Health care resource use after acute stroke in the Glycine Antagonist in Neuroprotection (GAIN) Americas trial.
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BACKGROUND AND PURPOSE: To compare 3-month stroke outcomes and stroke-related health care resource use between the US and Canada in the Glycine Antagonist in Neuroprotection (GAIN) Americas study. Delivery of medical care for stroke patients, often driven by efforts to curb costs, varies substantially between countries. Data on the potential impact of these variations on clinical outcomes are sparse. METHODS: The analysis of health care resource included total length of stay (LOS) in hospital, intensive care unit (ICU), and acute-care ward or rehabilitation unit, or both; number of outpatient rehabilitation sessions and visits to a physician; place of residence after discharge; and employment status. Cox proportional hazards models and logistic regression were used to calculate survival hazards and predictors of favorable functional outcome (Barthel Index of 95 to 100). RESULTS: One thousand six hundred four patients who were independent before stroke (mean age: 69.9+/-12.7 years, 53% men, 85% ischemic stroke, 69% in the US) were included. Three-month survival and functional outcome did not differ between the US and Canada. Survival rate was 80% in both countries. Favorable functional outcome was achieved in 43% of Canadian and 47% of US patients. Fewer Canadian patients received treatment in ICU (19% versus 63% in the US), and Canadians had longer stays in hospital or rehabilitation facility (median: 33 days versus 16 days in the US). CONCLUSIONS: Despite similar 3-month survival and functional outcome, patterns of health care resource varied substantially between the US and Canada. US patients had more intensive early care; Canadian patients had longer hospitalizations and rehabilitation care. Further research is required to determine the most cost-effective treatment and rehabilitation plan for people who have a stroke. (+info)
Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge.
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OBJECTIVES: This study was designed to assess outpatient angiotensin-converting enzyme inhibitor (ACEI) use after heart failure (HF) hospitalization. BACKGROUND: Assuring therapy with ACEIs at discharge after HF hospitalization is a key Medicare quality measure. The benefits of such quality improvement attempts will be limited if therapy is not continued long-term. METHODS: To assess the factors associated with filling an ACEI prescription in the 30 days postdischarge and the proportion of patients who filled such prescriptions subsequently up to 365 days postdischarge, we studied 219 patients with depressed ejection fraction (EF) specifically and 960 HF patients in general. RESULTS: Sixty-seven percent of patients with depressed EF and 55% of the total cohort were discharged with ACEIs. Overall 81.2%/77.1% (depressed EF/total cohort) of survivors discharged with ACEIs had filled a prescription by 30 days postdischarge; only 66.3%/63.3% were current users at 365 days. In contrast, for patients with no discharge order for ACEIs, only 12.7%/12.0% (depressed EF/total cohort) had filled such a prescription by 30 days and 12.5%/18.8% were current users at 365 days postdischarge. Patients with a discharge order for ACEIs were more likely to fill a prescription within 30 days postdischarge (hazard ratio 10.93, 95% confidence interval 5.28, 22.61, for patients with depressed EF). CONCLUSIONS: For patients with HF who are discharged while taking ACEIs, there is a significant decline in use after discharge. Patients not discharged with ACEIs are unlikely to be started as outpatients. Quality improvement efforts therefore need to be focused on both discharge planning and outpatient care. (+info)
Gemcitabine and vinorelbine as second-line therapy for non-small cell lung cancer after treatment with paclitaxel plus platinum.
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OBJECTIVE: To investigate the activity and feasibility of combination therapy of gemcitabine and vinorelbine for patients with advanced NSCLC after the failure of initial treatment with paclitaxel plus platinum. METHODS: From March 2000 to August 2002, 38 evaluable patients (median age 55 years) with NSCLC, who had failed to recover after treatment with paclitaxel plus platinum, received vinorelbine (30 mg/m(2) i.v.) followed by gemcitabine (1000 mg/m(2) i.v.), both being administered on days 1 and 8 and recycled every 3 weeks. RESULTS: Objective responses were as follows: partial response, 8/38 [21%; 95% confidence interval (CI) 8-23%]; and stable disease, 21/38 (55%). Median time to progression was 3.9 months and the median overall survival was 8.1 months. Grades III and IV neutropenia were seen in 17 and 11% of patients, respectively. CONCLUSION: This combination chemotherapy with gemcitabine and vinorelbine is active and highly tolerable as a second-line therapy for NSCLC. (+info)
Posthospital care transitions: patterns, complications, and risk identification.
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OBJECTIVES: To (1) describe patterns of posthospital care transitions; (2) characterize these patterns as uncomplicated or complicated; (3) identify those at greatest risk for complicated transitions. DATA SOURCES/STUDY SETTING: The Medicare Current Beneficiary Survey was used to identify beneficiaries aged 65 and older who were discharged from an acute care hospital in 1997-1998. STUDY DESIGN: Patterns of posthospital transfers were described over a 30-day time period following initial hospital discharge. Uncomplicated posthospital care patterns were defined as a sequence of transfers from higher-to lower-intensity care environments without recidivism, while complicated posthospital care patterns were defined as the opposite sequence of events. Indices were developed to identify patients at risk for complicated transitions. PRINCIPAL FINDINGS: Forty-six distinct types of care patterns were observed during the 30 days following hospital discharge. Among these patterns, 444 episodes (61.2 percent) were limited to a single transfer, 130 episodes (17.9 percent) included two transfers, 62 episodes (8.5 percent) involved three transfers, and 31 episodes (4.3 percent) involved four or more transfers. Fifty-nine episodes (8.1 percent) resulted in death. Between 13.4 percent and 25.0 percent of posthospital care patterns in the 1998 sample were classified as complicated. The area under the receiver operating curve was 0.771 for a predictive index that utilized administrative data and 0.833 for an index that used a combination of administrative and self-reported data. CONCLUSIONS: Posthospital care transitions are common among Medicare beneficiaries and patterns of care vary greatly. A significant number of beneficiaries experienced complicated care transitions-a finding that has important implications for both patient safety and cost-containment efforts. Patients at risk for complicated care patterns can be identified using data available at the time of hospital discharge. (+info)
Identification of rehabilitation needs after a stroke: an exploratory study.
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BACKGROUND: Services to meet adequate rehabilitation needs of elderly stroke survivors are not always provided. Indeed, since 1995, in the wake of the Quebec shift to ambulatory care, home care services, mainly those related to rehabilitation of the elderly, are either unavailable or incomplete. The aim of this study was to examine the rehabilitation needs of this clientele from their hospitalization to their reintegration into the community. METHODS: The "Handicap Production Process" conceptual approach was chosen to help identify the rehabilitation needs of persons affected by physical or cognitive disabilities due to the interactions between personal and environmental factors, and (activities of daily living, social roles). This qualitative exploratory study was performed in 2003. Data were collected among four groups of experts: patients, caregivers, health care providers and administrators. Data triangulation was used to ensure a rigorous analysis and validity of the results. RESULTS: Unfulfilled needs could be found in the categories of pertaining to residence, community living, psychological and emotional needs. Indeed, it appears that a psychological follow-up to discuss acceptance and consequences of non-acceptance would facilitate mid-to long-term rehabilitation. CONCLUSION: Improving accessibility to healthcare services, respecting priority parking spaces for the disabled as well as promoting public awareness would enable a better social reintegration and recovery of social roles, thus limiting the onset of handicap situations. (+info)
Effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences after treatment for early-stage invasive breast cancer: a meta-analysis and systematic review.
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PURPOSE: To review the effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences in asymptomatic patients after treatment for early-stage invasive breast cancer. METHODS: Systematic review and meta-analysis. The proportion of isolated locoregional recurrences diagnosed during routine visits or routine tests in asymptomatic patients was compared with the proportion of isolated locoregional recurrences in symptomatic patients. RESULTS: Twelve studies that involved a total of 5,045 patients and 378 isolated locoregional recurrences were identified. Pooling data showed an overall estimate of 40% of isolated locoregional recurrences diagnosed during routine visits or routine tests in asymptomatic patients (95% CI, 35 to 45). Of these, 47% (95% CI, 39 to 54) were diagnosed after mastectomy, and 36% (95% CI, 28 to 43) were diagnosed after breast-conserving therapy (relative risk, 1.327; 95% CI, 1.014 to 1.738). Apart from differences in therapy, we have not been able to discern subgroups of patients for whom results were different. CONCLUSION: Approximately 40% of isolated locoregional recurrences are diagnosed during routine visits and routine tests in asymptomatic patients treated for early-stage invasive breast cancer. We could not assess whether these were detected by either physical examination or other tests, nor if the detection of asymptomatic isolated recurrences had any influence on potential for cure or quality of life. As the overall quality of the included studies and the overall incidence of isolated locoregional recurrences are low, this systematic review highlights the need for prospective comparative studies on cost-effective strategies for the follow-up of patients after a diagnosis of breast cancer. (+info)
Post-disaster health effects: strategies for investigation and data collection. Experiences from the Enschede firework disaster.
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BACKGROUND: Public health policy is increasingly concerned with the care for victims of a disaster. This article describes the design and implementation of an epidemiological study, which seeks to match care services to the specific problems of persons affected by a large scale incident. The study was prompted by the explosion of a firework depot in Enschede, the Netherlands. STUDY POPULATION: All those directly affected by this incident (residents, emergency services personnel, and people who happened to be in the area at the time), some of whom suffered personal loss or injury. The project investigates both the physical and psychological effects of the disaster, as well as the target group's subsequent call on healthcare services. STUDY DESIGN: A questionnaire based follow up survey of those directly affected and an ongoing monitoring of health problems relying on reports from healthcare professionals. The follow up survey started three weeks after the incident and was repeated 18 months and almost four years after the incident. The monitoring is conducted over a four year period by general practitioners, the local mental health services department, occupational health services, and the youth healthcare services department. It provides ongoing information. RESULTS AND CONCLUSIONS: The results of the study are regularly discussed with healthcare professionals and policy makers, and are made known to the research participants. The paper also explains the considerations that were made in designing the study to help others making up their research plans when confronted with possible health effects of a disaster. (+info)
Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home: systematic review.
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This article presents the results of a Cochrane review which was conducted to determine the effectiveness of providing written and verbal health information compared with verbal information only to patients being discharged from acute hospital settings to home. Only two trials met the review inclusion criteria. In both trials the participants were parents of children being discharged from hospital to home. The two outcomes measured in both trials were knowledge and satisfaction. The review confirms that providing written and verbal health information is more effective in improving knowledge and satisfaction than providing verbal information only for parents of children being discharged from hospital to home. There is no evidence of the effectiveness of the intervention in adults who provide their own care after discharge from hospital. Further research is required which involves adult patients being discharged from hospital to home, and research which measures a range of outcomes which include readmission rates, recovery times, patient/carer knowledge, complication rates, service utilization and costs (community, outpatient and inpatient), confidence in one's own care management, stress and anxiety levels, satisfaction with services provided prior to discharge, and adherence to recommended care. (+info)