Patient-centered Factors Research Articles

Ulnar Nonunion After Osteoclasis for Rotational Deformities of the Forearm

Osteoclasis, a minimally invasive technique to rotate the radius and ulna, is used commonly to correct forearm rotational deformities in children. The purpose of this investigation was to evaluate objectively osteotomy healing in patients treated with osteoclasis, with specific attention given to the risk for nonunion. We identified 69 extremities in 65 children treated with osteoclasis and performed retrospective chart and radiographic reviews to evaluate the time to union of the radius and ulna and factors influencing healing. The average rotational correction was 90 degrees. Twenty-one ulnas had either delayed union or nonunion. Forty-eight of the forearms healed in less than 3 months. Factors correlated with a significantly decreased union rate included increased patient age, percutaneous technique, osteoclasis site in the proximal ulna, and primary diagnoses other than congenital radioulnar synostosis. Preoperative forearm position, magnitude of position correction, and treatment of the periosteum were not associated with changes in union rates. Forearm osteoclasis has a delayed union rate of 16%. Timely union of the ulna appears to be influenced by both patient-centered factors and surgical technique. Therapeutic, Level IV.

Nursing Home Capabilities and Decisions to Hospitalize: A Survey of Medical Directors and Directors of Nursing

To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents. Cross-sectional survey. Four hundred forty-eight nursing homes, 76% of which were nonprofit, from 25 states. Medical directors and directors of nursing (DONs). Participants were surveyed about resource availability, determinants of hospitalization, causes of overhospitalization, and nursing home practice. The survey response rate was 81%, with at least one survey from 93% of the facilities. Medical directors and DONs agreed that resident preference was the most important determinant in the decision to hospitalize, followed by quality of life. Although both groups ranked on-site doctor/nurse practitioner evaluation within 4 hours as the least accessible resource, they did not rank doctors not being quickly available as an important cause of overhospitalization. Rather, medical directors perceived the lack of information and support to residents and families around end-of-life care and the lack of familiarity with residents by covering doctors as the most important causes of overhospitalization. DONs agreed but reversed the order. Medical directors and DONs expressed confidence in provider and staff ability, although DONs were significantly more positive. Medical directors and DONs agree about most factors that influence decisions to hospitalize nursing home residents. Patient-centered factors play the largest roles, and the most important causes of overhospitalization are potentially modifiable.

A Systematic Review of Interventions to Improve Outcomes for Elders Discharged from the Emergency Department

To evaluate the evidence for interventions designed to improve outcomes for elders discharged from the emergency department (ED). The study was a systematic review of English-language articles indexed in MEDLINE and CINAHL (1966-2005) with 1) key words "geriatric," "older adults," or "seniors," or 2) Medical Subject Heading (MeSH) terms "Geriatrics" or "Health Services for the Aged" AND key word "emergency," or 3) MeSH terms "Emergencies," "Emergency Service, Hospital," or "Emergency Treatment." Bibliographies of the retrieved articles were reviewed for additional references, and the authors consulted with content experts to identify relevant unpublished work. Patients of interest were community-dwelling elder patients discharged home from the ED. Data were abstracted from selected articles by the authors. Studies with interventions limited to patients with a single presentation or diagnosis (falls, delirium, etc.) or delivered only to patients who would have otherwise been hospitalized were not included. Of 669 citations, 27 studies (reported in 33 articles) met study criteria and were reviewed; six randomized controlled trials (RCTs), two nonrandomized clinical trials, and 19 observational studies or program descriptions. Three of four RCTs designed to measure functional outcomes showed a reduction in functional decline in the intervention group. The trials that resulted in functional benefits enrolled high-risk patients and included geriatric nursing assessment and home-based services as part of the intervention. Results of trials to decrease health service utilization rates following an ED visit were mixed. A significant number of programs to improve outcomes for elders discharged from the ED exist, but few have been systematically examined. Development of interventions to improve the care of elder patients following ED visits requires further research into system and patient-centered factors that impact health care delivery in this situation.

Exercise training raises daily activity stronger than predicted from exercise capacity in patients with COPD

The 6-min walking (6MWD) and 6-min treadmill distance (6MTD) are often used as measures of exercise performance in patients with COPD. The aim of our study was to assess their relationship to daily activity in the course of an exercise training program. Eighty-eight patients with stable COPD (71m/17f; mean +/- SD age, 60 +/-8 year; FEV1, 43+/-14% pred) were recruited, 66 of whom performed a hospital-based 10-day walking training, whereas 22 were treated as control. On day 16MTD, and on days 8 and 10, 6MTD and 6MWD were determined. In addition, patients used an accelerometer (TriTrac-R3D) to record 24 h-activity, whereby training sessions were excluded. In both groups there was a linear relationship (r > or = 0.84 and P < 0.0001) between 6MTD and 24 h-activity, the slope of which was 2.5-fold greater in the training group (P < 0.01). Similar relationships emerged for 6MWD. There was no association between baseline 6MTD, FEV1 or BMI and any of the other measures. These data suggest that daily activity did not markedly vary with exercise capacity under baseline conditions. Participation in a training program increased activity significantly stronger than predicted from the gain in exercise capacity. This underlines the importance of non-physiological, patient-centered factors associated with training in COPD.

Comorbidity and social factors predicted hospitalization in frail elderly patients

ObjectiveStudies on factors predicting the hospital admission of geriatric patients have reported different findings. The present study was undertaken to examine the rate of hospitalization among a large sample of frail elderly people living in the community and to identify the most important clinical and patient-centered factors associated with the hospital admission. Study design and settingThis is an observational cohort study. All patients (n=1,291) in six Italian home health care agencies were assessed by a trained staff who collected data on the Minimum Data Set for Home Care (MDS-HC) form. We constructed a longitudinal database including MDS-HC data and information on hospital utilization by each patient. ResultsDuring the follow-up of 12 months, the rate of hospitalization was about 26% of the studied sample. Persons living alone were more likely to have a hospital admission than those living with an informal caregiver (odds ratio OR=2.59, 95% confidence interval CI=1.82–3.69). Similarly, persons with economic hardship were more frequently hospitalized than those without these problems (OR=3.01, 95% CI=1.75–5.18). Comorbidity and previous hospital admission were associated with a higher risk to be hospitalized, too. ConclusionOur results support the hypothesis that a mix of social and health problems are independent predictors of hospitalization. Identification of those factors that best predict hospital admissions and readmissions gives direction for potential interventions and further research toward reducing unnecessary hospitalizations.

Guidelines for the Systematic Treatment of the Depressed Patient

Back to table of contents Previous article Next article Book Forum: Treatment of DepressionFull AccessGuidelines for the Systematic Treatment of the Depressed PatientWILLIAM M. GREENBERG, M.D., WILLIAM M. GREENBERGSearch for more papers by this author, M.D., Ramsey, N.J.Published Online:1 Jul 2002https://doi.org/10.1176/appi.ajp.159.7.1256AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The authors of this monograph are three senior professors of psychology who are dissatisfied with available professional guidelines for the treatment of depression (e.g., those of APA and the Agency for Health Care and Policy Research). The authors offer a thoughtful critique and, in later chapters, mix in scholarly reviews of several related topics, although the one on basic research in psychobiology seems misplaced in this volume. Their focus, however, is an ambitious effort to develop their own treatment guidelines, comprising general treatment principles and not based on a particular model of psychotherapy.The authors analyzed published studies of individuals with symptoms of depression to elucidate which patient-centered factors appeared related to treatment outcome. They extracted provisional guidelines from these studies based on reviewers’ consensus, tested these principles on several retrospective and one new patient sample with a systematic approach, and produced this book to promote their resulting theses and computerized rating instrument. Their guidelines address the intensity and duration of treatment as well as the effect of therapists’ directiveness and actions on raising or lowering patients’ levels of distress, relating these variables to patients’ levels of functional impairment, experienced social support, and distress.This is an important and worthwhile effort, but its credibility nonetheless falters as it strains to achieve generalizations, frequently combining proverbial apples and oranges to offer fruit salad conclusions. For example, in reviewing old and disparate studies, the authors confound several issues into a notion of “complexity/chronicity” relating to the severity, chronicity, and multiple types of comorbidity someone with a depressive disorder might have. In addition, in addressing the important question of how valuable psychotropic medication may be for patients with mild depressive episodes, they principally draw conclusions from one study of 184 patients, 20 of whom received an antidepressant (desipramine); details of dose, duration, compliance, and comorbidity are not mentioned. There is a general bias against psychopharmacology, and only an idiosyncratic, selective review could result in assertions such as that depression fails to be a specific entity because it lacks a specific treatment, citing two studies allegedly demonstrating that “nonantidepressant medications and a variety of psychotherapies are all, on the average, similarly effective among patients diagnosed with Major Depression.” The fact that selective serotonin reuptake inhibitors may successfully treat individuals with depression, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, social phobia, panic disorder, and premature ejaculation does not mean that these disorders are not usefully separated, any more than the fact that propranolol is useful in treating hypertension, angina, essential tremor, and performance anxiety means that these disorders are not validly separable. There is poor understanding of the psychopharmacological literature, an atavistic belief in the validity of “endogenous depression,” and an opinion that psychotropic medication should not be a first-line treatment even for moderately severe depression.This volume could be somewhat more tightly and cleanly edited, and it is not pitched to the general mental health professional. Its flaws notwithstanding, it is scholarly and stimulating in its review of several areas and would be of interest to individuals writing guidelines for the treatment of depression or conducting such research, those who have an interest in factors relating to psychotherapy outcome, and forensic psychiatrists who need to be knowledgeable about guidelines and standards of care.By Larry E. Beutler, Ph.D., John F. Clarkin, Ph.D., and Bruce Bongar, Ph.D. New York, Oxford University Press, 2000, 455 pp., $55.00. FiguresReferencesCited byDetailsCited ByNone Volume 159Issue 7 July 2002Pages 1256-1256 Metrics History Published online 1 July 2002 Published in print 1 July 2002

Depression and self-reported physical health in patients with coronary disease: mediating and moderating factors.

The purpose of this study was to define how the relation between depression and self-reported physical health in patients with coronary disease is modified by other patient-centered factors. We conducted a prospective cohort study of 111 patients (members of a health maintenance organization) with angiographically documented coronary disease, examining factors (physical symptoms, psychological states and traits, and spousal support) modifying the relation between depression and patient-reported physical health 5 years later using multiple hierarchical regression models. Five regression models (all including demographic and disease severity covariates) were constructed to predict physical health from depression only (R2 = 0.22); depression plus angina and fatigue (R2 = 0.53); depression plus positive affect and novelty seeking and their interaction (R2 = 0.48); depression plus spousal support (R2 = 0.27); and depression, angina, fatigue, positive affect, and novelty seeking (overall model) (R2 = 0.65). Depression remained significant in each model, but the proportion of variance it predicted was diminished in the presence of the other variables (bivariate r = 0.39, partial r = 0.37-0.13). The effect of depression on self-reported physical health is significantly mediated by physical symptoms (angina and fatigue), personality states and traits (positive affect and novelty seeking), and spousal support. Positive affect and novelty seeking had more marked effects on physical health in the presence of more depression. Thus, a broad range of factors beyond the severity of coronary disease itself affect the perceived physical health of patients with coronary heart disease.

Predicting non-elective hospital readmissions:: A multi-site study

Objective: To determine clinical and patient-centered factors predicting non-elective hospital readmissions. Design: Secondary analysis from a randomized clinical trial. Clinical setting. Nine VA medical centers. Participants. Patients discharged from the medical service with diabetes mellitus, congestive heart failure, and/or chronic obstructive pulmonary disease (COPD). Main outcome measurement. Non-elective readmission within 90 days. Results: Of 1378 patients discharged, 23.3% were readmitted. After controlling for hospital and intervention status, risk of readmission was increased if the patient had more hospitalizations and emergency room visits in the prior 6 months, higher blood urea nitrogen, lower mental health function, a diagnosis of COPD, and increased satisfaction with access to emergency care assessed on the index hospitalization. Conclusions: Both clinical and patient-centered factors identifiable at discharge are related to non-elective readmission. These factors identify high-risk patients and provide guidance for future interventions. The relationship of patient satisfaction measures to readmission deserves further study.

Increasing Clinical Prevention Efforts in a Family Practice Residency Program Through CQI Methods

As primary care physicians develop ongoing relationships with their patients, each contact provides another opportunity for primary, secondary, or tertiary prevention activities. In 1991 an interdisciplinary prevention project team using continuous quality improvement (CQI) principles was established to improve family practice residents' provision of such services. For a random sample of 60 patient charts, abstractors looked for documentation of 23 clinical preventive services, including nursing screens, physician on-site and off-site implemented services, lifestyle education (diet, tobacco use), and self-screening education. After the chart review, the physicians, nurses, residents, and clinical staff used a fishbone analysis to identify physician-, clinic system-, and patient-centered factors contributing to the lack of conformance with clinical prevention guidelines. REMADIAL JOURNEY: The residency program began a series of didactic sessions on clinical prevention and instituted a procedures rotation to teach prevention procedure skills such as flexible sigmoidoscopy, stress testing, and colposcopy. On the CQI team's recommendation, a checklist developed by physicians and staff which itemized age- and gender-specific clinical prevention services was placed at the front of all patient charts. Clinic-system and patient factors were also addressed. HOLDING THE GAINS--MONITORING PERFORMANCE: The 1993 postintervention chart review showed significant improvements for 17 (81%) of the 21 targeted services. Providing educational sessions on prevention, permitting residents to select the areas of prevention on which to focus, and giving feedback on resident and staff performance through ongoing, nonpunitive monitoring resulted in increased provision of clinical prevention services in a family practice residency training center.