders is also reviewed.
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Affiliation(s)
- S N Hastings
- Psychiatry Service Center, University of Virginia Health System, Charlottesville, USA
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