Journal of the American Geriatrics Society, Oct 1, 2000
OBJECTIVE To describe the healthcare utilization of a long-term care population receiving primary... more OBJECTIVE To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. SETTING A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. PARTICIPANTS Residents (n = 700) living in the community between September 1995 and February 1996. METHODS Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. RESULTS Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. CONCLUSIONS Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.
To assess the effectiveness of low-air-loss beds for the treatment of pressure ulcers in nursing ... more To assess the effectiveness of low-air-loss beds for the treatment of pressure ulcers in nursing homes. Prospective, randomized, clinical trial. Three teaching nursing homes in Los Angeles, Calif. Eighty-four nursing home residents with trunk or trochanter pressure ulcers (Shea stage > or = 2). Subjects were randomly assigned to use either a low-air-loss bed (n = 43) or a 10-cm corrugated foam mattress (n = 41) throughout the healing of their ulcers. Ulcers were assessed twice weekly using surface area and two observational scales (median follow-up, 37.5 days; range, 4 to 571 days). Groups were similar with respect to demographics, medical variables, wound care, and early dropouts. Results indicate more than a threefold improvement in median rate of healing for low-air-loss beds compared with foam mattresses (9.0 vs 2.5 mm2/d; P = .0002). This finding was true for deep as well as superficial ulcers (deep ulcers, 9.9 vs 0.7 mm2/d; P = .02; superficial ulcers, 9.0 vs 3.2 mm2/d; P = .004). Cox regression models revealed that the bed, ulcer depth, and fecal continence had independent effects on healing. After controlling for fecal continence, the deep and superficial subgroups using low-air-loss beds remained 2.5 times more likely to heal in a given length of time compared with those using foam mattresses (combined cure probability ratio, 2.66; 95% confidence interval, 1.34 to 5.17; P < .004). Low-air-loss beds provide substantial improvement compared with foam mattresses despite other factors in pressure ulcer healing.
The clinical features of 47 frail nursing home diabetic patients with a mean age of 81 +/- 1.6 ye... more The clinical features of 47 frail nursing home diabetic patients with a mean age of 81 +/- 1.6 years were compared to those of 61 nondiabetic nursing home residents with a mean age of 80.2 +/- 1.2 years. Diabetic patients had a higher prevalence of renal failure, proteinuria, retinopathy, neuropathy, and infections than did other nursing home residents. Macroangiopathic disease tended to be equally common in both age groups. Diabetic nursing home residents had higher body weights compared to nondiabetic nursing home residents. Surprisingly, however, 21% of nursing home diabetics were greater than 20% below average body weight (compared to 24.5% of other nursing home residents), suggesting that undernutrition is a major problem in diabetic patients in a nursing home setting. Overall, the diabetic nursing home patients had better blood glucose control than younger ambulatory diabetic patients (mean age 66.2 +/- 4.7 years). The glycosylated hemoglobin (HbA1) level in those on oral agents was 8.9% +/- 0.7% for nursing home patients compared to 11.8% +/- 0.7% in ambulatory patients (P less than 0.01). The HbA1 in insulin-treated patients was similarly lower in nursing home diabetics (9.6% +/- 0.4% vs 11.8% +/- 0.7, P less than 0.05). There were only two mild hypoglycemic episodes in nursing home patients over 6-month observation period, whereas 12 ambulatory patients reported hypoglycemic episodes during the same period of time. We conclude that although the diabetic nursing home patients are sicker than the ambulatory diabetics, it is possible to achieve a fair blood glucose control in nursing home patients without a significant risk of recurrent hypoglycemia.
1. J Am Geriatr Soc. 1990 Apr;38(4):409-14. Pain in the nursing home. Ferrell BA, Ferrell BR, Ost... more 1. J Am Geriatr Soc. 1990 Apr;38(4):409-14. Pain in the nursing home. Ferrell BA, Ferrell BR, Osterweil D. UCLA School of Medicine. Pain is an understudied problem in geriatric medicine and especially among nursing home residents. ...
A 14-year-old girl presented with severe haemorrhagic diathesis. Her past history suggested a con... more A 14-year-old girl presented with severe haemorrhagic diathesis. Her past history suggested a congenital bleeding disorder. Investigations disclosed severe deficiency of all four vitamin K-dependent factors and a functional defect of platelets. These were caused by simultaneous administration of vitamin K antagonists and anti-inflammatory drugs. A complete clinical and laboratory recovery took place following withdrawal of drugs. The severity of the haemorrhagic diathesis prompted us to describe the case in order to draw the attention of medical personnel to the dangerous potentiation effects of different drugs administered with vitamin K antagonists.
A 67-year-old woman with a double atherosclerotic aortic valvulopathy and rheumatoid arthritis pr... more A 67-year-old woman with a double atherosclerotic aortic valvulopathy and rheumatoid arthritis presented recurrent episodes of gastrointestinal bleeding. Selective arteriography of the superior mesenteric artery demonstrated the existence of vascular malformations with extravasation of the contrast. The physiopathology of this lesion is unknown, but its incidence in adulthood suggests a degenerative process. A selective angiogram of the superior mesenteric artery is mandatory in patients with gastrointestinal bleeding and double aortic valvulopathy in order to establish the etiological diagnosis of the hemorrhage.
The objective of this work was to determine if nursing homes that score differently on prevalence... more The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression. A cross-sectional study with 396 long-term residents in 14 skilled nursing facilities was conducted: 10 homes in the lower (25th percentile: low prevalence 0-2%) quartile and 4 homes in the upper (75th percentile: high prevalence 12-14%) quartile on the MDS depression quality indicator. Ten care processes related to depression were defined and operationalized into clinical indicators. Measurement of nursing home staff implementation of each care process and the assessment of depressive symptoms were conducted by trained research staff during 3 consecutive 12-hr days (7 a.m. to 7 p.m.), which included resident interviews (Geriatric Depression Scale), direct observations, and medical record review using standardized protocols. The prevalence of depressive symptoms according to independent assessments was significantly higher than prevalence based on the MDS quality indicator and comparable between homes reporting low versus high rates of depression (46% and 41%, respectively). Documentation of depressive symptoms was significantly more common in homes reporting a high prevalence rate; however, documentation of symptoms on the MDS did not result in better treatment or management of depression according to any care-process measure. Psychosocial prevention and intervention efforts, such as resident participation in organized social group activities, were not widely used within either group of homes. The MDS depression quality indicator underestimates the prevalence of depressive symptoms in all homes but, in particular, among those reporting low or nonexistent rates. The indicator may be more reflective of measurement processes related to detection of symptoms than of prevention, intervention, or management of depression outcomes. A depression quality indicator should not be eliminated from MDS reports because of the importance and prevalence of the condition. However, efforts to improve nursing home staff detection of depressive symptoms should be initiated prior to the use of any MDS-based depression indicator for improvement purposes. Homes that report a low prevalence of depression according to the nationally publicized MDS quality indicator should not be regarded as providing better care.
Journal of the American Medical Directors Association, 2000
If we take the rhetoric of recent academic and policy discourse at face value, crossing disciplin... more If we take the rhetoric of recent academic and policy discourse at face value, crossing disciplinary and institutional boundaries and engaging extra-scientific actors in the production and distribution of knowledge has become a kind of ‘gold standard’ . This is particularly true for fields like sustainability research, which is supposed to address the complexity of so-called ‘grand challenges’ of contemporary societies. Investigating the projects of a funding scheme for participatory sustainability research, this paper explores how researchers frame participatory research practices in their prospective narrations in research proposals and in their retrospective reflections in the framework of interviews. Thereby we focus on their stories about (1 ) the overall value of participation, (2) the roles allocated to different actors, (3) the temporal organization of participation as well as the (4) spatial dimension of collaboration. Building on this analysis, the paper concludes that eve...
Institutes of Health. We would like you to join the project. You have been asked to participate b... more Institutes of Health. We would like you to join the project. You have been asked to participate because you 1)are 55 years of age or older; 2) have had one or more drinks containing alcohol in the past 3 months; 3) have an email account and are willing to share your email address with the study team; 4) are comfortable using the Internet 5) have access to high-speed Internet; and 6) are willing to spend about 15 to 30 minutes on two separate occasions one month apart to complete an online alcohol education program and answer online questions in English about alcohol and health.
OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performa... more OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performance in old and very old frail residential care subjects.
This article begins with a brief overview of what subacute care is and why it is growing exponent... more This article begins with a brief overview of what subacute care is and why it is growing exponentially. It then discusses the characteristics of patients appropriate for treatment in a transitional care unit (TCU) and the evolving role of physicians in their care. The process of care in a typical hospital-based TCU from admission to discharge is discussed with an emphasis on documentation and an interdisciplinary approach. The role of the medical director is emphasized. The article closes with strategies the authors feel are useful for improving care in hospital-based TCUs.
We performed a retrospective review of an outbreak of Salmonella gastroenteritis that occurred in... more We performed a retrospective review of an outbreak of Salmonella gastroenteritis that occurred in a community nursing home in 1987. Forty-four of 199 residents had a diarrheal illness; Salmonella heidelberg was isolated from the stool in 19 cases. Although the distribution of cases suggested a common source for the outbreak, no common source of infection could be demonstrated, despite extensive investigation. The clinical presentation of symptomatic individuals ranged from mild diarrhea to a severe gastrointestinal illness, and 26% of symptomatic, culture-positive patients required hospitalization. The median duration of pathogen excretion during convalescence in untreated residents was six weeks, but six patients who were treated with antibiotics shed S. heidelberg for a median duration of 14.5 weeks. We conclude that (1) the clinical spectrum of Salmonella gastroenteritis in nursing-home patients is variable, ranging from mild to severe illness; and (2) nursing-home Salmonella out...
Summary A 25-year-old woman, admitted on account of rubella infection, developed sudden loss of h... more Summary A 25-year-old woman, admitted on account of rubella infection, developed sudden loss of hearing in her right ear a few days after admission, which was diagnosed as severe sensorineural hearing loss. In view of the recent rubella infection, it seems reasonable to assume that this was a case of complicated neuritis confined to a single eighth nerve.
Journal of the American Geriatrics Society, Oct 1, 2000
OBJECTIVE To describe the healthcare utilization of a long-term care population receiving primary... more OBJECTIVE To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. SETTING A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. PARTICIPANTS Residents (n = 700) living in the community between September 1995 and February 1996. METHODS Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. RESULTS Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. CONCLUSIONS Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.
To assess the effectiveness of low-air-loss beds for the treatment of pressure ulcers in nursing ... more To assess the effectiveness of low-air-loss beds for the treatment of pressure ulcers in nursing homes. Prospective, randomized, clinical trial. Three teaching nursing homes in Los Angeles, Calif. Eighty-four nursing home residents with trunk or trochanter pressure ulcers (Shea stage > or = 2). Subjects were randomly assigned to use either a low-air-loss bed (n = 43) or a 10-cm corrugated foam mattress (n = 41) throughout the healing of their ulcers. Ulcers were assessed twice weekly using surface area and two observational scales (median follow-up, 37.5 days; range, 4 to 571 days). Groups were similar with respect to demographics, medical variables, wound care, and early dropouts. Results indicate more than a threefold improvement in median rate of healing for low-air-loss beds compared with foam mattresses (9.0 vs 2.5 mm2/d; P = .0002). This finding was true for deep as well as superficial ulcers (deep ulcers, 9.9 vs 0.7 mm2/d; P = .02; superficial ulcers, 9.0 vs 3.2 mm2/d; P = .004). Cox regression models revealed that the bed, ulcer depth, and fecal continence had independent effects on healing. After controlling for fecal continence, the deep and superficial subgroups using low-air-loss beds remained 2.5 times more likely to heal in a given length of time compared with those using foam mattresses (combined cure probability ratio, 2.66; 95% confidence interval, 1.34 to 5.17; P < .004). Low-air-loss beds provide substantial improvement compared with foam mattresses despite other factors in pressure ulcer healing.
The clinical features of 47 frail nursing home diabetic patients with a mean age of 81 +/- 1.6 ye... more The clinical features of 47 frail nursing home diabetic patients with a mean age of 81 +/- 1.6 years were compared to those of 61 nondiabetic nursing home residents with a mean age of 80.2 +/- 1.2 years. Diabetic patients had a higher prevalence of renal failure, proteinuria, retinopathy, neuropathy, and infections than did other nursing home residents. Macroangiopathic disease tended to be equally common in both age groups. Diabetic nursing home residents had higher body weights compared to nondiabetic nursing home residents. Surprisingly, however, 21% of nursing home diabetics were greater than 20% below average body weight (compared to 24.5% of other nursing home residents), suggesting that undernutrition is a major problem in diabetic patients in a nursing home setting. Overall, the diabetic nursing home patients had better blood glucose control than younger ambulatory diabetic patients (mean age 66.2 +/- 4.7 years). The glycosylated hemoglobin (HbA1) level in those on oral agents was 8.9% +/- 0.7% for nursing home patients compared to 11.8% +/- 0.7% in ambulatory patients (P less than 0.01). The HbA1 in insulin-treated patients was similarly lower in nursing home diabetics (9.6% +/- 0.4% vs 11.8% +/- 0.7, P less than 0.05). There were only two mild hypoglycemic episodes in nursing home patients over 6-month observation period, whereas 12 ambulatory patients reported hypoglycemic episodes during the same period of time. We conclude that although the diabetic nursing home patients are sicker than the ambulatory diabetics, it is possible to achieve a fair blood glucose control in nursing home patients without a significant risk of recurrent hypoglycemia.
1. J Am Geriatr Soc. 1990 Apr;38(4):409-14. Pain in the nursing home. Ferrell BA, Ferrell BR, Ost... more 1. J Am Geriatr Soc. 1990 Apr;38(4):409-14. Pain in the nursing home. Ferrell BA, Ferrell BR, Osterweil D. UCLA School of Medicine. Pain is an understudied problem in geriatric medicine and especially among nursing home residents. ...
A 14-year-old girl presented with severe haemorrhagic diathesis. Her past history suggested a con... more A 14-year-old girl presented with severe haemorrhagic diathesis. Her past history suggested a congenital bleeding disorder. Investigations disclosed severe deficiency of all four vitamin K-dependent factors and a functional defect of platelets. These were caused by simultaneous administration of vitamin K antagonists and anti-inflammatory drugs. A complete clinical and laboratory recovery took place following withdrawal of drugs. The severity of the haemorrhagic diathesis prompted us to describe the case in order to draw the attention of medical personnel to the dangerous potentiation effects of different drugs administered with vitamin K antagonists.
A 67-year-old woman with a double atherosclerotic aortic valvulopathy and rheumatoid arthritis pr... more A 67-year-old woman with a double atherosclerotic aortic valvulopathy and rheumatoid arthritis presented recurrent episodes of gastrointestinal bleeding. Selective arteriography of the superior mesenteric artery demonstrated the existence of vascular malformations with extravasation of the contrast. The physiopathology of this lesion is unknown, but its incidence in adulthood suggests a degenerative process. A selective angiogram of the superior mesenteric artery is mandatory in patients with gastrointestinal bleeding and double aortic valvulopathy in order to establish the etiological diagnosis of the hemorrhage.
The objective of this work was to determine if nursing homes that score differently on prevalence... more The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression. A cross-sectional study with 396 long-term residents in 14 skilled nursing facilities was conducted: 10 homes in the lower (25th percentile: low prevalence 0-2%) quartile and 4 homes in the upper (75th percentile: high prevalence 12-14%) quartile on the MDS depression quality indicator. Ten care processes related to depression were defined and operationalized into clinical indicators. Measurement of nursing home staff implementation of each care process and the assessment of depressive symptoms were conducted by trained research staff during 3 consecutive 12-hr days (7 a.m. to 7 p.m.), which included resident interviews (Geriatric Depression Scale), direct observations, and medical record review using standardized protocols. The prevalence of depressive symptoms according to independent assessments was significantly higher than prevalence based on the MDS quality indicator and comparable between homes reporting low versus high rates of depression (46% and 41%, respectively). Documentation of depressive symptoms was significantly more common in homes reporting a high prevalence rate; however, documentation of symptoms on the MDS did not result in better treatment or management of depression according to any care-process measure. Psychosocial prevention and intervention efforts, such as resident participation in organized social group activities, were not widely used within either group of homes. The MDS depression quality indicator underestimates the prevalence of depressive symptoms in all homes but, in particular, among those reporting low or nonexistent rates. The indicator may be more reflective of measurement processes related to detection of symptoms than of prevention, intervention, or management of depression outcomes. A depression quality indicator should not be eliminated from MDS reports because of the importance and prevalence of the condition. However, efforts to improve nursing home staff detection of depressive symptoms should be initiated prior to the use of any MDS-based depression indicator for improvement purposes. Homes that report a low prevalence of depression according to the nationally publicized MDS quality indicator should not be regarded as providing better care.
Journal of the American Medical Directors Association, 2000
If we take the rhetoric of recent academic and policy discourse at face value, crossing disciplin... more If we take the rhetoric of recent academic and policy discourse at face value, crossing disciplinary and institutional boundaries and engaging extra-scientific actors in the production and distribution of knowledge has become a kind of ‘gold standard’ . This is particularly true for fields like sustainability research, which is supposed to address the complexity of so-called ‘grand challenges’ of contemporary societies. Investigating the projects of a funding scheme for participatory sustainability research, this paper explores how researchers frame participatory research practices in their prospective narrations in research proposals and in their retrospective reflections in the framework of interviews. Thereby we focus on their stories about (1 ) the overall value of participation, (2) the roles allocated to different actors, (3) the temporal organization of participation as well as the (4) spatial dimension of collaboration. Building on this analysis, the paper concludes that eve...
Institutes of Health. We would like you to join the project. You have been asked to participate b... more Institutes of Health. We would like you to join the project. You have been asked to participate because you 1)are 55 years of age or older; 2) have had one or more drinks containing alcohol in the past 3 months; 3) have an email account and are willing to share your email address with the study team; 4) are comfortable using the Internet 5) have access to high-speed Internet; and 6) are willing to spend about 15 to 30 minutes on two separate occasions one month apart to complete an online alcohol education program and answer online questions in English about alcohol and health.
OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performa... more OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performance in old and very old frail residential care subjects.
This article begins with a brief overview of what subacute care is and why it is growing exponent... more This article begins with a brief overview of what subacute care is and why it is growing exponentially. It then discusses the characteristics of patients appropriate for treatment in a transitional care unit (TCU) and the evolving role of physicians in their care. The process of care in a typical hospital-based TCU from admission to discharge is discussed with an emphasis on documentation and an interdisciplinary approach. The role of the medical director is emphasized. The article closes with strategies the authors feel are useful for improving care in hospital-based TCUs.
We performed a retrospective review of an outbreak of Salmonella gastroenteritis that occurred in... more We performed a retrospective review of an outbreak of Salmonella gastroenteritis that occurred in a community nursing home in 1987. Forty-four of 199 residents had a diarrheal illness; Salmonella heidelberg was isolated from the stool in 19 cases. Although the distribution of cases suggested a common source for the outbreak, no common source of infection could be demonstrated, despite extensive investigation. The clinical presentation of symptomatic individuals ranged from mild diarrhea to a severe gastrointestinal illness, and 26% of symptomatic, culture-positive patients required hospitalization. The median duration of pathogen excretion during convalescence in untreated residents was six weeks, but six patients who were treated with antibiotics shed S. heidelberg for a median duration of 14.5 weeks. We conclude that (1) the clinical spectrum of Salmonella gastroenteritis in nursing-home patients is variable, ranging from mild to severe illness; and (2) nursing-home Salmonella out...
Summary A 25-year-old woman, admitted on account of rubella infection, developed sudden loss of h... more Summary A 25-year-old woman, admitted on account of rubella infection, developed sudden loss of hearing in her right ear a few days after admission, which was diagnosed as severe sensorineural hearing loss. In view of the recent rubella infection, it seems reasonable to assume that this was a case of complicated neuritis confined to a single eighth nerve.
To evaluate 52 fourth-year medical students' skills in giving physical examinations, a list o... more To evaluate 52 fourth-year medical students' skills in giving physical examinations, a list of 89 skills was composed and distributed to students and instructors of a course in introduction to clinical medicine. During the test students were given 10 min. to demonstrate their skills on 10 randomly selected tasks. Three examiners independently evaluated each of the 10 performances. It was demonstrated that such a procedure results in an efficient test which possesses content validity. In the absence of well defined criteria for grading, the inter-judge reliability of the scores was rather low.
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