RESUMEN
OBJECTIVES: To examine the association between function measured according to activities of daily living (ADLs), instrumental activ1ities of daily living (IADLs), and cognition assessed according to Mini-Mental State Examination (MMSE) scores of older African-American and non-Hispanic white community-dwelling men and women. DESIGN: Cross-sectional study assessing associations between self-reported ADL and IADL difficulty and MMSE scores for race- and sex-specific groups. SETTING: Homes of community-dwelling older adults. PARTICIPANTS: A random sample of 974 African-American and non-Hispanic white Medicare beneficiaries aged 65 and older living in west-central Alabama and participating in the University of Alabama at Birmingham Study of Aging, excluding those with reported diagnoses of dementia or with missing data. MEASUREMENTS: Function, based on self-reported difficulty in performing ADLs and IADLs, and cognition, using the MMSE. Multivariable linear regression models were used to test the association between function and cognition in race- and sex-specific groups after adjusting for covariates. RESULTS: Mini-Mental State Examination scores were modestly correlated with ADL and IADL difficulty in all four race- and sex-specific groups, with Pearson correlation coefficients ranging from −0.189 for non-Hispanic white women to −0.429 for African-American men. Correlations between MMSE and ADL or IADL difficulty in any of the race- and sex-specific groups were no longer significant after controlling for sociodemographic factors and comorbidities. CONCLUSION: Mini-Mental State Examination was not significantly associated with functional difficulty in older African-American and non-Hispanic white men and women after adjusting for sociodemographic factors and comorbidities, suggesting a mediating role in the relationship between cognition and function.
Asunto(s)
Actividades Cotidianas , Trastornos del Conocimiento/etnología , Anciano , Anciano de 80 o más Años , Alabama/epidemiología , Trastornos del Conocimiento/epidemiología , Estudios Transversales , Femenino , Evaluación Geriátrica , Humanos , Vida Independiente , Masculino , Prevalencia , Estudios Prospectivos , Factores Sexuales , Factores SocioeconómicosRESUMEN
PURPOSE: To identify racial/ethnic differences in retention of older adults at 3 levels of participation in a prospective observational study: telephone, in-home assessments, and home visits followed by blood draws. DESIGN AND METHODS: A prospective study of 1,000 community-dwelling Medicare beneficiaries aged 65 years and older included a baseline in-home assessment and telephone follow-up calls at 6-month intervals; at 4 years, participants were asked to complete an additional in-home assessment and have blood drawn. RESULTS: After 4 years, 21.7% died and 0.7% withdrew, leaving 776 participants eligible for follow-up (49% African American; 46% male; 51% rural). Retention for telephone follow-up was 94.5% (N = 733/776); 624/733 (85.1%) had home interviews, and 408/624 (65.4%) had a nurse come to the home for the blood draw. African American race was an independent predictor of participation in in-home assessments, but African American race and rural residence were independent predictors of not participating in a blood draw. IMPLICATIONS: Recruitment efforts designed to demonstrate respect for all research participants, home visits, and telephone follow-up interviews facilitate high retention rates for both African American and White older adults; however, additional efforts are required to enhance participation of African American and rural participants in research requiring blood draws.
Asunto(s)
Envejecimiento , Negro o Afroamericano/estadística & datos numéricos , Participación de la Comunidad , Cooperación del Paciente/estadística & datos numéricos , Selección de Paciente , Población Blanca/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Alabama/epidemiología , Algoritmos , Recolección de Muestras de Sangre/estadística & datos numéricos , Escolaridad , Femenino , Estudios de Seguimiento , Evaluación Geriátrica , Conductas Relacionadas con la Salud , Estado de Salud , Visita Domiciliaria/estadística & datos numéricos , Humanos , Renta/estadística & datos numéricos , Masculino , Medicare/estadística & datos numéricos , Salud Mental , Estudios Prospectivos , Población Rural/estadística & datos numéricos , Muestreo , Encuestas y Cuestionarios , Análisis de Supervivencia , Teléfono , Factores de Tiempo , Estados Unidos , Población Urbana/estadística & datos numéricosRESUMEN
OBJECTIVES: To evaluate the feasibility and effectiveness of a falls management program (FMP) for nursing homes (NHs). DESIGN: A quality improvement project with data collection throughout FMP implementation. SETTING: NHs in Georgia owned and operated by a single nonprofit organization. PARTICIPANTS: All residents of participating NHs. INTERVENTION: A convenience sample of 19 NHs implemented the FMP. The FMP is a multifaceted quality improvement and culture change intervention. Key components included organizational leadership buy-in and support, a designated facility-based falls coordinator and interdisciplinary team, intensive education and training, and ongoing consultation and oversight by advanced practice nurses with expertise in falls management. MEASUREMENTS: Process-of-care documentation using a detailed 24-item audit tool and fall and physical restraint use rates derived from quality improvement software currently used in all Georgia NHs (MyInnerView). RESULTS: Care process documentation related to the assessment and management of fall risk improved significantly during implementation of the FMP. Restraint use decreased substantially during the project period, from 7.9% to 4.4% in the intervention NHs (a relative reduction of 44%), and decreased in the nonintervention NHs from 7.0% to 4.9% (a relative reduction of 30%). Fall rates remained stable in the intervention NHs (17.3 falls/100 residents per month at start and 16.4 falls/100 residents per month at end), whereas fall rates increased 26% in the NHs not implementing the FMP (from 15.0 falls/100 residents/per month to 18.9 falls/100 residents per month). CONCLUSION: Implementation was associated with significantly improved care process documentation and a stable fall rate during a period of substantial reduction in the use of physical restraints. In contrast, fall rates increased in NHs owned by the same organization that did not implement the FMP. The FMP may be a helpful tool for NHs to manage fall risk while attempting to reduce physical restraint use in response to the Centers for Medicare and Medicaid Services quality initiatives.
Asunto(s)
Accidentes por Caídas/prevención & control , Implementación de Plan de Salud , Hogares para Ancianos/organización & administración , Casas de Salud/organización & administración , Administración de la Seguridad/organización & administración , Accidentes por Caídas/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Ensayos Clínicos como Asunto , Estudios Transversales , Recolección de Datos/estadística & datos numéricos , Estudios de Factibilidad , Femenino , Georgia , Hogares para Ancianos/estadística & datos numéricos , Humanos , Masculino , Estudios Multicéntricos como Asunto , Casas de Salud/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud , Garantía de la Calidad de Atención de Salud/organización & administración , Restricción Física/estadística & datos numéricos , Factores de RiesgoRESUMEN
There is an urgent need for model programs to effectively manage fall risk in nursing homes. Such programs should use best practices and quality improvement (QI) methodology in a manner that is practical for sustained implementation in the current resource-constrained long-term care environment. The Falls Management Program (FMP) represents 13 years of fieldwork (1993-2006). It is an interdisciplinary, multifaceted approach to reducing fall risk that includes systematic screening, assessment, individualized care planning, resident monitoring, and the elimination of environmental safety hazards. The FMP is initiated by a self-assessment process that assists nursing homes in identifying areas that need improvement so that staff can tailor implementation to their own facility's needs. The FMP incorporates education on best practices and uses several QI tools designed to assist nursing homes with program implementation. Core components of the program include administrative and clinical leadership, interdisciplinary teamwork using QI methodology, support by advance practice nurses, and an 8-step fall response system to facilitate the comprehensive investigation and documentation of falls, primary care provider involvement, and development of individualized fall risk reduction strategies.
Asunto(s)
Accidentes por Caídas/prevención & control , Casas de Salud/estadística & datos numéricos , Accidentes por Caídas/estadística & datos numéricos , Documentación , Humanos , Control de Calidad , Factores de RiesgoRESUMEN
Although several clinical studies have demonstrated success in reducing falls among nursing home residents, the degree of adherence to these strategies varies widely among studies and facilities, especially following the removal of external consultants or advance practice nurses (APNs). This article identified contextual factors that challenged the effective implementation of a falls reduction program. For nurses, the major problems with implementing the project involved inadequate nursing assessment and clinical decision making. APNs who influence nursing staff behavior via education and individual resident consultation may fill the critical gap in professional nursing care in nursing homes.
Asunto(s)
Accidentes por Caídas/prevención & control , Enfermeras Practicantes , Casas de Salud/organización & administración , Humanos , Capacitación en Servicio , Cuidados a Largo Plazo/organización & administración , Innovación Organizacional , Estados UnidosRESUMEN
Traditional "one-patient-at-a-time," doctor-centered primary care practice models do not achieve optimal immunization rates for pneumonia and influenza, in part because of time pressures and competing demands from a burgeoning list of clinical guidelines. Some widely used quality improvement methods (physician education, provider feedback, academic detailing, etc.) have only a modest and short-lived impact on improving immunization rates. Evidence is mounting that practices can substantially improve immunization rates by changing practice systems and processes with standing orders and algorithms, expanded nurse decision-making, patient education and incentives, and partnerships with community-based pharmacies. Quality-focused, constantly-learning practices that cultivate a culture of excellence will be most effective in adopting such changes.
Asunto(s)
Accesibilidad a los Servicios de Salud , Inmunización/estadística & datos numéricos , Atención Primaria de Salud/organización & administración , Garantía de la Calidad de Atención de Salud/métodos , Adulto , Sistemas de Información en Atención Ambulatoria , Medicina Basada en la Evidencia , Humanos , Vacunas contra la Influenza/administración & dosificación , Vacunas contra la Influenza/provisión & distribución , Gripe Humana/prevención & control , Innovación Organizacional , Farmacias/organización & administración , Factores Socioeconómicos , Estados UnidosRESUMEN
OBJECTIVES: To determine whether there were racial or ethnic disparities in the use of antidepressants in low-income elderly patients insured by Medicaid. DESIGN: Examination of 1998 Medicaid claims data. SETTING: Centers for Medicare and Medicaid Services Medicaid claims data for five U.S. states. PARTICIPANTS: All Medicaid recipients aged 65 to 84 with a diagnosis of depression. MEASUREMENTS: Treatment versus no treatment; in those treated, treatment with drugs was classified as old- or new-generation antidepressants. RESULTS: In 1998, 7,339 unique individuals aged 65 to 84 had at least one outpatient encounter with depression as the primary diagnosis. Nearly one in four (24.2%) received no antidepressant drug therapy, and 22% received neither psychotherapy nor an antidepressant. African-American individuals were substantially more likely to be untreated (37.1%) than Hispanic (23.6%), white (22.4%), or Asian (13.8%) individuals. In logistic regression models adjusting for sex, state, long-term care status, and age group, African Americans with a primary diagnosis of depression were almost twice as likely as whites not to receive an antidepressant within the study period (odds ratio=1.91, 95% confidence interval=1.62-2.24). Patients in long-term care facilities and those aged 65 to 74 were less likely to receive treatment. CONCLUSION: Substantial numbers of elderly Medicaid enrollees with a primary diagnosis of depression did not receive antidepressants or behavioral therapy. This gap in care disproportionately affected African-American patients.