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Affiliation(s)
- Thomas R Miller
- From the Department of Analytics and Research Services, American Society of Anesthesiologists, Schaumburg, Illinois
| | - Tiffany A Radcliff
- Department of Health Policy & Management, Texas A&M University School of Public Health, College Station, Texas.,Veterans Emergency Management Evaluation Center, Veterans Affairs (VA) Greater Los Angeles Healthcare System, North Hills, California
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Perri MG, Shankar MN, Daniels MJ, Durning PE, Ross KM, Limacher MC, Janicke DM, Martin AD, Dhara K, Bobroff LB, Radcliff TA, Befort CA. Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e206764. [PMID: 32539150 PMCID: PMC7296388 DOI: 10.1001/jamanetworkopen.2020.6764] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities. OBJECTIVE To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019. INTERVENTIONS Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss. MAIN OUTCOMES AND MEASURES The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up. RESULTS Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02054624.
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Affiliation(s)
- Michael G. Perri
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | - Meena N. Shankar
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | | | - Patricia E. Durning
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | - Kathryn M. Ross
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | | | - David M. Janicke
- Department of Clinical and Health Psychology, University of Florida, Gainesville
| | - A. Daniel Martin
- Department of Physical Therapy, University of Florida, Gainesville
| | - Kumaresh Dhara
- Department of Statistics, University of Florida, Gainesville
| | - Linda B. Bobroff
- Department of Family, Youth, and Community Sciences, University of Florida, Gainesville
| | - Tiffany A. Radcliff
- Department of Health Policy and Management, Texas A&M University, College Station
| | - Christie A. Befort
- Department of Population Health, University of Kansas Medical Center, Kansas City
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Radcliff TA, Côté MJ, Whittington MD, Daniels MJ, Bobroff LB, Janicke DM, Perri MG. Cost-Effectiveness of Three Doses of a Behavioral Intervention to Prevent or Delay Type 2 Diabetes in Rural Areas. J Acad Nutr Diet 2020; 120:1163-1171. [PMID: 31899170 DOI: 10.1016/j.jand.2019.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/28/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention. OBJECTIVE This analysis extended earlier Rural Lifestyle Intervention Treatment Effectiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service offices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas. DESIGN A cost-utility analysis was conducted. PARTICIPANTS/SETTING Trial participants (n=317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identified as healthy. INTERVENTION Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status. MAIN OUTCOME MEASURES T2D categories by treatment arm were used to estimate participants' expected annual health care expenditures and expected health-related utility measured as quality adjusted life years (ie, QALYs) over a 5-year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost-effectiveness ratios for each behavioral coaching intervention dose relative to the education-only comparator. STATISTICAL ANALYSES PERFORMED Using a third-party payer perspective, Markov transition matrices were used to model participant transitions between T2D states. Replications of the individual participant behavior were conducted using Monte Carlo simulation. RESULTS All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education-only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored. CONCLUSIONS Because most rural Americans live in counties with cooperative extension service offices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.
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Hong YA, Liang C, Radcliff TA, Wigfall LT, Street RL. Metadata and Table Caption Correction: What Do Patients Say About Doctors Online? A Systematic Review of Studies on Patient Online Reviews. J Med Internet Res 2019; 21:e14823. [PMID: 31322126 PMCID: PMC6670278 DOI: 10.2196/14823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/13/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Y Alicia Hong
- Department of Health Administration and PolicyGeorge Mason UniversityFairfax, VAUnited States
- School of Public HealthTexas A&M UniversityCollege Station, TXUnited States
| | - Chen Liang
- Arnold School of Public HealthUniversity of South CarolinaColumbia, SCUnited States
| | - Tiffany A Radcliff
- School of Public HealthTexas A&M UniversityCollege Station, TXUnited States
| | - Lisa T Wigfall
- Department of Health KinesiologyTexas A&M UniversityCollege Station, TXUnited States
| | - Richard L Street
- Department of CommunicationTexas A&M UniversityCollege Station, TXUnited States
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McCreight MS, Gilmartin HM, Leonard CA, Mayberry AL, Kelley LR, Lippmann BK, Coy AS, Radcliff TA, Côté MJ, Burke RE. Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans. J Gen Intern Med 2019; 34:67-74. [PMID: 31098974 PMCID: PMC6542877 DOI: 10.1007/s11606-019-04968-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities. OBJECTIVE We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program. DESIGN AND PARTICIPANTS Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams. KEY RESULTS We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact. CONCLUSIONS Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs.
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Affiliation(s)
- Marina S McCreight
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA. .,VA Eastern Colorado Health Care System, Denver, CO, USA.
| | - Heather M Gilmartin
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA.,Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Chelsea A Leonard
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Ashlea L Mayberry
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Lynette R Kelley
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Brandi K Lippmann
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Andrew S Coy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Tiffany A Radcliff
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, 77843, USA
| | - Murray J Côté
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, 77843, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Hospital Medicine Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
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Hong YA, Liang C, Radcliff TA, Wigfall LT, Street RL. What Do Patients Say About Doctors Online? A Systematic Review of Studies on Patient Online Reviews. J Med Internet Res 2019; 21:e12521. [PMID: 30958276 PMCID: PMC6475821 DOI: 10.2196/12521] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/16/2018] [Accepted: 01/31/2019] [Indexed: 01/20/2023] Open
Abstract
Background The number of patient online reviews (PORs) has grown significantly, and PORs have played an increasingly important role in patients’ choice of health care providers. Objective The objective of our study was to systematically review studies on PORs, summarize the major findings and study characteristics, identify literature gaps, and make recommendations for future research. Methods A major database search was completed in January 2019. Studies were included if they (1) focused on PORs of physicians and hospitals, (2) reported qualitative or quantitative results from analysis of PORs, and (3) peer-reviewed empirical studies. Study characteristics and major findings were synthesized using predesigned tables. Results A total of 63 studies (69 articles) that met the above criteria were included in the review. Most studies (n=48) were conducted in the United States, including Puerto Rico, and the remaining were from Europe, Australia, and China. Earlier studies (published before 2010) used content analysis with small sample sizes; more recent studies retrieved and analyzed larger datasets using machine learning technologies. The number of PORs ranged from fewer than 200 to over 700,000. About 90% of the studies were focused on clinicians, typically specialists such as surgeons; 27% covered health care organizations, typically hospitals; and some studied both. A majority of PORs were positive and patients’ comments on their providers were favorable. Although most studies were descriptive, some compared PORs with traditional surveys of patient experience and found a high degree of correlation and some compared PORs with clinical outcomes but found a low level of correlation. Conclusions PORs contain valuable information that can generate insights into quality of care and patient-provider relationship, but it has not been systematically used for studies of health care quality. With the advancement of machine learning and data analysis tools, we anticipate more research on PORs based on testable hypotheses and rigorous analytic methods. Trial Registration International Prospective Register of Systematic Reviews (PROSPERO) CRD42018085057; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=85057 (Archived by WebCite at http://www.webcitation.org/76ddvTZ1C)
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Affiliation(s)
- Y Alicia Hong
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, United States.,School of Public Health, Texas A&M University, College Station, TX, United States
| | - Chen Liang
- Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Tiffany A Radcliff
- School of Public Health, Texas A&M University, College Station, TX, United States
| | - Lisa T Wigfall
- Department of Health Kinesiology, Texas A&M University, College Station, TX, United States
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, TX, United States
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Lorden AL, Jiang L, Radcliff TA, Kelly KA, Ohsfeldt RL. Potentially Preventable Hospitalizations and the Burden of Healthcare-Associated Infections. Health Serv Res Manag Epidemiol 2017; 4:2333392817721109. [PMID: 28894766 PMCID: PMC5582652 DOI: 10.1177/2333392817721109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 06/15/2017] [Accepted: 06/15/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND An estimated 4% of hospital admissions acquired healthcare-associated infections (HAIs) and accounted for $9.8 (USD) billion in direct cost during 2011. In 2010, nearly 140 000 of the 3.5 million potentially preventable hospitalizations (PPHs) may have acquired an HAI. There is a knowledge gap regarding the co-occurrence of these events. AIMS To estimate the period occurrences and likelihood of acquiring an HAI for the PPH population. METHODS Retrospective, cross-sectional study using logistic regression analysis of 2011 Texas Inpatient Discharge Public Use Data File including 2.6 million admissions from 576 acute care hospitals. Agency for Healthcare Research and Quality Prevention Quality Indicator software identified PPH, and existing administrative data identification methodologies were refined for Clostridium difficile infection, central line-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia. Odds of acquiring HAIs when admitted with PPH were adjusted for demographic, health status, hospital, and community characteristics. FINDINGS We identified 272 923 PPH, 14 219 HAI, and 986 admissions with PPH and HAI. Odds of acquiring an HAI for diabetic patients admitted for lower extremity amputation demonstrated significantly increased odds ratio of 2.9 (95% confidence interval: 2.16-3.91) for Clostridium difficile infection. Other PPH patients had lower odds of acquiring HAI compared to non-PPH patients, and results were frequently significant. CONCLUSIONS Clinical implications include increased risk of HAI among diabetic patients admitted for lower extremity amputation. Methodological implications include identification of rare events for inpatient subpopulations and the need for improved codification of HAIs to improve cost and policy analyses regarding allocation of resources toward clinical improvements.
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Affiliation(s)
- Andrea L. Lorden
- Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
- Department of Health Administration and Policy, College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Luohua Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
- Department of Epidemiology, School of Medicine, The University of California, Irvine, CA, USA
| | - Tiffany A. Radcliff
- Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Kathleen A. Kelly
- Department of Nursing, School of Health Sciences, The Sage Colleges, Troy, NY, USA
| | - Robert L. Ohsfeldt
- Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
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Kim J, Ohsfeldt RL, Gamm LD, Radcliff TA, Jiang L. Hospital Characteristics are Associated With Readiness to Attain Stage 2 Meaningful Use of Electronic Health Records. J Rural Health 2016; 33:275-283. [PMID: 27424940 DOI: 10.1111/jrh.12193] [Citation(s) in RCA: 10] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/22/2016] [Accepted: 05/25/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine the difference between rural and urban hospitals as to their overall level of readiness for stage 2 meaningful use of electronic health records (EHRs) and to identify other key factors that affect their readiness for stage 2 meaningful use. METHODS A conceptual framework based on the theory of organizational readiness for change was used in a cross-sectional multivariate analysis using 2,083 samples drawn from the HIMSS Analytics survey conducted with US hospitals in 2013. FINDINGS Rural hospitals were less likely to be ready for stage 2 meaningful use compared to urban hospitals in the United States (OR = 0.49) in our final model. Hospitals' past experience with an information exchange initiative, staff size in the information system department, and the Chief Information Officer (CIO)'s responsibility for health information management were identified as the most critical organizational contextual factors that were associated with hospitals' readiness for stage 2. Rural hospitals lag behind urban hospitals in EHR adoption, which will hinder the interoperability of EHRs among providers across the nation. The identification of critical factors that relate to the adoption of EHR systems provides insights into possible organizational change efforts that can help hospitals to succeed in attaining meaningful use requirements. CONCLUSION Rural hospitals have increasingly limited resources, which have resulted in a struggle for these facilities to attain meaningful use. Given increasing closures among rural hospitals, it is all the more important that EHR development focus on advancing rural hospital quality of care and linkages with patients and other organizations supporting the care of their patients.
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Affiliation(s)
- Jungyeon Kim
- World Innovation Summit for Health, Qatar Foundation, Doha, Qatar
| | - Robert L Ohsfeldt
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Larry D Gamm
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Tiffany A Radcliff
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Luohua Jiang
- Department of Epidemiology, School of Medicine, University of California-Irvine, Irvine, California
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Jiang L, Zhang B, Smith ML, Lorden AL, Radcliff TA, Lorig K, Howell BL, Whitelaw N, Ory MG. Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program. Front Public Health 2015; 3:222. [PMID: 26501047 PMCID: PMC4597005 DOI: 10.3389/fpubh.2015.00222] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/18/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the concordance between self-reported data and variables obtained from Medicare administrative data in terms of chronic conditions and health care utilization. DESIGN Retrospective observational study. PARTICIPANTS We analyzed data from a sample of Medicare beneficiaries who were part of the National Study of Chronic Disease Self-Management Program (CDSMP) and were eligible for the Centers for Medicare and Medicaid Services (CMS) pilot evaluation of CDSMP (n = 119). METHODS Self-reported and Medicare claims-based chronic conditions and health care utilization were examined. Percent of consistent numbers, kappa statistic (κ), and Pearson's correlation coefficient were used to evaluate concordance. RESULTS The two data sources had substantial agreement for diabetes and chronic obstructive pulmonary disease (COPD) (κ = 0.75 and κ = 0.60, respectively), moderate agreement for cancer and heart disease (κ = 0.50 and κ = 0.47, respectively), and fair agreement for depression (κ = 0.26). With respect to health care utilization, the two data sources had almost perfect or substantial concordance for number of hospitalizations (κ = 0.69-0.79), moderate concordance for ED care utilization (κ = 0.45-0.61), and generally low agreement for number of physician visits (κ ≤ 0.31). CONCLUSION Either self-reports or claim-based administrative data for diabetes, COPD, and hospitalizations can be used to analyze Medicare beneficiaries in the US. Yet, caution must be taken when only one data source is available for other types of chronic conditions and health care utilization.
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Affiliation(s)
- Luohua Jiang
- Department of Epidemiology, School of Medicine, University of California Irvine , Irvine, CA , USA ; Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M Health Science Center , College Station, TX , USA
| | - Ben Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M Health Science Center , College Station, TX , USA
| | - Matthew Lee Smith
- Department of Health Promotion and Behavior, College of Public Health, University of Georgia , Athens, GA , USA
| | - Andrea L Lorden
- Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center , College Station, TX , USA
| | - Tiffany A Radcliff
- Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center , College Station, TX , USA
| | - Kate Lorig
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University , Stanford, CA , USA
| | | | - Nancy Whitelaw
- Center for Healthy Aging, National Council on Aging , Washington, DC , USA
| | - Marcia G Ory
- Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M Health Science Center , College Station, TX , USA
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Hutt E, Radcliff TA, Henderson W, Maciejewski M, Cowper-Ripley D, Whitfield E. Comparing Survival Following Hip Fracture Repair in VHA and Non-VHA Facilities. Geriatr Orthop Surg Rehabil 2015; 6:22-7. [PMID: 26246949 DOI: 10.1177/2151458514561787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Although postsurgical outcomes are similar between Veterans Health Administration (VHA) and non-VHA hospitals for many procedures, no studies have compared 30-day and 1-year survival following hip fracture repair. Therefore, this study compared survival of veterans aged 65 years and older treated in VHA hospitals with a propensity-matched cohort of Medicare beneficiaries in non-VHA hospitals. MATERIALS AND METHODS Retrospective cohort study of 1894 hip fracture repair patients in VHA or non-VHA hospitals between 2003 and 2005. Current Procedural Terminology codes identified 3542 male patients aged >65 years who had hip fracture repair between 2003 and 2005 in the Veterans Affairs' National Surgical Quality Improvement Program database. The Medicare comparison sample was drawn from 2003 to 2005 Medicare Part A inpatient hospital claims files. To create comparable VHA and Medicare cohorts, patients were propensity score matched on age, admission source (community vs. nursing home), repair type, comorbidity index, race, year, and region. Thirty-day and 1-year survival after surgery were compared between cohorts after further adjustment for selected comorbidities, year of surgery, and pre- and postsurgical length of hospital stay using logistic regression. RESULTS Odds of survival were significantly better in the Medicare than the VHA cohort at 30 days (1.68, 95% CI 1.15-2.44) and 1 year (1.35, 95% CI 1.08-1.69). CONCLUSION Medicare beneficiaries with hip fracture repair in non-VHA hospitals had better survival than veterans in VHA hospitals. Whether this is driven by unobserved patient characteristics or systematic care differences is unknown.
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Affiliation(s)
- Evelyn Hutt
- Denver-Seattle Center of Innovation VA Eastern Colorado Health Care System Denver, CO, USA ; Department of Medicine and School of Public Health University of Colorado Anschutz Medical Campus Aurora, CO, USA
| | - Tiffany A Radcliff
- Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - William Henderson
- Department of Medicine and School of Public Health University of Colorado Anschutz Medical Campus Aurora, CO, USA
| | - Matthew Maciejewski
- Department of Medicine, Duke University Medical Center, Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Diane Cowper-Ripley
- Department of Health Outcomes and Policy Malcolm G. Randall VA Medical Center, Gainesville, FL, USA
| | - Emily Whitfield
- Denver-Seattle Center of Innovation VA Eastern Colorado Health Care System Denver, CO, USA
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Wald HL, Epstein AM, Radcliff TA, Kramer AM. Extended Use of Urinary Catheters in Older Surgical Patients: A Patient Safety Problem? Infect Control Hosp Epidemiol 2015; 29:116-24. [DOI: 10.1086/526433] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objectives.To explore the relationship between the extended postoperative use of indwelling urinary catheters and outcomes for older patients who have undergone cardiac, vascular, gastrointestinal, or orthopedic surgery in skilled nursing facilities and to describe patient and hospital characteristics associated with the extended use of indwelling urinary catheters.Design.Retrospective cohort study.Setting.US acute care hospitals and skilled nursing facilities.Patients.A total of 170,791 Medicare patients aged 65 years or more who were admitted to skilled nursing facilities after discharge from a hospital with a primary diagnosis code indicating major cardiac, vascular, orthopedic, or gastrointestinal surgery in 2001.Main Outcome Measures.Patient-specific 30-day rate of rehospitalization for urinary tract infection (UTI) and 30-day mortality rate, as well as the risk of having an indwelling urinary catheter at the time of admission to a skilled nursing facility.Results.A total of 39,282 (23.0%) of the postoperative patients discharged to skilled nursing facilities had indwelling urinary catheters. After adjusting for patient characteristics, the patients with catheters had greater odds of rehospitalization for UTI and death within 30 days than patients who did not have catheters. The adjusted odds ratios (aORs) for UTI ranged from 1.34 for patients who underwent gastrointestinal surgery (P<.001) to 1.85 for patients who underwent cardiac surgery (P<.001); the aORs for death ranged from 1.25 for cardiac surgery (P= .01) to 1.48 for orthopedic surgery (P= .002) and for gastrointestinal surgery (P< .001). After controlling for patient characteristics, hospitalization in the northeastern or southern regions of the United States was associated with a lower likelihood of having an indwelling urinary catheter, compared with hospitalization in the western region (P= .002 vsP= .03).Conclusions.Extended postoperative use of indwelling urinary catheters is associated with poor outcomes for older patients. The likelihood of having an indwelling urinary catheter at the time of discharge after major surgery is strongly associated with a hospital's geographic region, which reflects a variation in practice that deserves further study.
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Perri MG, Limacher MC, von Castel-Roberts K, Daniels MJ, Durning PE, Janicke DM, Bobroff LB, Radcliff TA, Milsom VA, Kim C, Martin AD. Comparative effectiveness of three doses of weight-loss counseling: two-year findings from the rural LITE trial. Obesity (Silver Spring) 2014; 22:2293-300. [PMID: 25376396 PMCID: PMC4225635 DOI: 10.1002/oby.20832] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/18/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the effects and costs of three doses of behavioral weight-loss treatment delivered via Cooperative Extension Offices in rural communities. METHODS Obese adults (N = 612) were randomly assigned to low, moderate, or high doses of behavioral treatment (i.e., 16, 32, or 48 sessions over two years) or to a control condition that received nutrition education without instruction in behavior modification strategies. RESULTS Two-year mean reductions in initial body weight were 2.9% (95% Credible Interval = 1.7-4.3), 3.5% (2.0-4.8), 6.7% (5.3-7.9), and 6.8% (5.5-8.1) for the control, low-, moderate-, and high-dose conditions, respectively. The moderate-dose treatment produced weight losses similar to the high-dose condition and significantly larger than the low-dose and control conditions (posterior probability > 0.996). The percentages of participants who achieved weight reductions ≥ 5% at two years were significantly higher in the moderate-dose (58%) and high-dose (58%) conditions compared with low-dose (43%) and control (40%) conditions (posterior probability > 0.996). Cost-effectiveness analyses favored the moderate-dose treatment over all other conditions. CONCLUSIONS A moderate dose of behavioral treatment produced two-year weight reductions comparable to high-dose treatment but at a lower cost. These findings have important policy implications for the dissemination of weight-loss interventions into communities with limited resources.
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Affiliation(s)
- Michael G. Perri
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | | | - Kristina von Castel-Roberts
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - Michael J. Daniels
- Department of Statistics & Data Sciences and Department of Integrative Biology, University of Texas at Austin
| | - Patricia E. Durning
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - David M. Janicke
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - Linda B. Bobroff
- Department of Family, Youth and Community Sciences, University of Florida Institute of Food and Agricultural Sciences
| | | | - Vanessa A. Milsom
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions
| | - Chanmin Kim
- Department of Statistics & Data Sciences and Department of Integrative Biology, University of Texas at Austin
| | - A. Daniel Martin
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions
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Maciejewski ML, Radcliff TA, Henderson WG, Cowper Ripley D, Vogel WB, Regan E, Hutt E. Determinants of postsurgical discharge setting for male hip fracture patients. ACTA ACUST UNITED AC 2014; 50:1267-76. [PMID: 24458966 DOI: 10.1682/jrrd.2013.02.0041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 02/13/2013] [Revised: 05/24/2013] [Indexed: 11/05/2022]
Abstract
Veterans hospitalized for hip fracture repair may be discharged to one of several rehabilitation settings, but it is not known what factors influence postsurgical discharge setting. The purpose of the study was to examine the patient, facility, and market factors that influence the choice of postsurgical discharge setting. Using a retrospective cohort design, we linked 11,083 veterans who had hip fracture surgeries in a Department of Veterans Affairs (VA) hospital from 1998 to 2005 as assessed by the VA National Surgical Quality Improvement Program dataset with administrative data. The factors associated with five postdischarge settings were analyzed using multinomial logistic regression. We found that few veterans (0.8%) hospitalized for hip fracture were discharged with home health. Higher proportions of veterans were discharged to a nursing home (15.4%), to outpatient rehabilitation (18.8%), to inpatient rehabilitation (16.9%), or to home (48.2%). Patients were more likely to be discharged to nonhome settings for VA-provided rehabilitation if they had total function dependence, had American Society of Anesthesiologists class 4 or 5, had surgical complications prior to discharge, or lived in counties with lower nursing home bed occupancy rates. Future research should compare postsurgical and longer-term morbidity, mortality, and healthcare utilization across these rehabilitation settings.
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Affiliation(s)
- Matthew L Maciejewski
- Center for Health Services Research in Primary Care (152), Durham VA Medical Center, 508 Fulton St, Durham, NC 27705.
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Lorden AL, Radcliff TA, Jiang L, Horel SA, Smith ML, Lorig K, Howell BL, Whitelaw N, Ory M. Leveraging Administrative Data for Program Evaluations: A Method for Linking Data Sets Without Unique Identifiers. Eval Health Prof 2014; 39:245-59. [PMID: 25139849 DOI: 10.1177/0163278714547568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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
In community-based wellness programs, Social Security Numbers (SSNs) are rarely collected to encourage participation and protect participant privacy. One measure of program effectiveness includes changes in health care utilization. For the 65 and over population, health care utilization is captured in Medicare administrative claims data. Therefore, methods as described in this article for linking participant information to administrative data are useful for program evaluations where unique identifiers such as SSN are not available. Following fuzzy matching methodologies, participant information from the National Study of the Chronic Disease Self-Management Program was linked to Medicare administrative data. Linking variables included participant name, date of birth, gender, address, and ZIP code. Seventy-eight percent of participants were linked to their Medicare claims data. Linking program participant information to Medicare administrative data where unique identifiers are not available provides researchers with the ability to leverage claims data to better understand program effects.
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Affiliation(s)
- Andrea L Lorden
- Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Tiffany A Radcliff
- Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Luohua Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Scott A Horel
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Matthew L Smith
- Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA, USA
| | - Kate Lorig
- Department of Medicine/Immunology & Rheumatology, Stanford University, Stanford, CA, USA
| | - Benjamin L Howell
- Centers for Medicare and Medicaid Innovation and Strategic Planning, Centers for Medicare and Medicaid Services, Baltimore, MD, USA
| | - Nancy Whitelaw
- Center for Healthy Aging, National Council on Aging, Washington, DC, USA
| | - Marcia Ory
- Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
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Menser TL, Radcliff TA, Schuller KA. Implementing a medical screening and referral program for rural emergency departments. J Rural Health 2014; 31:126-34. [PMID: 25124750 DOI: 10.1111/jrh.12085] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CONTEXT Emergency Department (ED) overcrowding due to nonemergent use is an ongoing concern. In 2011, a regional health system that primarily serves rural communities in Texas instituted a new program to medically screen and refer nonemergent patients to nearby affiliated rural health clinics (RHCs). PURPOSE This formative evaluation describes the program goals, process, and early implementation experiences at 2 sites that adopted the program before wider implementation within the rural health system. METHODS Primary data collection including document review, internal stakeholder interviews, and direct observation of program processes were used for this formative evaluation of program implementation in light of program goals and objectives. Fourteen key informants were asked questions related to the program concept, structure, and implementation. RESULTS The program, as implemented, aligned with initial program goals, but it was dependent on ED screening staff and RHC availability. Some adjustments to the program were needed, including RHC hours, consistency among staff in making referrals, patient education, and improving patient uptake on the referral. Stakeholders reported lessons learned related to training, staff buy-in, Emergency Medical Treatment and Labor Act (EMTALA), and intraorganizational cooperation. DISCUSSION The system was able to leverage excess capacity of affiliated RHCs to accommodate low-acuity patients referred from the ED and may lead to improvements in Triple Aim goals of increased patient satisfaction, better population health and outcomes, and lower per capita costs. Lessons learned from this program may inform similar processes aimed to reduce nonemergency ED utilization by other rural health systems.
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Affiliation(s)
- Terri L Menser
- Department of Health Policy & Management, Center for Health Organization Transformation, Texas A&M Health Science Center, School of Public Health, College Station, Texas
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Radcliff TA, White A, West DR, Hurd D, Côté MJ. Evaluation of a seven state criminal history screening pilot program for long-term care workers. J Elder Abuse Negl 2014; 25:375-95. [PMID: 23941421 DOI: 10.1080/08946566.2013.780955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article summarizes results from an evaluation of a federally sponsored criminal history screening (CHS) pilot program to improve screening for workers in long-term care settings. The evaluation addressed eight key issues specified through enabling legislation, including efficiency, costs, and outcomes of screening procedures. Of the 204,339 completed screenings, 3.7% were disqualified due to criminal history, and 18.8% were withdrawn prior to completion for reasons that may include relevant criminal history. Lessons learned from the pilot program experiences may inform a new national background check demonstration program.
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Affiliation(s)
- Tiffany A Radcliff
- School of Medicine, University of Colorado Denver, Aurora, Colorado, USA.
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Ross SE, Radcliff TA, LeBlanc WG, Dickinson LM, Libby AM, Nease DE. Effects of health information exchange adoption on ambulatory testing rates. J Am Med Inform Assoc 2013; 20:1137-42. [PMID: 23698257 PMCID: PMC3822119 DOI: 10.1136/amiajnl-2012-001608] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 04/22/2013] [Accepted: 04/27/2013] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the effects of the adoption of ambulatory electronic health information exchange (HIE) on rates of laboratory and radiology testing and allowable charges. DESIGN Claims data from the dominant health plan in Mesa County, Colorado, from 1 April 2005 to 31 December 2010 were matched to HIE adoption data on the provider level. Using mixed effects regression models with the quarter as the unit of analysis, the effect of HIE adoption on testing rates and associated charges was assessed. RESULTS Claims submitted by 306 providers in 69 practices for 34 818 patients were analyzed. The rate of testing per provider was expressed as tests per 1000 patients per quarter. For primary care providers, the rate of laboratory testing increased over the time span (baseline 1041 tests/1000 patients/quarter, increasing by 13.9 each quarter) and shifted downward with HIE adoption (downward shift of 83, p<0.01). A similar effect was found for specialist providers (baseline 718 tests/1000 patients/quarter, increasing by 19.1 each quarter, with HIE adoption associated with a downward shift of 119, p<0.01). Even so, imputed charges for laboratory tests did not shift downward significantly in either provider group, possibly due to the skewed nature of these data. For radiology testing, HIE adoption was not associated with significant changes in rates or imputed charges in either provider group. CONCLUSIONS Ambulatory HIE adoption is unlikely to produce significant direct savings through reductions in rates of testing. The economic benefits of HIE may reside instead in other downstream outcomes of better informed, higher quality care.
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Affiliation(s)
- Stephen E Ross
- University of Colorado Division of General Internal Medicine, Aurora, Colorado,USA
| | - Tiffany A Radcliff
- Department of Health Policy and Management, Texas A&M School of Rural Public Health, College Station, Texas, USA
- Department of Family Medicine, University of Colorado, Aurora, Colorado, USA
| | - William G LeBlanc
- Department of Family Medicine, University of Colorado, Aurora, Colorado, USA
| | - L Miriam Dickinson
- Department of Family Medicine, University of Colorado, Aurora, Colorado, USA
| | - Anne M Libby
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Donald E Nease
- Department of Family Medicine, University of Colorado, Aurora, Colorado, USA
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Abstract
UNLABELLED Hip fractures in the elderly have high rates of mortality and perioperative complications. Both men and COPD patients have worse mortality and complications but this may be due to more co-morbid disease. We assessed mortality and complications in a large cohort (n = 12,646) of men undergoing hip fracture surgery within the Veteran's Health Affairs (VHA) to define the association of COPD to these outcomes after adjusting for other key factors. We looked for opportunities to improve outcomes for COPD patients. METHODS Using the VA Surgical Quality Improvement Program (VASQIP), and administrative databases, we determined COPD status, types of co-morbid conditions and surgical factors, and compared these to outcomes of surgical complications, 30-day and one-year mortality for patients who underwent hip fracture repair during 1998 to 2005. RESULTS COPD was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the COPD was "severe: (indicated by functional disability, previous hospitalization for exacerbation, chronic drug treatment or record of FEV(1) <75% predicted), and in 2,736 (21%) cases it was considered "mild" (any previous outpatient visit or hospitalization with a coded diagnosis of COPD). Severe COPD patients had one year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD subjects. Current smoking, use of general anesthesia and delays to surgery were significant modifiable risk factors identified in adjusted models. Osteoporosis was known pre-fracture in only 3% of subjects. CONCLUSIONS COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications. Increased use of regional anesthesia and urgent scheduling of hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.
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Radcliff TA, Bobroff LB, Lutes LD, Durning PE, Daniels MJ, Limacher MC, Janicke DM, Martin AD, Perri MG. Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings. J Acad Nutr Diet 2012; 112:1363-1373. [PMID: 22818246 PMCID: PMC3432696 DOI: 10.1016/j.jand.2012.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [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: 01/10/2011] [Accepted: 04/24/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND A major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources. OBJECTIVE This study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program. DESIGN We conducted a 1-year prospective randomized controlled clinical trial. PARTICIPANTS/SETTING The study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007. INTERVENTION The intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74). MAIN OUTCOME MEASURES Program delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample. STATISTICAL ANALYSES PERFORMED Nonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance. RESULTS Median weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control). CONCLUSIONS Both the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.
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Affiliation(s)
- Tiffany A. Radcliff
- Department of Family Medicine, University of Colorado Denver, Mail Stop F413, P.O. Box 6508, Aurora, CO 80045-0508 (during study and present); Department of Health Policy and Management, Texas A&M Health Science Center, School of Rural Public Health, MS 1266, College Station, TX 77843-1266. (present) , tel. 979-862-7821, fax: 979-458-0656
| | - Linda B. Bobroff
- Department of Food and Nutrition, IFAS, University of Florida, 3026-B McCarty Hall D PO BOX 110310, Gainesville, FL 32611-0310 , tel. 352-273-3521 fax: 352-392-8196
| | - Lesley D. Lutes
- Department of Psychology, East Carolina University, 104 Rawl Building, Greenville, NC 27858-4353 , tel. 252-328-6283
| | - Patricia E. Durning
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, P.O. Box 10065, Gainesvillve, FL 32610 , tel. 352-273-6037, fax: 352-273-6199
| | - Michael J. Daniels
- Department of Statistics, 102 Griffin-Floyd Hall, P.O. Box 118545 Gainesville, FL 32611-8545, , tel. 352-273-1845, fax: 352-392-5175
| | - Marian C. Limacher
- Division of Cardiiovascular Medicine, School of Medicine, University of Florida, PO Box 100277, Room M-409 Gainesville, FL 32611-0277, , tel.: 352-846-1228, fax: 352-846-1217
| | - David M. Janicke
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, P.O. Box 10065, Gainesvillve, FL 32610 , tel. 352-273-6046, fax: (352) 273-6156
| | - A. Daniel Martin
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, P.O. Box 100154, Gainesville, FL 32610 , tel. 352-273-6105, fax: 352-273-6109
| | - Michael G. Perri
- University of Florida, College of Public Health and Health Professions, 101 S. Newell Drive, Suite 4101, Gainesvillve, FL 32610 , tel. 352-273-6214, fax: 352-273-6199
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Radcliff TA, Regan E, Cowper Ripley DC, Hutt E. Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study. J Bone Joint Surg Am 2012; 94:833-40. [PMID: 22552673 DOI: 10.2106/jbjs.i.01403] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intramedullary nails for stabilizing intertrochanteric proximal femoral fractures have been available since the early 1990s. The nails are inserted percutaneously and have theoretical mechanical advantages over plates and screws, but they have not been demonstrated to improve patient outcomes. Still, use of intramedullary nails is becoming more common. The goal of this study was to examine trends in the use and associated outcomes of intramedullary nailing compared with sliding hip screws in Veterans Affairs (VA) hospitals. METHODS Review of the VA Surgical Quality Improvement Program (VASQIP) data identified 5244 male patients in whom an intertrochanteric proximal femoral fracture had been treated in a VA hospital between 1998 and 2005. The overall sample was used to assess trends in device use, thirty-day mortality, thirty-day surgical complications, and one-year mortality. Next, propensity score matching methods were used to compare 1013 patients identified as having been treated with an intramedullary nail with 1013 patients who had a sliding-screw procedure. Multiple logistic regression models for the matched sample were used to calculate odds ratios for mortality and complications according to the choice of internal fracture fixation. RESULTS Use of intramedullary nails in VA facilities increased from 1998 through 2005 and varied by geographic region. Unadjusted mortality and complication percentages were similar for the two procedures, with approximately 8% of patients dying within thirty days after surgery, 28% dying within one year, and 19% having at least one perioperative complication. While the choice of an intramedullary nail or sliding-screw procedure was related to the geographic region, year of surgery, surgeon characteristics, and several patient characteristics, it was not associated with thirty-day outcomes in either the descriptive or the multiple regression analysis. CONCLUSIONS Intramedullary nail use increased from 1998 through 2005 but did not decrease perioperative mortality or comorbidity compared with standard plate-and-screw devices for patients treated for intertrochanteric proximal femoral fractures in VA facilities.
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Affiliation(s)
- Tiffany A Radcliff
- Colorado REAP to Improve Care Coordination, VA Eastern Colorado Healthcare System, Denver, Colorado, USA.
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Radcliff TA, Côté MJ, Olson DL, Liebrecht D. Rehabilitation settings after joint replacement: an application of multiattribute preference elicitation. Eval Health Prof 2012; 35:182-98. [PMID: 22222416 DOI: 10.1177/0163278711427558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
While advances in medical treatment and technologies have the potential to improve the delivery of health care, their use typically involves making multiple, complex decisions. Patients and their medical providers may share in the decision-making processes and balance a variety of criteria and/or attributes in the pursuit of improved health. This necessitates a stronger understanding of the role of human behavior in health care processes and presents a timely opportunity to use decision analysis tools to contribute to this important aspect of health care operations. This article reports on the application of multiattribute preference elicitation to identify postsurgical rehabilitation setting options for elective hip and knee replacement patients and their discharge planning team prior to placement in these settings. These preferences are analyzed to identify trends in emphases across patients and the discharge planning team, including a comparison with actual outcomes to determine the extent of congruence with each other, an important component of patient-centered care. Variances are identified in what patients and the discharge planning team expected and what actually happened. Reasons for these variances are discussed.
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Affiliation(s)
- Tiffany A Radcliff
- Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX 77843, USA
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Linnebur SA, Fish DN, Ruscin JM, Radcliff TA, Oman KS, Fink R, Van Dorsten B, Liebrecht D, Fish R, McNulty M, Hutt E. Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia. ACTA ACUST UNITED AC 2011; 9:442-450.e1. [PMID: 22055208 DOI: 10.1016/j.amjopharm.2011.09.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines. OBJECTIVE The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home-acquired pneumonia (NHAP) guidelines related to use of antibiotics. METHODS This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline. RESULTS A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use. CONCLUSIONS The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.
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Hutt E, Ruscin JM, Linnebur SA, Fish DN, Oman KS, Fink RM, Radcliff TA, Van Dorsten B, Liebrecht D, Fish R, McNulty MC. A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia. J Am Med Dir Assoc 2010; 12:499-507. [PMID: 21450174 DOI: 10.1016/j.jamda.2010.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 03/10/2010] [Accepted: 03/26/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates. DESIGN Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial. SETTING Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007. PARTICIPANTS Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible. INTERVENTION Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education. MEASUREMENTS Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding. RESULTS Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections. CONCLUSIONS Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.
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Hutt E, Radcliff TA, Oman KS, Fink R, Ruscin JM, Linnebur S, Fish D, Liebrecht D, Fish R, McNulty M. Impact of NHAP guideline implementation intervention on staff and resident vaccination rates. J Am Med Dir Assoc 2010; 11:365-70. [PMID: 20511104 DOI: 10.1016/j.jamda.2009.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Revised: 09/30/2009] [Accepted: 09/30/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home acquired pneumonia (NHAP), including influenza and pneumococcal vaccination, improves resident subject and staff vaccination rates. METHODS Quasi-experimental, mixed-methods multifaceted intervention trial conducted at 16 nursing homes (NHs) from 1 corporation (8 in metropolitan Denver, Colorado; 8 in Kansas and Missouri) during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI) and NH staff and physicians were eligible. Subjects' NH records were reviewed for vaccination. Each director of nursing (DON) completed a questionnaire assessing staffing and the number of direct care staff vaccinated against influenza. DONs and study liaison nurses were interviewed after the intervention. Bivariate analysis compared vaccination outcomes and covariates between intervention and control homes, and risk-adjusted models were fit. Qualitative interview transcripts were analyzed using content coding. RESULTS No statistically significant relationship between the intervention and improved resident vaccination rates was found, so other factors associated with improved rates were explored. Estimated direct patient care staff vaccination rates were better during the baseline and improved more in the intervention NHs. Qualitative results suggested that facility-specific factors and national policy changes impacted vaccination rates. CONCLUSIONS External factors influence staff and resident vaccination rates, diluting the potential impact of a comprehensive program to improve care for NHAP on vaccination.
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Affiliation(s)
- Evelyn Hutt
- Denver VA Medical Center, Denver, CO 80220, USA.
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Radcliff TA, Levy CR. Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents. J Hosp Med 2010; 5:E3-E10. [PMID: 20104634 DOI: 10.1002/jhm.622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Previous studies have examined differences in care for acute myocardial infarction (AMI) according to patient characteristics such as age, gender, or insurance, but little attention has been given to whether admission source is related to guideline adherence. OBJECTIVE To investigate: (1) the use of aspirin and reperfusion in the care of post-acute/long-term care (PAC/LTC) patients who are hospitalized for AMI, and (2) 30-day mortality associated with these treatments. DESIGN Secondary examination of data from the Cooperative Cardiovascular Project (CCP) national baseline data. SETTING A total of 4013 U.S. hospitals. SUBJECTS Patients hospitalized with a confirmed AMI admitted from PAC/LTC (n = 8151) or community-dwelling (n = 120,032) settings. MEASUREMENTS Early administration of aspirin and reperfusion via either thrombolysis or percutaneous intervention. RESULTS PAC/LTC patients were less likely to receive treatment for AMI, even after adjustment for multiple variables associated with treatment choice. Differences persisted with additional econometric adjustment using seemingly-unrelated regression. Multivariable logistic regression results indicated that aspirin was related to improved 30-day survival for both PAC/LTC and community admissions (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.58 for PAC/LTC, and OR, 0.57; 95% CI, 0.54-0.60 for community). Reperfusion was associated with higher ORs for mortality for eligible patients admitted from community setting (OR, 1.24; 95% CI, 1.13-1.35), but ideally-eligible candidates had lower ORs for mortality (OR, 0.58; 95% CI, 0.35-0.95 for PAC/LTC, and OR, 0.74; 95% CI, 0.68-0.81 for community). CONCLUSIONS Patients transferred from PAC/LTC settings were less likely to receive early treatment for AMI than other patients. Future trials should inform which guidelines are applicable to PAC/LTC patients.
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Affiliation(s)
- Tiffany A Radcliff
- Colorado Research to Improve Care Coordination, Veterans Affairs (VA) Eastern Colorado Healthcare System, Denver, Colorado, USA.
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Levy CR, Radcliff TA, Williams ET, Hutt E. Acute myocardial infarction in nursing home residents: adherence to treatment guidelines reduces mortality, but why is adherence so low? J Am Med Dir Assoc 2008; 10:56-61. [PMID: 19111854 DOI: 10.1016/j.jamda.2008.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 08/05/2008] [Accepted: 08/08/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To investigate the applicability of clinical practice guidelines (CPGs) to the care of nursing home (NH) residents who experience acute myocardial infarction (AMI). DESIGN Secondary examination of data from the national Cooperative Cardiovascular Project. SETTING 6684 US hospitals. PARTICIPANTS A NH-dwelling (N = 8151) cohort and a community-dwelling cohort (N = 119,012). MEASUREMENTS Adherence to AMI guidelines and associated mortality rates. RESULTS Mortality at 30 days and 1 year respectively was 39.5% and 65.4% in the NH cohort versus 17.5% and 31.1% in the community-dwelling cohort (P < .001). Among patients who were ideally eligible to receive aspirin, 58.8% of the NH cohort and 78.9% of the community-dwelling cohort actually received aspirin (P < .001). Among patients who were ideally eligible for beta-blockers, 43.8% of the NH cohort and 61.4% of the community-dwelling cohort received beta-blockers (P < .001). The 30-day mortality for NH patients who were ideally eligible for aspirin but did not receive aspirin was significantly higher compared with NH patients who were ideally eligible but did receive aspirin (49.2% versus 26.0%, P < .001). Similarly, mortality was significantly higher for NH patients who were ideally eligible for beta-blockers but did not receive a beta-blocker (35.3% versus 18.6%, P < .001). CONCLUSION Only half of NH patients who are ideally eligible for aspirin and beta-blockers received these medications, yet mortality was significantly lower in patients who were treated with these medications. These results demonstrate the effect of applying AMI guidelines to NH patients while also raising the question of what factors guided decisions not to provide these medications.
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Affiliation(s)
- Cari R Levy
- VA Eastern Colorado Healthcare System, HSR&D TREP for Long-term Care Research, Denver, CO 80220, USA.
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Perri MG, Limacher MC, Durning PE, Janicke DM, Lutes LD, Bobroff LB, Dale MS, Daniels MJ, Radcliff TA, Martin AD. Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Arch Intern Med 2008; 168:2347-54. [PMID: 19029500 PMCID: PMC3772658 DOI: 10.1001/archinte.168.21.2347] [Citation(s) in RCA: 204] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Rural counties in the United States have higher rates of obesity, sedentary lifestyle, and associated chronic diseases than nonrural areas, yet the management of obesity in rural communities has received little attention from researchers. METHODS Obese women from rural communities who completed an initial 6-month weight-loss program at Cooperative Extension Service offices in 6 medically underserved rural counties (n = 234) were randomized to extended care or to an education control group. The extended-care programs entailed problem-solving counseling delivered in 26 biweekly sessions via telephone or face to face. Control group participants received 26 biweekly newsletters containing weight-control advice. RESULTS Mean weight at study entry was 96.4 kg. Mean weight loss during the initial 6-month intervention was 10.0 kg. One year after randomization, participants in the telephone and face-to-face extended-care programs regained less weight (mean [SE], 1.2 [0.7] and 1.2 [0.6] kg, respectively) than those in the education control group (3.7 [0.7] kg; P = .03 and .02, respectively). The beneficial effects of extended-care counseling were mediated by greater adherence to behavioral weight-management strategies, and cost analyses indicated that telephone counseling was less expensive than face-to-face intervention. CONCLUSIONS Extended care delivered either by telephone or in face-to-face sessions improved the 1-year maintenance of lost weight compared with education alone. Telephone counseling constitutes an effective and cost-efficient option for long-term weight management. Delivering lifestyle interventions via the existing infrastructure of the Cooperative Extension Service represents a viable means of adapting research for rural communities with limited access to preventive health services. Trial Registration clinicaltrials.gov Identifier: NCT00201006.
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Affiliation(s)
- Michael G Perri
- College of Public Health and Health Professions, University of Florida, 101 S Newell Dr, Ste 4101, Gainesville, FL 32610-0185, USA.
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Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am 2008; 90:34-42. [PMID: 18171955 DOI: 10.2106/jbjs.g.00065] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although more than 1200 hip fracture repairs are performed in United States Department of Veterans Affairs hospitals annually, little is known about the relationship between perioperative care and short-term outcomes for veterans with hip fracture. The purpose of the present study was to test whether perioperative care impacts thirty-day outcomes, with patient characteristics being taken into account. METHODS A national sample of 5683 community-dwelling male veterans with an age of sixty-five years or older who had been hospitalized for the operative treatment of a hip fracture at one of 108 Veterans Administration hospitals between 1998 and 2003 was identified from the National Surgical Quality Improvement Program data set. Operative care characteristics were assessed in relation to thirty-day outcomes (mortality, complications, and readmission to a Veterans Administration facility for inpatient care). RESULTS A surgical delay of four days or more after admission was associated with a higher adjusted mortality risk (odds ratio, 1.29; 95% confidence interval, 1.02 to 1.61) but a reduced risk of readmission (odds ratio, 0.70; 95% confidence interval, 0.54 to 0.91). Compared with spinal or epidural anesthesia, general anesthesia was related to a significantly higher risk of both mortality (odds ratio, 1.27; 95% confidence interval, 1.01 to 1.55) and complications (odds ratio, 1.33; 95% confidence interval, 1.15 to 1.53). The type of procedure was not significantly associated with outcome after controlling for other variables in the model. However, a higher American Society of Anesthesiologists Physical Status Classification (ASA class) was associated with worse thirty-day outcomes. CONCLUSIONS In addition to recognizing the importance of patient-related factors, we identified operative factors that were related to thirty-day surgical outcomes. It will be important to investigate whether modifying operative factors, such as reducing surgical delays to less than four days, can directly improve the outcomes of hip fracture repair.
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Affiliation(s)
- Tiffany A Radcliff
- Colorado REAP to Improve Care Coordination, VA Eastern Colorado Health Care System, 1055 Clermont Street (MS 151), Denver, CO 80220, USA.
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Radcliff TA, Dobalian A, Levy C. Do Orders Limiting Aggressive Treatment Impact Care for Acute Myocardial Infarction? J Am Med Dir Assoc 2007; 8:91-7. [PMID: 17289538 DOI: 10.1016/j.jamda.2006.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Revised: 06/05/2006] [Accepted: 06/23/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Little is known about whether advance directives impact inpatient care for a condition with clear treatment guidelines. The goal of this research was to determine the association between limitation of aggressive treatment (LAT) orders and guideline adherence for acute myocardial infarction (AMI). DESIGN Secondary examination of data from the national Cooperative Cardiovascular Project (CCP) baseline data. We used seemingly unrelated regression to correct for potential selection bias between patients with and without LAT orders and to determine whether such orders predict guideline adherence for several treatments related to acute myocardial infarction. SETTING The setting included 4111 short-term non-federal acute care hospitals in the United States. PARTICIPANTS Participants were 147,475 AMI cases with complete data abstracted from inpatient hospital charts, representing most fee-for-service Medicare patients who were hospitalized with AMI between February 1994 and July 1995. MEASUREMENTS Adherence to guidelines for treating acute myocardial infarction, including aspirin, Beta blockers, and reperfusion via thrombolytics or PTCA. RESULTS Patients with LAT orders are less likely to receive care in accordance with guidelines when controlling for other factors that may explain a lower likelihood of guideline adherence. After adjustment for selection effects, we found a lower predicted probability that patients received more invasive treatments. CONCLUSION Patients with LAT orders appear to receive care that is less aggressive and less congruent with acute myocardial infarction care guidelines compared with patients without such orders. Quality improvement measures will need to take this difference into account and ensure that physicians are not penalized for complying with patient care preferences.
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Affiliation(s)
- Tiffany A Radcliff
- VA Eastern Colorado Healthcare System, HSR and D TREP for Long-term Care Research, Denver, CO 80220, USA.
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Hutt E, Ruscin JM, Corbett K, Radcliff TA, Kramer AM, Williams EM, Liebrecht D, Klenke W, Hartmann S. A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing HomeâAcquired Pneumonia in a State Veterans Home. J Am Geriatr Soc 2006; 54:1694-700. [PMID: 17087696 DOI: 10.1111/j.1532-5415.2006.00937.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home-acquired pneumonia (NHAP) into practice using a small intervention trial. DESIGN Pre-posttest with untreated control group. SETTING Two Colorado State Veterans Homes (SVHs) during two influenza seasons. PARTICIPANTS Eighty-six residents with two or more signs of lower respiratory tract infection. INTERVENTION Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing. MEASUREMENTS Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test. RESULTS At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year. CONCLUSION Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents.
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Affiliation(s)
- Evelyn Hutt
- Department of Medicine, Denver Veterans Affairs Medical Center, Denver, Colorado 80220, USA.
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Hu HM, Duncan RP, Radcliff TA, Porter CK, Hall AG. Variations in health insurance coverage for rural and urban nonelderly adult residents of Florida, Indiana, and Kansas. J Rural Health 2006; 22:147-50. [PMID: 16606426 DOI: 10.1111/j.1748-0361.2006.00023.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Evidence exists for differences in health insurance coverage among states, but less is known about variations across different kinds of communities within states. PURPOSE This article assesses the role of residential setting (metropolitan county, rural adjacent, and rural nonadjacent) in health insurance coverage for adult residents, under age 65, using data from large-scale surveys collected in 3 diverse states (Florida, Indiana, and Kansas). METHODS Descriptive statistics are provided, and logistic regression models are used to examine the relationship between uninsurance status and residential settings while controlling for personal characteristics. Adjusted uninsurance rates by residential settings are presented for each state. FINDINGS Residential settings are significantly associated with uninsurance status in 2 of the 3 states we examined. We find that adult Floridians of rural adjacent counties are more likely to be uninsured than those in urban counties, but, for Indiana residents, uninsurance status is comparable between urban and rural adjacent residents. Rural nonadjacent Indiana residents are more likely to be uninsured compared to those in urban counties. The insurance status of adult Kansans does not vary across residential settings. CONCLUSION Residential settings are significantly associated with being uninsured, but the significance of this link between residential locations and uninsurance status varies from state to state.
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Affiliation(s)
- Hsou Mei Hu
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109, USA.
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Abstract
The authors examine whether retrospective claims data are useful to distinguish future high-cost cases among the uninsured. They rely on internal claims and accounting data for the calendar years from 1999 to 2001 from a representative safety net facility to describe the distribution of costs and any characteristics that distinguish high-cost patients from other uninsured patients. They conclude that administrative data combined with in-depth survey information could be a useful approach for identifying cases for intensive case management.
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Dobalian A, Tsao JCI, Radcliff TA. Diagnosed mental and physical health conditions in the United States nursing home population: differences between urban and rural facilities. J Rural Health 2003; 19:477-83. [PMID: 14526506 DOI: 10.1111/j.1748-0361.2003.tb00585.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT There has been limited examination of the differences in health characteristics of the rural long-term care population. Recognizing these differences will allow policymakers to improve access to long-term care services in rural communities. PURPOSE To determine whether differences in likelihood of diagnosis exist between urban and rural nursing home residents for 8 common medical conditions: 4 mental health conditions (depression, anxiety, Alzheimer's, and non-Alzheimer's dementia) and 4 physical health conditions (cancer, emphysema/chronic obstructive pulmonary disease, heart disease, and stroke/transient ischemic attack). METHODS We used multivariate logistic regression to examine data derived from the 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multistage stratified probability sample of 815 nursing homes and 5899 residents, representing 3.1 million individuals in the United States who spent 1 or more nights in nursing homes during 1996. FINDINGS Residents in rural homes were less likely to be diagnosed with depression compared to those in homes in large metropolitan areas, and residents in homes in small metropolitan areas were less likely to have cancer than those in large metropolitan areas. Diagnostic status between urban and rural residents was comparable for the other 6 conditions. CONCLUSIONS Further research is necessary to determine whether and why depression is inadequately diagnosed in rural nursing homes and to ascertain which types of cancer are responsible for the observed differential. Such research is particularly important for elderly nursing home residents who are more likely to suffer from chronic conditions that require significant medical supervision.
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Affiliation(s)
- Aram Dobalian
- Department of Health Services Administration, University of Florida, PO Box 100195, Gainesville, FL 32610-0195, USA.
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Abstract
CONTEXT Though many rural hospitals offer a broad array of services, local residents may choose more distant facilities for inpatient care services. Depending on the extent of the bypass phenomenon, hospitals may experience financial distress, reduced service offerings, or closure. PURPOSE This study provides a descriptive analysis of rural hospital bypass behavior in 7 states. METHODS We examine hospital discharge data for calendar years 1991 and 1996 to determine the extent to which patients admitted from rural areas are bypassing local facilities. We also assess whether there are trends in bypass patterns over time. Our primary specification of bypass is defined as a discharge from a hospital between 15 and 1000 miles from the closest facility. FINDINGS We found an overall bypass rate of 30%. This overall rate changed little between 1991 and 1996. Subgroups of patients, defined by payer and diagnosis, had differing propensities to bypass local rural facilities. Patients with managed care or commercial insurance had higher bypass rates compared to patients who relied on other payer sources. Medicare and uninsured (self-pay) patients had lower bypass rates. Payer type differences persisted when cases were divided into emergent and scheduled categories. Patients seeking general medical or obstetrical care had lower bypass rates than patients discharged with a diagnosis related group (DRG) related to complex medical, general surgery, or specialty surgery services. With the exception of normal delivery, DRG codes frequently associated with bypass discharges involved procedures or surgery that may not be offered by smaller rural facilities. CONCLUSIONS Our results indicate that rural patients, or their admitting physicians, perceive local rural hospitals as a viable option for many inpatient care services but prefer other facilities for treatments beyond the scope of general medical or surgical treatment.
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Affiliation(s)
- Tiffany A Radcliff
- Department of Health Services Administration, University of Florida, PO Box 100195, Gainesville, FL 32610-0195, USA.
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Abstract
This study analyzes the changes in costs and prices from 1986 to 1994 for more than 3,500 U.S. short-term general hospitals, including 122 horizontal mergers. These mergers were generally financially beneficial to consumers, providing average price reductions of approximately 7 percent. Merger-related price reductions were considerably less in market areas with higher market concentration levels. Merger-related price reductions in areas with higher penetration by health maintenance organizations (HMOs) were approximately twice those in areas with lower HMO penetration. Merger-related price reductions were greater for low-occupancy hospitals, nonteaching hospitals, nonsystem hospitals, similar-size hospitals, and hospitals with greater premerger service duplication.
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Affiliation(s)
- R A Connor
- Healthcare Management Department, Carlson School of Management, USA
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