Asunto(s)

Terapia Genética , Humanos , Terapia Genética/economía , Tratamiento Basado en Trasplante de Células y Tejidos/economía , Estados Unidos , Compra Basada en Calidad

RESUMEN

OBJECTIVE: The COVID-19 public health emergency (PHE) has important implications for health care service delivery. Little is understood about how the PHE impacted community-based hospice providers and service delivery to hospice-eligible beneficiaries. The aim of this study was to describe hospice response to the PHE and correlated impacts on beneficiary receipt of hospice support services delivered to hospice-eligible beneficiaries participating in the Centers for Medicare & Medicaid Services (CMS) Medicare Care Choices Model (MCCM), a national model testing the provision of certain hospice-like supportive services with concurrent usual care among seriously ill, community-residing Medicare beneficiaries that have not elected to receive hospice care. METHODS: We employed descriptive analysis using concurrent qualitative and quantitative data sources, consisting of provider surveys, beneficiary-level encounter data submitted by hospices, and Medicare administrative claims describing beneficiary service utilization. The sample included both hospice providers (N = 82) and beneficiaries (N = 2294) voluntarily participating in MCCM. RESULTS: Nearly all participating MCCM hospices adopted operational changes to address their staff and beneficiaries' safety during the COVID-19 PHE. We report changes to service delivery, including declines in total encounters as well as service modality, and the types of services provided. CONCLUSIONS: While the analyses reported indicate that seriously ill Medicare beneficiaries participating in MCCM were directly impacted by the PHE, we are still unclear whether changes in the service modality and encounters by provider type and the decline in average service counts per beneficiary are driven more by hospices or by beneficiary decisions to minimize exposure. Future research should attempt to disentangle these factors.

Asunto(s)

COVID-19 , Cuidados Paliativos al Final de la Vida , Hospitales para Enfermos Terminales , Anciano , Humanos , Estados Unidos , Medicare , Atención a la Salud

RESUMEN

In public health insurance programs, federal and state regulators use network adequacy standards to ensure that health plans provide enrollees with adequate access to care. These standards are based on provider availability, anticipated enrollment, and patterns of care delivery. We anticipate that the coronavirus disease 2019 pandemic will have 3 main effects on provider networks and their regulation: enrollment changes, changes to the provider landscape, and changes to care delivery. Regulators will need to ensure that plans adjust their network size should there be increased enrollment or increased utilization caused by forgone care. Regulators will also require updated monitoring data and plan network data that reflect postpandemic provider availability. Telehealth will have a larger role in care delivery than in the prepandemic period, and regulators will need to adapt network standards to accommodate in-person and virtual care delivery.

Asunto(s)

COVID-19 , Planificación en Salud , Accesibilidad a los Servicios de Salud/normas , Cobertura del Seguro/normas , Seguro de Salud/normas , Sector Público , Intercambios de Seguro Médico , Humanos , Cobertura del Seguro/legislación & jurisprudencia , Cobertura del Seguro/organización & administración , Seguro de Salud/legislación & jurisprudencia , Seguro de Salud/organización & administración , Medicaid/legislación & jurisprudencia , Medicare/legislación & jurisprudencia , Estados Unidos

RESUMEN

A genuine opportunity exists to reform medical and long-term care systems to be more responsive to people's needs and preferences and provide efficient, cost-effective care delivery. California is preparing to test models of integration for those dually eligible for Medicare and Medicaid that aim to improve care while managing costs. The SCAN Foundation has created a conceptual framework for guiding investments in California and beyond that is intended to create a more "person-centered" system that integrates medical care and supportive services. This article describes the foundation's vision and framework for creating a more person-centered system and its support of California's efforts in achieving this goal.

Asunto(s)

Atención a la Salud/organización & administración , Fundaciones/economía , Cuidados a Largo Plazo/economía , Atención Dirigida al Paciente/organización & administración , Anciano , Anciano de 80 o más Años , California , Femenino , Evaluación Geriátrica/métodos , Necesidades y Demandas de Servicios de Salud/economía , Humanos , Masculino , Medicaid/economía , Medicare/economía , Estados Unidos

RESUMEN

Recent attention has focused on validity and feasibility of different approaches to developing performance indicators for the purposes of quality improvement and value-based purchasing. This paper presents the methodology used to develop a comprehensive set of performance indicators that will be used for a national evaluation of the mental healthcare provided by the Veterans Health Administration. The paper report on the indicators' technical specifications and the United States Public Health System Task Force defined strength of supporting evidence. Indicators were reviewed iteratively for meaningfulness, utility, feasibility, and supporting evidence until a final set of measures of acceptable validity and feasibility was produced with technical specifications. Fifty-seven mental health performance indicators that use information from both the medical record and administrative data (hybrid indicators) and 31 administrative-data only indicators are presented. Of the 57 hybrid indicators, 13 indicators are supported by Agency for Healthcare Research and Quality grade I evidence, 5 indicators are grade II, and 39 indicators are grade III. This paper describes the methodology used to develop 88 performance indicators of the quality of mental health and substance abuse treatment, and presents the technical specifications associated with each indicator.

Asunto(s)

Registros Médicos , Servicios de Salud Mental/normas , Indicadores de Calidad de la Atención de Salud , Salud de los Veteranos , Humanos , Estados Unidos , United States Agency for Healthcare Research and Quality

RESUMEN

BACKGROUND: Pain is a common, often undertreated problem among patients with palliative needs. OBJECTIVES: To evaluate clinician factors associated with intention to address diverse aspects of pain. DESIGN: Clinicians reviewed a clinical vignette describing a frail elderly patient with advanced hormone-refractory metastatic prostate cancer, depression, and pain not on analgesic therapy. Clinicians were surveyed about their intentions for treatment. PARTICIPANTS: All 280 primary care and specialist clinicians working in 19 hospital and community-based primary care, oncology, and cardiology clinics at eight geographically dispersed sites in two large VA hospital systems. MAIN MEASURES: Endpoints were clinician intention to deliver guideline-concordant care: prescribe opioids/antidepressants, assess existential wellbeing, and offer mental health referral. Demographic and behavioral measures were evaluated in association with endpoints. KEY RESULTS: Of 208 (74%) responding practitioners, 189 were responsible for prescribing decisions. Of those, 86, 77, 75, and 69 were "very"/"somewhat likely" to prescribe opioids, antidepressants, refer to a mental health specialist, or assess existential wellbeing, respectively. Factors associated with greater intent to prescribe an opioid or antidepressant included female gender, being an attending physician, being a primary care clinician, and greater confidence in pain management skills. Greater trust in the validity of pain ratings was associated with intent to prescribe an antidepressant and assess existential wellbeing. Prescribing opioids was less likely if perceived as an administrative burden. Assessing existential wellbeing was less likely if time constraints were perceived a barrier to evaluating pain. Female gender was the only factor associated with intent to refer to a mental health specialist. CONCLUSIONS: Our findings suggest useful targets for improving pain management include bolstering clinician confidence in pain management and their trust in pain ratings.

Asunto(s)

Analgésicos/uso terapéutico , Actitud del Personal de Salud , Pacientes Ambulatorios , Dolor/tratamiento farmacológico , Médicos/psicología , Pautas de la Práctica en Medicina , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Antidepresivos/uso terapéutico , Recolección de Datos , Depresión/tratamiento farmacológico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad

RESUMEN

CONTEXT: Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate. OBJECTIVES: This study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated. METHODS: This was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS). RESULTS: Pain underestimation (N-NRSS-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staff's use of the full NRS protocol and with a distracting environment in which patient vitals were taken. CONCLUSION: Despite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.

Asunto(s)

Dimensión del Dolor/métodos , Dimensión del Dolor/enfermería , Dolor/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Estudios Transversales , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Personal de Enfermería , Pacientes Ambulatorios , Veteranos

RESUMEN

Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to identify variables associated with proclivity to address patient fears about addiction risks in a population where pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely to take action. Health technicians were less likely to address addiction concerns than registered or licensed vocational nurses (odds ratio [OR] 0.116; p=.004). Nursing staff with more years' experience (OR 1.070; p=.005) and higher levels of self-efficacy/confidence (OR 1.380; p=.001) were more likely to engage in discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of less experienced and less skilled staff.

Asunto(s)

Actitud del Personal de Salud , Actitud Frente a la Salud , Personal de Enfermería/psicología , Dolor/psicología , Trastornos Relacionados con Sustancias , Adulto , Anciano , Competencia Clínica , Miedo , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Modelos Logísticos , Los Angeles , Masculino , Persona de Mediana Edad , Análisis Multivariante , Rol de la Enfermera/psicología , Investigación Metodológica en Enfermería , Personal de Enfermería/educación , Personal de Enfermería/organización & administración , Dolor/complicaciones , Dolor/tratamiento farmacológico , Educación del Paciente como Asunto , Pautas de la Práctica en Enfermería/organización & administración , Factores de Riesgo , Autoeficacia , Trastornos Relacionados con Sustancias/etiología , Trastornos Relacionados con Sustancias/prevención & control , Estados Unidos , United States Department of Veterans Affairs

RESUMEN

Establishing goals of care is important in advance care planning. However, such discussions require a significant time investment on the part of trained personnel and may be overwhelming for the patient. The Go Wish card game was designed to allow patients to consider the importance of common issues at the end of life in a nonconfrontational setting. By sorting through their values in private, patients may present to their provider ready to have a focused conversation about end-of-life care. We evaluated the feasibility of using the Go Wish card game with seriously ill patients in the hospital. Of 133 inpatients approached, 33 (25%) were able to complete the game. The "top 10" values were scored based on frequency and adjusted for rank. The value selected of highest importance by the most subjects was "to be free from pain." Other highly ranked values concerned spirituality, maintaining a sense of self, symptom management, and establishing a strong relationship with health care professionals. Average time to review the patient's rank list after the patient sorted their values in private was 21.8 minutes (range: 6-45 minutes). The rankings from the Go Wish game are similar to those from other surveys of seriously ill patients. Our results suggest that it is feasible to use the Go Wish card game even in the chaotic inpatient setting to obtain an accurate portrayal of the patient's goals of care in a time-efficient manner.

Asunto(s)

Comunicación , Juegos Experimentales , Cuidados Paliativos/psicología , Participación del Paciente/métodos , Participación del Paciente/psicología , Relaciones Médico-Paciente , Cuidado Terminal/psicología , Adulto , Anciano , Anciano de 80 o más Años , California , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad

RESUMEN

BACKGROUND: Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. OBJECTIVE: To assess adherence to measures of pain management quality and identify associated patient and provider factors. DESIGN: A cross-sectional visit-based study. PARTICIPANTS: One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. MEASUREMENT AND MAIN RESULTS: We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that "patients want me to ask about pain" and "pain can have negative consequences on patient's functioning". Charts were more likely to document character of pain if providers agreed that "patients are able to rate their pain". Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. CONCLUSIONS: Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.

Asunto(s)

Analgésicos/uso terapéutico , Actitud del Personal de Salud , Hospitales de Veteranos , Dimensión del Dolor , Pautas de la Práctica en Medicina , Indicadores de Calidad de la Atención de Salud , Estudios Transversales , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Servicio Ambulatorio en Hospital , Satisfacción del Paciente , Relaciones Médico-Paciente

RESUMEN

Although dyspnea and fatigue are hallmark symptoms of heart failure (HF), the burden of pain may be underrecognized. This study assessed pain in HF and identified contributing factors. As part of a multicenter study, 96 veterans with HF (96% male, 67+/-11 years) completed measures of symptoms, pain (Brief Pain Inventory [BPI]), functional status (Functional Morbidity Index), and psychological state (Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Single items from the BPI interference and the quality of life-end of life measured social and spiritual well-being. Demographic and clinical variables were obtained by chart audit. Correlation and linear regression models evaluated physical, emotional, social, and spiritual factors associated with pain. Fifty-three (55.2%) HF patients reported pain, with a majority (36 [37.5%]) rating their pain as moderate to severe (pain>or=4/10). The presence of pain was reported more frequently than dyspnea (67 [71.3%] vs. 58 [61.7%]). Age (P=0.02), psychological (depression: P=0.002; anxiety: P=0.001), social (P<0.001), spiritual (P=0.010), and physical (health status: P=0.001; symptom frequency: P=0.000; functional status: P=0.002) well-being were correlated with pain severity. In the resulting model, 38% of the variance in pain severity was explained (P<0.001); interference with relations (P<0.001) and symptom number (P=0.007) contributed to pain severity. The association of physical, psychological, social, and spiritual domains with pain suggests that multidisciplinary interventions are needed to address the complex nature of pain in HF.

Asunto(s)

Insuficiencia Cardíaca/complicaciones , Manejo del Dolor , Dolor/etiología , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/psicología , Dimensión del Dolor , Cuidados Paliativos

RESUMEN

Patients with advanced cancer often do not receive high-quality pain and symptom management or support with coordination of care, communication, and decision making. Implementing quality indicators that are reflective of the scope of care, feasible to implement, and supported by evidence might help to identify areas and settings most in need of improvement. However, recent reviews and policy initiatives identified only a few indicators that met these criteria. To help advance quality indicator development and implementation in this area, we developed a conceptual framework based on previous related initiatives, updated reviews of end-of-life cancer quality indicators and relevant data sources, and expert input. The framework describes five steps for developing and assessing a quality indicator for end-of-life care, defining the 1) population of focus, 2) broad quality domains, 3) specific target areas, 4) steps of the care process, and 5) evaluation criteria for quality indicators. The defined population includes seriously or terminally ill cancer patients, who are unlikely to recover or stabilize, and their families. Domains include the structure and processes of care; the physical, psychiatric, psychosocial, spiritual, and cultural aspects of care; as well as the care of the imminently dying, ethical and legal issues, and the delivery of care. Evaluation criteria include importance; scientific acceptability, including validity, evidence to improve outcomes, reliability, responsiveness, and variability; usability; and feasibility, including ready data sources. By using this conceptual framework, indicator developers, researchers, and policymakers can refine and implement indicator sets to effectively evaluate and improve care at the end of life.

Asunto(s)

Neoplasias/terapia , Humanos , Modelos Organizacionales , Garantía de la Calidad de Atención de Salud , Indicadores de Calidad de la Atención de Salud , Cuidado Terminal/normas , Resultado del Tratamiento

RESUMEN

In the United States and abroad, the aging of the population and changes in its demographic and social composition raise important considerations for the future of health care and the systems that pay for care. Studies in the United States on end-of-life expenditures and utilization focus primarily on Medicare and have reported differences in formal end-of-life spending and types of services used by age, race, gender, and other personal characteristics, with most notable differences attributed to age at death. Although overall health care spending tends to be higher for people who are white and women, these patterns tend to either reverse themselves or narrow at the end of life. However, age at death continues to be associated with large spending differences at the end of life, with end-of-life spending declining at older ages. Although different data sources, analytic methods, and definitions of end-of-life care make comparisons of the absolute level of end-of-life spending in the United States to that of other countries difficult, a reading of the existing literature reveals some similarities in the distribution of spending across patient characteristics, even across different systems of health care and insurance. In particular, end-of-life spending tends to decline with age, indicating that treatment intensity likely declines with age in most countries to varying degrees. Future international collaborations may help to make data collection and analysis efforts more comparable, enabling identification of factors associated with high-quality end-of-life care and helping health care planners across countries to learn from the successes of others.

Asunto(s)

Costo de Enfermedad , Costos de la Atención en Salud/estadística & datos numéricos , Medicaid/economía , Medicare/economía , Cuidados Paliativos/economía , Cuidado Terminal/economía , Distribución por Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Medicaid/normas , Medicare/normas , Cuidados Paliativos/estadística & datos numéricos , Distribución por Sexo , Cuidado Terminal/estadística & datos numéricos , Estados Unidos/epidemiología

RESUMEN

Quality indicators applicable to cancer end-of-life care exist, but have not been widely implemented. To advance this field, the authors worked with the Agency for Health Care Research and Quality and the National Cancer Institute to organize a national symposium to discuss key issues and future goals, based on a conceptual framework. Discussions focused on 8 key domains in end-of-life cancer care: pain; dyspnea; communication, care planning, and decision making; psychosocial care; communication about chemotherapy; depression; continuity, coordination, and care transitions; and spirituality and closure. Key themes included the need for clarity on definitions and key aspects of care within domains, the need to start implementing indicators in more developed domains, and the importance of high-quality symptom assessment and documentation of key processes. Key areas for future work include development of more outcome indicators, methods to better incorporate indicators and patient-reported outcomes into clinical processes of care, and coordination across domains and settings. Measuring the quality of end-of-life cancer care is essential to understanding how best to improve patient outcomes and care.

Asunto(s)

Neoplasias/terapia , Indicadores de Calidad de la Atención de Salud , Cuidado Terminal/normas , Comunicación , Humanos , Evaluación de Necesidades , Neoplasias/psicología , Evaluación de Programas y Proyectos de Salud , Calidad de la Atención de Salud , Apoyo Social

RESUMEN

BACKGROUND: Previous research suggests that disparities in non-small-cell lung cancer (NSCLC) survival can be explained in part by disparities in the receipt of cancer treatment. Few studies, however, have considered race and sex disparities in the timing and appropriateness of treatment across stages of diagnosis. OBJECTIVE: To evaluate the relationship of sex and race with the receipt of timely and clinically appropriate NSCLC treatment for each stage of diagnosis. METHOD: Surveillance Epidemiology and End Result data linked to Medicare claims for beneficiaries diagnosed with NSCLC between 1995 and 1999 were used to evaluate the relationship between race and sex with timely and appropriate NSCLC treatment while controlling for other demographic characteristics, comorbidities, socioeconomic status, and provider supply (N = 22,145). RESULTS: Overall adjusted rates of timely and appropriate treatment are 37.2%, 58.1%, and 29.2% for Medicare beneficiaries diagnosed with stage I or II, III, and IV NSCLC, respectively. Among stage I or II patients, women were 25% less likely to receive timely surgical resection relative to men, and blacks were 66% less likely to receive timely and appropriate treatment than whites. Black men were least likely to receive resection (22.2% compared with 43.7% for white men). Blacks were 34% less likely to receive timely surgery, chemotherapy, or radiation for stage III disease and were 51% less likely to receive chemotherapy in a timely fashion for stage IV disease relative to whites. CONCLUSION: Significant variations in appropriate timely treatment were found within and across stages of diagnosis, confirming that sex and race differences in NSCLC treatment exist.

Asunto(s)

Negro o Afroamericano/estadística & datos numéricos , Carcinoma de Pulmón de Células no Pequeñas/terapia , Disparidades en Atención de Salud/estadística & datos numéricos , Neoplasias Pulmonares/terapia , Población Blanca/estadística & datos numéricos , Negro o Afroamericano/etnología , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Carcinoma de Pulmón de Células no Pequeñas/etnología , Femenino , Adhesión a Directriz/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Investigación sobre Servicios de Salud , Humanos , Formulario de Reclamación de Seguro/estadística & datos numéricos , Modelos Logísticos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/etnología , Masculino , Medicare/estadística & datos numéricos , Hombres , Análisis Multivariante , Selección de Paciente , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Programa de VERF , Sensibilidad y Especificidad , Factores Sexuales , Estados Unidos/epidemiología , Población Blanca/etnología , Mujeres

RESUMEN

BACKGROUND: Although many health care organizations require routine pain screening (eg, "5th vital sign") with the 0 to 10 numeric rating scale (NRS), its accuracy has been questioned; here we evaluated its accuracy and potential causes for error. METHODS: We randomly surveyed veterans and reviewed their charts after outpatient encounters at 2 hospitals and 6 affiliated community sites. Using correlation and receiver operating characteristic analysis, we compared the routinely measured "5th vital sign" (nurse-recorded NRS) with a research-administered NRS (research-recorded NRS) and the Brief Pain Inventory (BPI). RESULTS: During 528 encounters, nurse-recorded NRS and research-recorded NRS correlated moderately (r = 0.627), as did nurse-recorded NRS and BPI severity scales (r = 0.613 for pain during the last 24 hours and r = 0.588 for pain during the past week). Correlation with BPI interference was lower (r = 0.409). However, the research-recorded NRS correlated substantially with the BPI severity during the past 24 hours (r = 0.870) and BPI severity during the last week (r = 0.840). Receiver operating characteristic analysis showed similar results. Of the 98% of cases where a numeric score was recorded, 51% of patients reported their pain was rated qualitatively, rather than with a 0 to 10 scale, a practice associated with pain underestimation (chi2 = 64.04, P < .001). CONCLUSION: Though moderately accurate, the outpatient "5th vital sign" is less accurate than under ideal circumstances. Personalizing assessment is a common clinical practice but may affect the performance of research tools such as the NRS adopted for routine use.

Asunto(s)

Dimensión del Dolor/métodos , Dolor/diagnóstico , Anciano , California/epidemiología , Femenino , Indicadores de Salud , Humanos , Masculino , Persona de Mediana Edad , Dolor/epidemiología , Dolor/enfermería , Dimensión del Dolor/estadística & datos numéricos , Reproducibilidad de los Resultados , Veteranos/estadística & datos numéricos

RESUMEN

BACKGROUND: Depression and anxiety frequently co-occur with pain and may affect treatment outcomes. Early identification of these co-occurring psychiatric conditions during routine pain screening may be critical for optimal treatment. OBJECTIVE: To determine aspects of pain related to psychological distress, and, among distressed patients, to determine whether pain factors are related to provider identification of distress. DESIGN: Cross-sectional interview of primary care patients and their providers participating in a Veteran's Administration HELP-Vets study. SUBJECTS: A total of 528 predominately male Veterans MEASUREMENTS AND MAIN RESULTS: We measured self-reported pain, including a 0-10 numeric rating scale and interference items from the Brief Pain Inventory. To evaluate distress, brief indicators of depression, anxiety and PTSD were combined. A substantial number of patients had psychological distress (41%), which was even higher (62%) among patients with moderate-severe current pain. Only 29% of those with distress reported talking to their provider about emotional problems during their visit. In multivariate analyses, other pain factors related to distress included interference with enjoyment of life and relationships with others, pain in multiple locations and joint pains. Prior diagnoses of depression and anxiety were also related to current distress. Only prior diagnosis and patient reported headaches and sleep interference because of pain were related to provider identification of distress. CONCLUSIONS: VA patients with moderate-severe pain are at high risk for psychological distress, which often goes unrecognized. Providers need to be more vigilant to mental health problems in patients experiencing high pain levels. Targeted screening for co-occurring conditions is warranted.

Asunto(s)

Ansiedad/complicaciones , Ansiedad/diagnóstico , Depresión/complicaciones , Depresión/diagnóstico , Dolor/complicaciones , Dolor/diagnóstico , Anciano , Ansiedad/psicología , Estudios Transversales , Depresión/psicología , Diagnóstico Precoz , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/psicología , Estrés Psicológico/complicaciones , Estrés Psicológico/diagnóstico , Estrés Psicológico/psicología

RESUMEN

BACKGROUND: Progress has been made in addressing pain in specific diseases such as cancer, but less attention has focused on understanding pain in nonmalignant states, including heart failure (HF). METHODS AND RESULTS: From March 2006 to June 2007, 672 veterans were surveyed and scores for the Brief Pain Inventory, pain distress, clinically significant pain levels (moderate to severe pain), and pain locations were compared using univariate and multivariate models. Fifteen percent of the final sample had HF (95/634). In our study, the HF patients were older (P < .000), reported lower levels of general health (P = .018), had more co-morbidities (P < .000), were more likely to have a history of cancer (P = .035), and suffered more chest pain and fewer headaches (P = .026, P = .03, respectively) than their non-HF cohorts. When controlling for age, co-morbidity and cancer disorders, HF and non-HF patients did not differ in pain severity, interference, distress or locations. Of the patients currently experiencing pain, 67.3% of HF patients and 68.4% of non-HF patients rated their pain as moderate or severe (pain >or=4 on a 0 to 10 scale). CONCLUSIONS: Although HF has not been identified as a painful condition, this study suggests the burden of pain is significant for both HF and non-HF ambulatory care patients.

Asunto(s)

Insuficiencia Cardíaca/fisiopatología , Dolor/etiología , Veteranos/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Atención Ambulatoria/estadística & datos numéricos , Análisis de Varianza , California/epidemiología , Enfermedad Crónica , Comorbilidad , Progresión de la Enfermedad , Femenino , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/epidemiología , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Dolor/diagnóstico , Dimensión del Dolor , Cuidados Paliativos , Proyectos Piloto , Estados Unidos/epidemiología , Adulto Joven

RESUMEN

OBJECTIVES: To examine nursing home (NH) residents' use of Medicare-paid skilled nursing facility (SNF) services and the outcomes of that care and to identify clinical and non-clinical factors associated with that care. DESIGN: Retrospective cohort. SETTING: United States. PARTICIPANTS: NH residents aged 65 and older with Medicare claims for a hospitalization for hip fracture or stroke during 2001 to 2003. MEASUREMENTS: Resident diagnoses and use of SNF postacute care were measured using Medicare hospital claims. Market and provider characteristics were drawn from the Provider of Services file. Baseline characteristics, institutionalization, and mortality outcomes were drawn from the Minimum Data Set and Medicare Denominator File. RESULTS: Of the NH population hospitalized for hip fracture (49,903) or stroke (23,084), 79.7% and 64.1%, respectively, used the SNF benefit. Residents not using the SNF benefit had poorer baseline health status; their mortality rates and rates of resuming long-term care were similar to the rates of residents who used the SNF benefit. CONCLUSION: NH residents used postacute SNF benefits at high rates yet had similar mortality and institutionalization outcomes as those without SNF care.

Asunto(s)

Fracturas de Cadera/rehabilitación , Hogares para Ancianos/estadística & datos numéricos , Medicare/estadística & datos numéricos , Casas de Salud/estadística & datos numéricos , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Rehabilitación de Accidente Cerebrovascular , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Estudios Transversales , Evaluación de la Discapacidad , Femenino , Fracturas de Cadera/economía , Fracturas de Cadera/mortalidad , Hogares para Ancianos/economía , Humanos , Beneficios del Seguro/economía , Masculino , Medicare/economía , Casas de Salud/economía , Alta del Paciente/economía , Estudios Retrospectivos , Instituciones de Cuidados Especializados de Enfermería/economía , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/mortalidad , Análisis de Supervivencia , Resultado del Tratamiento , Estados Unidos , Revisión de Utilización de Recursos/estadística & datos numéricos

RESUMEN

PURPOSE: Gender and age differences in medical care are well documented. We examined age and gender differences in Medicare expenditures for lung cancer decedents in the last year of life (LYOL) through a cross-sectional study of Medicare administrative and claims data. METHODS: Participants were aged Medicare beneficiaries (>or=68) with lung cancer, who were covered by Parts A and B for 36 months before death (1996-1999; n = 13,120). Regression techniques were used to estimate age and gender differences in mean Medicare utilization and expenditures in the LYOL overall and by type of service, conditional on use: inpatient, outpatient, physician, skilled nursing facility (SNF), home health, and hospice, controlling for demographic, clinical, geographic, and supply characteristics. RESULTS: Women were more likely than men to use inpatient, SNF, home health, and hospice services. Women's average expenditures were approximately dollars 1,900 greater than men's, with differences attributed to higher average expenditures for SNF, home health, and hospice. Older cohorts used fewer inpatient and outpatient services and used more SNF and hospice services in their LYOL. Average Medicare expenditures were significantly lower in older cohorts (dollars 8,487 less for those age >or=85 at death than for those 68-74). Adjusting for age explains most of the gender differences in average Medicare expenditures. Remaining gender differences vary across age cohorts, with larger gender differences in social-supportive service expenditures among those 68-74 and 75-84 and outpatient and physician services among those 75-84 and >or=85. DISCUSSION AND CONCLUSIONS: Our findings suggest that gender disparities in expenditures are generally small at the end of life for lung cancer decedents, particularly among the older cohorts. As expected, the bigger observed differences are by age although the direction of the association is not consistent across types of service. Higher expenditures for women on social-supportive services may reflect fewer informal supports for older women compared with men.

Asunto(s)

Gastos en Salud/normas , Neoplasias Pulmonares/economía , Neoplasias Pulmonares/terapia , Medicare/economía , Cuidado Terminal/economía , Enfermo Terminal/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Cuidados Paliativos al Final de la Vida/economía , Humanos , Neoplasias Pulmonares/mortalidad , Masculino , Medicaid/economía , Medicare/estadística & datos numéricos , Casas de Salud/economía , Evaluación de Resultado en la Atención de Salud , Mecanismo de Reembolso/economía , Distribución por Sexo , Apoyo Social , Cuidado Terminal/estadística & datos numéricos , Estados Unidos