A Qualitative Investigation of the Impact of Home-Based Primary Care on Family Caregivers

BACKGROUND

Home-based primary care (HBPC) provides team-based clinical care for homebound patients who have difficulty accessing typical outpatient care. Interdisciplinary team members also provide social and emotional support and serve as a resource for family caregivers, who often experience significant emotional stress.

OBJECTIVES

This qualitative study explores the impact of HBPC on family caregivers to identify aspects of the program that caregivers find most helpful and meaningful as well as areas for improvement.

DESIGN

Semi structured recorded interviews were conducted with family caregivers of frail, elderly homebound patients. Interviews included the following topics: overall program satisfaction and suggestions for improvement.

SETTING

A HBPC program serving patients in Queens, Nassau and Suffolk counties in New York.

PARTICIPANTS

Nineteen family caregivers: 13 women, 6 men; 10 were adult children; 6 were spouses, and 3 were other family members of patients in a HBPC program.

MEASUREMENTS

Thematic coding of all recorded transcribed interviews was prepared by 3 qualitative coders. Interrater reliability was conducted to ensure reliability across coders before themes were disseminated and discussed until consensus was achieved with the larger group of investigators.

RESULTS

Three main themes were identified: the importance of staff emotional support; the burden of caring for homebound patients; and the need for a broader range of home-based services. Multiple family members noted that the program not only had saved their loved one's life, but had also metaphorically saved their own.

CONCLUSIONS

Family caregivers value the communication and accessibility of HBPC and report that the program has a positive impact on their stress and mental health. Results can inform key aspects that need to be retained or enhanced with the expansion in HBPC programs.

Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net"

A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.

Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department

STUDY OBJECTIVE

We evaluate a computer-based intervention for screening and health promotion in the emergency department and determine its effect on patient recall of health advice.

METHODS

This controlled clinical trial, with alternating assignment of patients to a computer intervention (prevention group) or usual care, was conducted in a university hospital ED. The study group consisted of 542 adult patients with nonurgent conditions. The study intervention was a self-administered computer survey generating individualized health information. Outcome measures were (1) patient willingness to take a computerized health risk assessment, (2) disclosure of behavioral risk factors, (3) requests for health information, and (4) remembered health advice.

RESULTS

Eighty-nine percent (470/542) of eligible patients participated. Ninety percent were black. Eighty-five percent (210/248) of patients in the prevention group disclosed 1 or more major behavioral risk factors including current smoking (79/248; 32%), untreated hypertension (28/248; 13%), problem drinking (46/248; 19%), use of street drugs (33/248; 13%), major depression (87/248; 35%), unsafe sexual behavior (84/248; 33%), and several other injury-prone behaviors. Ninety-five percent of patients in the prevention group requested health information. On follow-up at 1 week, 62% (133/216) of the prevention group patients compared with 27% (48/180) of the control subjects remembered receiving advice on what they could do to improve their health (relative risk 2.3, 95% confidence interval 1.77 to 3.01).

CONCLUSION

Using a self-administered computer-based health risk assessment, the majority of patients in our urban ED disclosed important health risks and requested information. They were more likely than a control group to remember receiving advice on what they could do to improve their health. Computer methodology may enable physicians to use patient waiting time for health promotion and to target at-risk patients for specific interventions.

Preventive care in the emergency department, Part I: Clinical preventive services--are they relevant to emergency medicine? Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group

In 1998 the Society for Academic Emergency Medicine's (SAEM's) Board of Directors asked the SAEM Public Health and Education Task Force to develop recommendations for prevention, screening, and counseling activities to be conducted in emergency departments (EDs). The Task Force's work was divided into two phases: 1) a discussion of the rationale for preventive services in the ED, along with generation of a preliminary list of prevention activities that could be studied for ED implementation; and 2) a formal evidence-based review of topics chosen from the preliminary list, along with recommendations for ED implementation and further study. This paper represents Phase I of the project. Phase II, the formal evidence-based review and recommendations, is published separately in this issue.

Racial differences in the incidence of cardiac arrest and subsequent survival. The CPR Chicago Project

BACKGROUND

Differences between blacks and whites have been reported in the incidence of several forms of cardiovascular disease, including hypertension and stroke. We examined racial differences in the incidence of cardiac arrest in a large urban population and in subsequent survival.

METHODS

We collected data on all nontraumatic, out-of-hospital cardiac arrests in Chicago from January 1, 1987, through December 31, 1988, and compared the incidence and survival rates for blacks and whites. We examined the association between survival and race and seven other known risk factors by logistic-regression analysis. We computed incidence rates by coupling our data with U.S. Census population data.

RESULTS

Our study population comprised 6451 patients: 3207 whites, 2910 blacks, and 334 persons of other races. The incidence of cardiac arrest was significantly higher for blacks than for whites in every age group. The survival rate after cardiac arrest was 2.6 percent in whites, as compared with 0.8 percent in blacks (P < 0.001). Blacks were significantly less likely to have a witnessed cardiac arrest, bystander-initiated cardiopulmonary resuscitation, or a "favorable" initial rhythm or to be admitted to the hospital. When they were admitted, blacks were half as likely to survive. The association between race and survival persisted even when other recognized risk factors were taken into account. We did not find important differences between blacks and whites in the response times of the emergency medical services.

CONCLUSIONS

The black community in our study was at higher risk for cardiac arrest and subsequent death than the white community, even after we controlled for other variables.

Incidence of cardiac arrest: a neglected factor in evaluating survival rates

STUDY OBJECTIVES

To add to our understanding of survival rates in out-of-hospital cardiac arrest studies, we examined the incidence of cardiac arrest in the published literature. We specifically estimated if incidence rates are uniform between communities and if any relationship exists between incidence and the reported survival rates.

DESIGN

A retrospective study of nearly 100 cardiac arrest peer-reviewed articles from 1970 to 1989 was performed to identify reports that included rates for incidence and survival or provided sufficient data for the calculation of these rates.

MEASUREMENTS AND MAIN RESULTS

We were able to obtain reported or calculated incidence and survival rates for 20 communities. Statistical analysis was performed to compare incidence rates between communities and examine the relationship across these 20 studies between incidence rates and reported survival rates. Incidence rates ranged significantly from 35.7 to 128.3 per 100,000, with a mean of 62. Survival rates ranged significantly from 1.6% to 20.7%. Incidence rates in these communities were negatively related to survival rates; that is, as the incidence rate increased, the survival rate decreased. We determined the regression curve that describes this inverse relationship. This nomogram can be used to identify survival/incidence rate combinations that are significantly above or below average.

CONCLUSION

The marked variations in incidence and inverse relationship between incidence and survival could be due to true variation in risk among the populations reported (ie, some populations may be older or sicker than others). Also, different research methodologies may create artifactual differences among studies as standards for designing studies, terminology, and reporting data have not been uniform. Therefore, these findings may reflect methodological differences and true epidemiological differences among communities. Future reports should include a method, such as an incidence/survival nomogram, to analyze survival rates while taking into account the community incidence rate of cardiac arrest. Further analysis of incidence and survival is necessary to improve intersystem comparisons, a prerequisite to sound decisions about cardiac arrest treatment, health policy, and allocation of resources.