Outbreaks of influenza A in nursing homes in Sheffield during the 1997-1998 season: implications for diagnosis and control.
(33/1708)
Three recent outbreaks of influenza A in nursing and residential homes in Sheffield were characterized by high attack rates among both residents and staff, and a high mortality rate among residents. The epidemiology of the outbreaks was unusual in that all three occurred towards the end of a quiet influenza season, against a generally low level of community activity, and involved strains of influenza that were not included in the current season's vaccine. The outbreak investigation was aided by the use of a novel rapid diagnostic technique. In future the combination of vaccination, surveillance, rapid diagnosis and new antineuraminidase drugs should improve prospects for control of influenza within closed communities. (+info)
Direct medical costs of chronic obstructive pulmonary disease: chronic bronchitis and emphysema.
(34/1708)
In this study we aimed to estimate direct medical costs of Chronic Obstructive Pulmonary Disease (COPD) by disease type; chronic bronchitis and emphysema. This study estimates direct costs in 1996 dollars using a prevalence approach and both aggregate and microcosting. A societal perspective is taken using prevalence, and multiple national, state and local data sources are used to estimate health-care utilization and costs. Chronic bronchitis and emphysema together account for $14.5 billion in annual direct costs. Inpatient costs are greater than outpatient and emergency costs ($8.3 vs. $7.8 billion) and hospital and medication costs account for most resources spent. The high prevalence of chronic bronchitis accounts for its larger total costs ($11.7 billion) compared with emphysema ($2.8 billion). Emphysema, which is more severe, has higher costs per prevalent case ($1341 vs. $816). Hospital stays account for the highest costs, $6.0 billion for chronic bronchitis and $1.9 billion for emphysema. The hospitalization rate, length of stay and average cost per prevalent case are higher for emphysema than for chronic bronchitis. Medication costs are the second highest cost category ($4.4 billion for chronic bronchitis, $0.693 billion for emphysema). The high hospitalization and low home care costs (0.2% of total) suggest underuse of home care and room to shift from acute to preventive care. More attention to healthcare management of chronic bronchitis and emphysema is suggested, and improving inhaler and anti-smoking compliance might be important targets. (+info)
Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: development of a guideline.
(35/1708)
Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients. The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's health and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians (step 3), the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a "checklist of considerations" (step 4). Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline (step 5). The accordingly adapted "checklist of considerations" was tested in a pilot study (step 6), after which all experts endorsed the checklist (step 7). The resulting "checklist of considerations" structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest (see annex at end of paper). (+info)
Surveillance for outbreaks of respiratory tract infections in nursing homes.
(36/1708)
BACKGROUND: Outbreaks of respiratory tract infections are common in long-term care facilities for older people. The objective of our study was to determine both the frequency of such outbreaks and their clinical and epidemiological features. METHODS: Prospective surveillance for outbreaks of respiratory tract infections and a retrospective audit of surveillance records were conducted in 5 nursing homes in metropolitan Toronto over 3 years. The clinical manifestations of infected residents were identified and microbiological investigations for causal agents were conducted. RESULTS: Sixteen outbreaks, involving 480 of 1313 residents, were identified prospectively during 1 144 208 resident-days of surveillance, for an overall rate of 0.42 infections per 1000 resident-days. Another 30 outbreaks, involving 388 residents, were identified retrospectively. Outbreaks occurred year-round, with no seasonal pattern. Pathogens included influenza virus, parainfluenza virus, respiratory syncytial virus, Legionella sainthelensi and Chlamydia pneumoniae. Multiple pathogens were detected in 38% (6/16) of the prospectively identified outbreaks. Of the 480 residents in the prospectively identified outbreaks 398 (83%) had a cough, 194 (40%) had fever and 215 (45%) had coryza. Clinical findings were nonspecific and could not be used to distinguish between causal agents. Pneumonia developed in 72 (15%) of the 480 residents, and 58 (12%) required transfer to hospital. The case-fatality rate was 8% (37/480). INTERPRETATION: Our findings emphasize the importance of adequate surveillance for outbreaks of respiratory tract infections in nursing homes and of early diagnosis so that appropriate interventions can be promptly instituted. (+info)
Does treatment of constipation improve faecal incontinence in institutionalized elderly patients?
(37/1708)
OBJECTIVE: to evaluate whether faecal incontinence can be improved by treatment of constipation in elderly patients with faecal incontinence associated with impairment of rectal emptying. DESIGN: a prospective randomized study with a 2-month follow-up. SETTING: five long-term care units. SUBJECTS: 206 patients with daily faecal incontinence associated with chronic rectal emptying impairments such as faecal impaction received either a single osmotic laxative (group I) or an osmotic agent along with a rectal stimulant and weekly enemas (group II). MEASUREMENTS: episodes of faecal incontinence and associated details of soiled laundry (used as indicators of the workload for caregivers). We performed periodic digital rectal examinations on group II patients to evaluate whether treatment resulted in complete and long-lasting rectal emptying. We compared data between groups and in group II between persistently constipated patients and patients with complete rectal emptying. RESULTS: the frequency of faecal incontinence did not significantly differ between the two groups. The 23 patients in group II who had complete rectal emptying had 35% fewer episodes of faecal incontinence and 42% fewer incidents of soiled laundry than the rest of the group. CONCLUSIONS: when long-lasting and complete rectal emptying is achieved by laxatives, the number of episodes of faecal incontinence as well as the workload for caregivers is reduced. (+info)
Development of a minimum data set-based depression rating scale for use in nursing homes.
(38/1708)
BACKGROUND: depression is common but under-diagnosed in nursing-home residents. There is a need for a standardized screening instrument which incorporates daily observations of nursing-home staff. AIM: to develop and validate a screening instrument for depression using items from the Minimum Data Set of the Resident Assessment Instrument. METHODS: we conducted semi-structured interviews with 108 residents from two nursing homes to obtain depression ratings using the 17-item Hamilton Depression Rating Scale and the Cornell Scale for Depression in Dementia. Nursing staff completed Minimum Data Set assessments. In a randomly assigned derivation sample (n = 81), we identified Minimum Data Set mood items that were correlated (P < 0.05) with Hamilton and Cornell ratings. These items were factored using an oblique rotation to yield five conceptually distinct factors. Using linear regression, each set of factored items was regressed against Hamilton and Cornell ratings to identify a core set of seven Minimum Data Set mood items which comprise the Minimum Data Set Depression Rating Scale. We then tested the performance of the Minimum Data Set Depression Rating Scale against accepted cut-offs and psychiatric diagnoses. RESULTS: a cutpoint score of 3 on the Minimum Data Set Depression Rating Scale maximized sensitivity (94% for Hamilton, 78% for Cornell) with minimal loss of specificity (72% for Hamilton, 77% for Cornell) when tested against cut-offs for mild to moderate depression in the derivation sample. Results were similar in the validation sample. When tested against diagnoses of major or non-major depression in a subset of 82 subjects, sensitivity was 91% and specificity was 69%. Performance compared favourably with the 15-item Geriatric Depression Scale. CONCLUSION: items from the Minimum Data Set can be organized to screen for depression in nursing-home residents. Further testing of the instrument is now needed. (+info)
The effect of longevity on spending for acute and long-term care.
(39/1708)
BACKGROUND: The proportion of the population made up of elderly persons in the United States is projected to increase from 13 percent of the population in 2000 to 20 percent by 2030. The implications for health care expenditures may be profound, because elderly persons use health care services at a greater rate than younger persons. We estimated total expenditures for acute and long-term care from the age of 65 years until death and in the last two years of life. METHODS: We combined data from Medicare, the National Mortality Followback Survey, and the National Medical Expenditure Survey to estimate total national expenditures for health care according to the age at death. We also simulated expenditures with the use of projected demographic characteristics of two cohorts: people turning 65 in 2000 and those turning 65 in 2015. RESULTS: Total expenditures (in 1996 dollars) from the age of 65 years until death increase substantially with longevity, from $31,181 for persons who die at the age of 65 years to more than $200,000 for those who die at the age of 90, in part because of steep increases in nursing home expenditures for very old persons. Spending in the last two years of life also increases with longevity, but a reduction in Medicare expenditures ($37,000 for persons who die at the age of 75 years and $21,000 for those who die at the age of 95) moderates the effect of the increase in nursing home expenditures ($6,000 for those who die at the age of 75 years and $32,000 for those who die at the age of 95). Health care spending for women is consistently higher than that for men, after adjustment for the increased longevity of women. Simulations show that increased longevity after the age of 65 years has a relatively small effect on the anticipated increase in spending, especially for services covered by Medicare, from 2000 to 2015. The effects of the larger number of people born in 1950 than in 1935 and the larger number of people surviving to the age of 65 years are much more important. CONCLUSIONS: In the United States, the effect of longevity on expenditures for acute care differs from its effect on expenditures for long-term care. Acute care expenditures, principally for hospital care and physicians' services, increase at a reduced rate as the age at death increases, whereas expenditures for long-term care increase at an accelerated rate. Increases in longevity after the age of 65 years may result in greater spending for long-term care, but the increase in the number of elderly persons has a more important effect on total spending. (+info)
The National Nursing Home Survey: 1995 summary.
(40/1708)
OBJECTIVE: The 1995 National Nursing Home Survey (NNHS) was conducted to collect data on nursing homes and their current residents. This report presents detailed data on the characteristics of the nursing homes including ownership, certification, bed size, location, affiliation, and services provided. Data on current residents are presented by basic demographics, living arrangement prior to admission, functional status, and other health and personal characteristics of the residents. METHODS: The 1995 NNHS is a sample survey consisting of a two-stage design with a probability sample of 1,500 nursing facilities in the first stage and up to six current residents from each facility in the second stage. RESULTS: About 1.5 million residents were receiving care in an estimated 16,700 nursing homes in 1995. Nearly 1.8 million beds were available and facilities operated at about 87 percent of their capacity. Nearly 90 percent of the residents were 65 years and over. They were predominantly female and white with a large portion needing assistance in the activities of daily living (ADL's) and instrumental activities of daily living (IADL's). (+info)