Pharmacoeconomic and health outcome comparison of lithium and divalproex in a VA geriatric nursing home population: influence of drug-related morbidity on total cost of treatment.
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OBJECTIVE: Clinicians use mood stabilizers for treating agitation in older patients, but limited information is available regarding side effects and costs in clinical practice. Total costs of treatment were assessed for a subset of geriatric patients receiving either lithium carbonate or divalproex sodium for agitation. STUDY DESIGN: Retrospective cohort examination of the medical records of 72 patients, 55 years of age or older, in a Veterans Administration long-term, skilled nursing care facility, with a diagnosis of dementia or bipolar affective disorder or both. PATIENTS AND METHODS: Patients treated with lithium or divalproex during the previous 4 years (1994-1997) were evaluated. Quantitative information was collected and compared regarding routine care, including cost of treatment and laboratory monitoring; and occurrence of adverse events and associated diagnostic and treatment measurements. RESULTS: Routine care costs for the 2 groups were similar. The lower annual acquisition cost per patient-year for lithium ($15 vs $339 for divalproex) was offset by higher laboratory monitoring costs associated with its administration ($278 vs $53 for divalproex). Examining the adverse events showed that the lithium group had more medication-related adverse events (32 total) than the divalproex group (10 total) and more severe occurrences, including 6 cases requiring medical intensive care unit (MICU) hospitalization. The total mean cost of treating drug-related mild-to-moderate morbidity was $3472 for lithium and $672 for divalproex. An additional cost per admission of $12,910 ($77,462 for all 6 cases) increased total morbidity-related expenditures in the lithium group to $80,934. CONCLUSIONS: Treating geriatric patients with lithium requires careful monitoring because of side effects. Staffing and resource limitations of a skilled nursing care facility may compromise optimal lithium monitoring in elderly patients. The collected data indicated that divalproex does not result in as many as or as severe adverse events and is, therefore, a safer treatment. The use of lithium was not only more expensive (on average $2875 more per patient) than treatment with divalproex but, more importantly, it was associated with poorer patient outcomes. (+info)
Direct admission to an extended-care facility from the emergency department.
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BACKGROUND: Many patients are admitted to acute-care hospitals when their medical needs might be more appropriately met in an extended-care facility (ECF). OBJECTIVE: To describe a cohort of patients who were admitted from an emergency department to an ECF. DESIGN: Observational cohort study. PARTICIPANTS: 121 enrollees of Harvard Vanguard Medical Associates who were admitted directly from an emergency department to an ECF between October 1, 1994, and December 31, 1997. OUTCOME MEASURES: Mean length of stay, charges per patient, and discharge disposition (discharged to home, discharged to a long-term-care facility, died, or transferred to an acute-care hospital within 30 days of ECF admission). RESULTS: Patients admitted directly to an ECF were generally frail and elderly (median age, 75 years). Mean length of stay in the ECF was 11 days; the mean per-patient charge was $3290. Three quarters of patients were discharged from the ECF to their homes. Six percent (seven patients) were transferred from the ECF to an acute-care hospital within 30 days of ECF admission. None of these transfers clearly suggested that the initial decision to directly admit a patient to the ECF was inappropriate. Most patients were satisfied with direct ECF admission: Of the surviving, cognitively intact patients admitted to an ECF in 1997, 71% stated that they would choose direct admission to an ECF over admission to an acute-care hospital if they were "in a similar situation in the future." CONCLUSIONS: For selected patients, direct admission to an ECF seems to be feasible, safe, and acceptable. A randomized, clinical trial is needed to fully assess the safety and cost implications of direct ECF admission. (+info)
Was the decreasing trend in hospital mortality from heart failure attributable to improved hospital care? The Oregon experience, 1991-1995.
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OBJECTIVE: To assess the trend in risk-adjusted hospital mortality from heart failure. STUDY DESIGN: Oregon hospital discharge data from 1991 through 1995 were analyzed. PATIENTS AND METHODS: A total of 29,530 hospitalizations because of heart failure in elderly patients (age > or = 65 years) were identified from International Classification of Diseases, 9th Revision, codes 428.0-428.9. The logistic regression and life table analyses were used to assess the risk-adjusted trend in hospital mortality from heart failure. RESULTS: From 1991 through 1995, 1757 (5.9%) patients with heart failure died in the hospital; 920 (52.4%) of them died within 3 days. The percentage of patients discharged to skilled nursing facilities increased from 6.1% in 1991 to 9.8% in 1995 (P value for trend < .001), whereas the percentage of patients discharged directly to home decreased from 69.2% in 1991 to 62.4% in 1995 (P value for trend < .001). The mean length of stay decreased from 5.15 days in 1991 to 3.97 days in 1995. The age- and sex-standardized mortality rate decreased by 33.8% from 7.4 in 1991 to 4.8 in 1995 (P value for trend < .01). Additional adjustment for comorbidity using multiple logistic regression revealed a greater reduction of 41.0% in the mortality rate (odds ratio = 0.59; 95% confidence interval = 0.50, 0.69) and a reduction of 46.0% in the 3-day mortality rate (odds ratio = 0.54; 95% confidence interval = 0.43, 0.67) across the 5-year period. Life table analysis showed consistently lower cumulative mortality rates during the first week after admission in 1995 compared with those in 1991 (P < .001). CONCLUSION: There was a decreasing trend over time in the risk-adjusted hospital mortality rates from heart failure, which was not an artifact of decreasing length of stay. Our findings raised the possibility of improved hospital care for heart failure in Oregon. (+info)
HIV as a chronic disease: implications for long-term care at an AIDS-dedicated skilled nursing facility.
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OBJECTIVE: To describe the characteristics and outcomes of the first 3 years of admissions to a dedicated skilled nursing facility for people with acquired immunodeficiency syndrome (AIDS). METHODS: Systematic chart review of consecutive admissions to a 30-bed, AIDS-designated long-term care facility in New Haven, Connecticut, from October 1995 through December 1998. RESULTS: The facility has remained filled to 90% or more of its bed capacity since opening. Of 180 patients (representing 222 admissions), 69% were male; mean age was 41 years; 57% were injection drug users; 71% were admitted directly from a hospital. Leading reasons for admission were (1) the need for 24-hour nursing/medical supervision, (2) completion of acute medical treatment, and (3) terminal care. On admission, the median Karnofsky score was 40, and median CD4+ cell count was 24/mm3; 48% were diagnosed with serious neurologic disease, 44% with psychiatric illness; patients were receiving a median of 11 medications on admission. Of 202 completed admissions, 44% of patients died, 48% were discharged to the community, 8% were discharged to a hospital. Median length of stay was 59 days (range 1 to 1,353). Early (< or = 6 months) mortality was predicted by lower admission CD4+ count, impairments in activities of daily living, and the absence of a psychiatric history; long-term stay (> 6 months) was predicted by total number of admission medications, neurologic disease, and dementia. Comparison of admissions from 1995 to 1996 to those in 1997 to 1998 indicated significantly decreased mortality rates and increased prevalence of psychiatric illness between the two periods (P < .01). CONCLUSIONS: A dedicated skilled nursing facility for people with AIDS can fill an important service need for patients with advanced disease, acute convalescence, long-term care, and terminal care. The need for long-term care may continue to grow for patients who do not respond fully to current antiretroviral therapies and/or have significant neuropsychiatric comorbidities. This level of care may be increasingly important not only in reducing lengths of stay in the hospital, but also as a bridge to community-based residential options in the emerging chronic disease phase of the AIDS epidemic. (+info)
Psychiatric comorbidity and the long-term care of people with AIDS.
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OBJECTIVES: To examine the association of comorbid psychiatric disorders with admission and discharge characteristics for patients residing at a long-term care facility designated for acquired immunodeficiency syndrome (AIDS). METHODS: Demographic and clinical characteristics were obtained by systematic chart review for all patients (N = 180) admitted to the facility from its opening in October 1995 through December 1999. Lifetime history of severe and persistent psychiatric disorders (major depression, bipolar and psychotic disorders) was determined by current diagnosis on baseline clinical evaluation or a documented past history. RESULTS: Forty-five patients (25%) had comorbid psychiatric disorders. At admission, patients with comorbidity were more likely to be ambulatory (80% vs. 62%, P = .03) and had fewer deficits in activities of daily living (27% vs. 43%, P = .05). After controlling for human immunodeficiency virus (HIV) disease severity, patients with comorbidity had significantly lower discharge rates (relative risk = 0.43, 95% confidence interval 0.23-0.78, P = .0001) and death rates (relative risk = 0.53, 95% confidence interval 0.42-0.68, P = .009). CONCLUSIONS: Patients with AIDS and comorbid psychiatric disorders at this facility had more favorable admission characteristics and were less likely to be discharged or to die. They may have been admitted earlier in their disease course for reasons not exclusively due to HIV infection. Once admitted, community-based residential alternatives may be unavailable as a discharge option. These findings are unlikely to be an anomaly and may become more pronounced with prolonged survival due to further therapeutic improvements in HIV care. Health services planners must anticipate rising demands on the costs of care for an increasing number of patients who may require long-term care and expanded discharge options for the comanagement of HIV disease and chronic psychiatric disorders. (+info)
Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians' and nurses' perceptions.
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BACKGROUND: Antibiotic therapy for asymptomatic bacteriuria in institutionalized elderly people has not been shown to be of benefit and may in fact be harmful; however, antibiotics are still frequently used to treat asymptomatic bacteriuria in this population. The aim of this study was to explore the perceptions, attitudes and opinions of physicians and nurses involved in the process of prescribing antibiotics for asymptomatic bacteriuria in institutionalized elderly people. METHODS: Focus groups were conducted among physicians and nurses who provide care to residents of long-term care facilities in Hamilton, Ont. A total of 22 physicians and 16 nurses participated. The focus group discussions were tape-recorded, and the transcripts of each session were analysed for issues and themes emerging from the text. Content analysis using an open analytic approach was used to explore and understand the experience of the focus group participants. The data from the text were then coded according to the relevant and emergent themes and issues. RESULTS: We observed that the ordering of urine cultures and the prescribing of antibiotics for residents with asymptomatic bacteriuria were influenced by a wide range of nonspecific symptoms or signs in residents. The physicians felt that the presence of these signs justified a decision to order antibiotics. Nurses played a central role in both the ordering of urine cultures and the decision to prescribe antibiotics through their awareness of changes in residents' status and communication of this to physicians. Education about asymptomatic bacteriuria was viewed as an important priority for both physicians and nurses. INTERPRETATION: The presence of non-urinary symptoms and signs is an important factor in the prescription of antibiotics for asymptomatic bacteriuria in institutionalized elderly people. However, no evidence exists to support this reason for antibiotic treatment. Health care providers at long-term care facilities need more education about antibiotic use and asymptomatic bacteriuria. (+info)
Medicare program; prospective payment system and consolidated billing for skilled nursing facilities--update. Health Care Financing Administration (HCFA), HHS. Final rule.
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This final rule sets forth updates to the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs), for fiscal year 2001. Annual updates to the PPS rates are required by section 1888(e) of the Social Security Act, as amended by the Medicare, Medicaid and State Child Health Insurance Program Balanced Budget Refinement Act of 1999, related to Medicare payments and consolidated billing for SNFs. In addition, this rule sets forth certain conforming revisions to the regulations that are necessary in order to implement amendments made to the Act by section 103 of the Medicare, Medicaid and State Child Health Insurance Program Balanced Budget Refinement Act of 1999. (+info)
Prevention of influenza and pneumococcal pneumonia in Canadian long-term care facilities: how are we doing?
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BACKGROUND: Influenza and pneumococcal pneumonia are serious health problems among elderly people and a major cause of death in long-term care facilities. We describe the results of serial surveys of vaccination coverage and influenza outbreak management in Canadian long-term care facilities over the last decade. METHODS: Cross-sectional surveys consisting of questionnaires mailed to all Canadian residential long-term care facilities for elderly people in 1991 and to a random sample of respondents in 1995 and 1999. RESULTS: The response rates were 83% (430/515) in 1995 and 75% (380/506) in 1999. In 1999 the mean reported rates of influenza vaccination were 83% among residents and 35% among staff, and the mean rate of pneumococcal vaccination among residents was 71%; all 3 rates were significantly higher than those in 1991. The rates were also higher in facilities with an infection control practitioner than in those without such an individual (88% v. 82% for influenza vaccination among residents [p < 0.001], 42% v. 35% for influenza vaccination among staff [p = 0.008] and 75% v. 63% for pneumococcal vaccination among residents [p < 0.001]). Obtaining consent for vaccination on admission to the facility was associated with higher influenza and pneumococcal vaccination rates among residents (p = 0.04 and p < 0.001 respectively). Facilities with higher influenza vaccination rates among residents and staff reported lower rates of influenza outbreaks (p = 0.08 and 0.03 respectively). Despite recommendations from the National Advisory Committee on Immunization, only 50% of the facilities had policies for amantadine prophylaxis during influenza A outbreaks. Amantadine was judged effective in controlling 76% of the influenza A outbreaks and was discontinued because of side effects in 3% of the residents. INTERPRETATION: Influenza and pneumococcal vaccination rates among residents and staff in Canadian long-term care facilities have increased over the last decade but remain suboptimal. Vaccination of residents and staff against influenza is associated with a reduced risk of influenza outbreaks. Amantadine is effective in controlling influenza outbreaks in long-term care facilities. (+info)