Teaching Medical Students to Communicate With Empathy and Clarity Using Improvisation.

PROBLEM: Medical educators widely accept that health care providers need strong communication skills. The authors sought to develop a course incorporating improvisation to teach health professions students communication skills and build empathy. APPROACH: Teaching health care professionals to communicate more effectively with patients, the public, and each other is a goal of the Alan Alda Center for Communicating Science at Stony Brook University. The authors designed an interprofessional elective for medical, nursing, and dental students that differed in several respects from traditional communication training. The Communicating Science elective, which was offered by the Alda Center from 2012 to 2016, used verbal and nonverbal exercises, role-playing, and storytelling, including improvisation exercises, to teach students to communicate with empathy and clarity. OUTCOMES: In course evaluations completed by 76 students in 2012 and 2013, 100% said they would recommend the course to fellow students, saw the relevance of the course content to their careers, and desired more of the course content in their school's curriculum. As a result of this positive feedback, from 2014 to 2016, 10 hours of instruction pairing empathy and communication training was embedded in the preclinical curriculum at the Stony Brook University School of Medicine. NEXT STEPS: This course could be an effective model, and one that other institutions could employ, for improving communication skills and empathy in the next generation of health care professionals. Next steps include advocating for communication skills training to be embedded throughout the curriculum of a four-year medical school program.

A challenging empirical question: What are the effects of media on psychogenic illness during a community crisis?

Psychogenic illness during disasters can cripple emergency healthcare services. Almost all research into this phenomenon has been retrospective and observational, and much of it suggests that media coverage can amplify psychogenic outbreaks. But there is little empirical evidence that this is true or that, conversely, media reports can mitigate psychogenic symptoms. In their work experimentally inducing psychogenic illness, the authors became sharply aware that it is difficult to experimentally mimic real-time media coverage. Yet clarifying media's effects on psychogenic illness is important if we want to prevent psychological disturbance. To meet this challenge, the authors advocate the funding and development of research protocols in advance of public emergencies, ready to be implemented in real-time. Coupled with digital media, which can track the reading and viewing behavior of millions of people, this approach can help us better understand media's impact on public health during an emergency, for better or for worse.

Experimental induction of psychogenic illness in the context of a medical event and media exposure.

OBJECTIVES: Mass psychogenic illness can be a significant problem for triage and hospital surge in disasters; however, research has been largely limited to posthoc observational reports. Reports on the impact of public media during a disaster have suggested both salutary as well as iatrogenic psychological effects. This study was designed to determine if psychogenic illness can be evoked and if media will exacerbate it in a plausible, controlled experiment among healthy community adults. METHODS: A randomized controlled experiment used a simulated biological threat and elements of social contagion--essential precipitants of mass psychogenic illness. Participants were randomly assigned to one of three groups: no-intervention control group, psychogenic illness induction group, or psychogenic illness induction plus media group. Measures included three assessments of symptom intensity, heart rate, blood pressure, as well as questionnaires to measure potential psychogenic illness risk factors. RESULTS: The two psychogenic induction groups experienced 11 times more symptoms than the control group. Psychogenic illness was observed in both men and women at rates that were not significantly different. Higher rates of lifetime history of traumatic events and depression were associated with greater induction of illness. Media was not found to exacerbate symptom onset. CONCLUSIONS: Psychogenic illness relevant to public health disasters can be evoked in an experimental setting. This sets the stage for further research on psychogenic illness and strategies for mitigation.

Exploring the link between ambulatory care and avoidable hospitalizations at the Veteran Health Administration.

This paper explores the link between utilization of ambulatory care and the likelihood of rehospitalization for an avoidable reason in veterans served by the Veteran Health Administration (VA). The analysis used administrative data containing healthcare utilization and patient characteristics stored at the national VA data warehouse, the Corporate Franchise Data Center. The study sample consisted of 284 veterans residing in Florida who had been hospitalized at least once for an avoidable reason. A bivariate probit model with instrumental variables was used to estimate the probability of rehospitalization. Veterans who had at least 1 ambulatory care visit per month experienced a significant reduction in the probability of rehospitalization for the same avoidable hospitalization condition. The findings suggest that ambulatory care can serve as an important substitute for more expensive hospitalization for the conditions characterized as avoidable.

Central nervous system and musculoskeletal medication profile of a veteran cohort with blast-related injuries.

Little is known about the utilization of central nervous system (CNS) and musculoskeletal (MS) medications in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans with blast-related injuries (BRIs). We followed prescription drug use among a cohort of 133 OIF/OEF veterans with BRIs by using the Joint Theatre Trauma Registry, the Tampa Polytrauma Registry, and electronic medical records. We extracted 12 months of national medication records from the Veterans Health Administration Decision Support System and analyzed them with descriptive statistics. Over the 12-month period (fiscal year 2007), CNS medications comprised 27.9% (4,225/15,143) of total prescriptions dispensed to 90.2% (120/133) of our cohort. Approximately one-half (48.9%) of the 133 patients were treated with opioid analgesics. Nearly 60% received antidepressants. More than one-half (51.1%) of patients were treated with anticonvulsants. Benzodiazepines and antipsychotics were dispensed to 17.3% and 15.8%, respectively. For MS medicines, 804 were prescribed for 48.1% (64/133) of veterans. Nearly one-fourth (24.8%) were treated with skeletal muscle relaxants. The CNS and MS medications, in general, were continuously prescribed over the 12-month study period. This study provides insight into the complex medical management involved in the care of veterans with BRIs.

Rehabilitation outcomes for veterans with polytrauma treated at the Tampa VA.

Returning soldiers from Iraq and Afghanistan who have sustained polytrauma have a combination of complex physical and mental morbidities that require extensive therapy and rehabilitation. This study examined the effect of rehabilitation on 116 polytrauma patients with service-connected injuries treated at the Tampa VA; improvements in functional and cognitive abilities were measured using the Functional Independence Measure (FIM) scores and healthcare costs for rehabilitation treatment were also assessed. Intensive rehabilitation therapy increased functional ability in this cohort with an average improvement in total FIM scores of 23 points. Total inpatient costs for these patients exceeded $4 million in approximately 3 years. Rehabilitation nurses face challenges providing quality care to this target patient population, including characterizing war-related polytrauma, providing surveillance, coordinating care, synchronizing care for patients with multiple injuries, and conducting evidence-based pain management.

Benchmark data on the utilization and acquisition costs of central nervous system and muscular skeletal drugs among veterans with combat-related injuries.

BACKGROUND: Little is known about the utilization and costs of central nervous system (CNS) and musculoskeletal medications in veterans with blast injuries. METHODS: Two years of national medication records of Operations Enduring Freedom and Iraqi Freedom veterans with blast injuries were extracted from the Veterans Health Administration Decision Support System and analyzed with descriptive statistics. RESULTS: Over the 2-year period, there was a total of 23,795 pharmacy claims (various drug classes) for 60 patients with blast injuries with a 2-year drug acquisition cost of $111,535 (mean per patient = $1,858; median per patient = $960). There were 6,471 CNS pharmacy claims or 4.5 CNS pharmacy claims per patient per month. Over four (81.6%) of five veterans were prescribed opioid analgesics; 75.0% (45 of 60) received antidepressants; 68.3% (41 of 60) received anticonvulsants; 40% (24 of 60) received antipsychotics; and 41.6% (25 of 60) received sedative hypnotics. The drug acquisition cost of all CNS medications was $46,384 ($7.17 per claim) and accounted for over 41% of total medication spending. For musculoskeletal medications, there were 1,253 pharmacy claims for 32 patients or 53% of the cohort costing $5,015 ($4.00 per claim), which accounted for 4.5% ($5,015 of $111,535) of total medication spending. CONCLUSIONS: The analysis suggests that these combat-wounded veterans were discharged on CNS medications with potential side effects, although the magnitude of these side effects, if any, remains unknown.

Expanding participation in Alzheimer's association Safe Return by improving enrollment.

Every adult with a diagnosis of progressive dementia is at risk for wandering away or becoming lost. Those with dementia may not have the capacity to remember crucial contact information or recognize an unsafe situation, so enrollment in a program like Alzheimer's Association Safe Return is crucial. One facility-level enrollment plan at the James A. Haley Veterans Hospital in Florida has had a relatively high participation rate. A mailed survey was used to help evaluate that enrollment process and the results are described here. Of 262 respondents to the survey, 193 (74%) indicated the person with dementia enrolled in Safe Return. Potential enrollees need the following facilitators: perception of an unsafe situation, financial support and easy processing. Safe Return is not just focused on those who wander but is essential for all persons with dementia as these individuals can become lost in the course of normal daily activities.

A national perspective of Medicare expenditures for elderly veterans with hip fractures.

INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently announced that beginning in October 2008, Medicare will no longer reimburse hospitals for the costs of treating injuries from several preventable conditions, including inpatient falls resulting in hip fracture. If hospitals try to shift this care to other payers, elderly veterans who are dually eligible for care in Medicare and Veterans Health Administration (VHA) facilities may be adversely affected. As health care provided for a hip fracture can be substantial, the goal of this research was to calculate Medicare payments for a national cohort of elderly veterans with hip fractures, beginning with the first inpatient admission and continuing through one year. METHODS: This was a retrospective, secondary data analysis of national VHA-eligible Medicare beneficiaries. The study population was 43,104 veterans with a hip fracture first admitted to a Medicare-eligible facility during 1999-2002. The estimation method was an ordinary least squares regression model of Medicare payments to providers for hip fracture patients over 4 time periods, up to 1 year after discharge, controlling for age, gender, inpatient length of stay, 1-year mortality, and selected Elixhauser comorbidities. RESULTS: Medicare reimbursed providers for nearly $3 billion of health care for hip fracture patients the first year of injury. Approximately 71.4% ($49,544) of the total annual Medicare payments (for all services) occurred within the first 30 days of hospital admission. Inpatient and carrier (physician) providers received the majority of the payments. The average annual payment per individual was $69,389 (99% confidence interval: $68,539-$70,239). Almost 7 in 10 hip fracture patients obtained care in a skilled nursing facility (SNF) during the year, with these providers comprising only 12% of total annual Medicare payments. In this elderly veteran cohort, hip fracture patients with renal failure, diabetes, lymphoma, and metastatic cancer generated the highest payments. CONCLUSION: This analysis provides proxy cost estimates for hip fracture patients useful for the forthcoming CMS reimbursement policy changes for inpatient fall-related injuries. The VHA and dually eligible elderly veterans could be disproportionately exposed to the economic consequences of the new CMS policy change.

Rehospitalization after hip fracture: predictors and prognosis from a national veterans study.

OBJECTIVES: To estimate the risk and long-term prognostic significance of 30-day readmission postdischarge of a 4-year cohort of elderly veterans first admitted to Medicare hospitals for treatment of hip fractures (HFx), controlling for comorbidities. DESIGN: Retrospective, national secondary data analysis. SETTING: National Medicare and Veterans Health Administration (VHA) facilities. PARTICIPANTS: The study cohort was 41,331 veterans with a HFx first admitted to a Medicare eligible facility during 1999 to 2002. MEASUREMENTS: HFxs were linked with all other Medicare and VHA inpatient discharge files to capture dual inpatient use. Logistic regression was used to examine the relationship between 30-day readmission and age, sex, inpatient length of stay, and selected Elixhauser comorbidities. RESULTS: Approximately 18.3% (7,579/41,331) of HFx patients were readmitted within 30 days. Of those with 30-day readmissions, 48.5% (3,675/7,579) died within 1 year, compared with 24.9% (8,388/33,752) of those without 30-day readmissions. Readmission risk was significantly greater in the presence of specific comorbidities, ranging from 11% greater risk for patients with fluid and electrolyte disorders (95% confidence interval (CI)=1.04-1.20) to 43% for renal failure (95% CI=1.29-1.60). For this cohort, cardiac arrhythmias (24%), chronic pulmonary disease (28%), and congestive heart failure (16%) were common comorbidities, and all affected the risk of 30-day readmission. CONCLUSION: Patients with HFx with 30-day readmissions were nearly twice as likely to die within 1 year. Identification of several predictive comorbidities at discharge and examination of reasons for subsequent readmission suggests that readmission was largely due to active comorbid clinical problems. These comorbidity findings have implications for the current Centers for Medicare and Medicaid Services (CMS) pay-for-performance initiatives, especially those related to better coordination of care for patients with chronic illnesses. These comorbidity findings for elderly patients with HFx may also provide data to enable CMS and healthcare providers to more accurately differentiate between comorbidities and hospital-acquired complications under the current CMS initiative related to nonpayment for certain types of medical conditions and hospital acquired infections.

Bone mineral density scans in veterans.

GOALS: Recent findings suggest the prevalence of osteoporosis among men is under-recognized. The patient population of the Veterans Health Administration (VA) is predominantly male and many elderly veterans may be at risk of osteoporosis. Given the lack of data on male osteoporosis, we provide initial insight into diagnostic procedures for patients at one VA medical center. PROCEDURES: A review and descriptive analysis of patients undergoing radiological evaluation for osteoporosis at one VA medical center. RESULTS: We identified 4,919 patients who had bone mineral density scans from 2001-2004. VA patients receiving bone mineral density scans were commonly white, male, over age 70 and taking medications with potential bone-loss side effects. CONCLUSIONS: While further research is needed, preliminary evidence suggests that the VA screens the most vulnerable age groups in both genders. Heightened awareness among primary care providers of elderly male patients at risk of osteoporosis can lead to early intervention and improved management of this age-related condition.

Agitation and resistiveness to care are two separate behavioral syndromes of dementia.

OBJECTIVES: To distinguish two behavioral syndromes of dementia: Agitation and resistiveness to care. DESIGN: Analysis of Minimum Data Set (MDS) data. SETTING: MDS data from Veterans Administration nursing homes collected from October 13, 2000, through October 14, 2004. PARTICIPANTS: Participants were 23,837 residents with a positive diagnosis for Alzheimer's disease or dementia other than Alzheimer's. MEASUREMENTS: Presence of agitation in each patient was based on the recorded value for 6 MDS variables: repetitive questions, repetitive verbalizations, expressions of what appear to be unrealistic fears, repetitive health complaints, repetitive anxious complaints or concerns, and repetitive physical movements. Patients who exhibited the MDS variable "resists care; resisted taking medications/injections, ADL assistance or eating" anytime within the last 7 days of the assessment and whose behavior was not easily altered were considered "resistive to care." Severity of dementia was measured by the Cognitive Performance Scale using 3 MDS items: short-term memory, cognitive skills for daily decision making, and making self understood. RESULTS: Agitation alone was present in 17%, resistiveness to care alone in 9%, and both syndromes in 8% of residents. Agitation was present in a significant number of residents who were borderline intact, was most common in subjects with moderate cognitive impairment, and decreased thereafter. In contrast, resistiveness to care was relatively rare in borderline intact and mildly impaired residents and increased gradually, with the highest prevalence in those with very severe cognitive impairment. The prevalence of resistiveness to care increased as the ability to understand deteriorated. Most residents who were rated as having abusive symptoms were also resistive to care. CONCLUSION: Agitation and resistiveness to care are 2 separate behavioral syndromes that may also occur together. It is important to distinguish between agitation and resistiveness to care because these syndromes require different management strategies.

Risk-adjusted mortality rates of elderly veterans with hip fractures.

PURPOSE: The goal of this research was to estimate 12-month survival rates for a large sample of elderly veterans after hip fracture with a risk-adjusted model and to compare the results of men to those of women. METHODS: The study design was a retrospective, secondary data analysis of national Veterans Health Administration (VHA) Medicare beneficiaries. The study population was 43,165 veterans with hip fracture first admitted to a Medicare-eligible facility during our specified enrollment period of 1999-2002. Measurement was a Cox proportional hazard model or survival analysis of hip fracture patients with an outcome of death over a 1 year period after discharge controlled by age, gender, and selected Elixhauser comorbidities. RESULTS: The unadjusted, 1 year mortality rates (30 days = 9.7%, 90 days = 17.5%, 180 days = 24%, 365 days = 32.2%) were slightly higher than the adjusted rates (30 days = 8.9%, 90 days = 15.6%, 180 days = 21.8%, 1 year = 29.9%). The mortality odds for women 12 months after hip fracture were 18%, compared with 32% for men. The comorbidity adjustment suggested that the presence of metastatic cancer increased the risk of death by almost 4 times compared with those patients without this diagnosis. Other particularly high-risk conditions included congestive heart failure, renal failure, liver disease, lymphoma, and weight loss, each of which increased the 1 year mortality risk by approximately two-fold. CONCLUSIONS: One in 3 elderly male veterans who sustain a hip fracture dies within 1 year. Our work represents the first large study of hip fractures with a predominantly male sample and confirms that men have a higher mortality risk than women, as reported by previous researchers who used smaller samples that were mostly female. Fracture patients with metastatic cancer, renal failure, lymphoma, weight loss, and liver disease have higher mortality risks. The adverse outcomes associated with hip fracture argue for clinical intervention strategies, such as gait and balance testing, and osteoporosis diagnosis that may prevent fractures in both genders.

The declining rate of avoidable hospitalizations in the Veterans Health Administration.

Most research shows a lower rate of avoidable hospitalizations associated with better access to outpatient care. Such findings have important implications for the Veterans Health Administration (VHA), with its change from delivering mainly inpatient services to emphasizing quality ambulatory care. From 1999 to 2004 the number of avoidable hospitalizations at the VHA increased while the rate per 10,000 enrollees declined. The trend in the rate of avoidable hospitalizations and the rapid growth of the beneficiary population indicate that new enrollees had a higher health status and perhaps better access to outpatient care.

The enigma of higher income immigrants with lower rates of health insurance coverage in the United States.

This research compares rates of health insurance coverage among middle-class non-elderly immigrants to native-born American adults using data from the March 1996-2000 Supplements to the Current Population Survey. Probit regressions reveal that immigrants were three times as likely to be uninsured at income levels exceeding $50,000, controlling for economic, demographic and immigrant-related characteristics. Work-related characteristics, income, martial status and nativity considerably influenced health insurance status for all adults, but work-related factors had the strongest effect on immigrants' rates of coverage. Why, ceteris paribus, immigrants have lower coverage rates is unclear. Many low-income and recent immigrants face barriers to access due to legal status or job sector. But lower rates of health insurance coverage which persist among long-time residents at higher income levels cannot be explained by such barriers, a finding highly relevant for policy makers. Encouraging uninsured immigrants to opt into health plans voluntarily will remain a challenge.

Economic aspects of dementia special care units in Veterans Affairs nursing homes.

Given the intermittent use of special care units (SCUs), we consider economic aspects associated with dementia SCUs by reviewing the literature and surveying 2 nursing homes in the VA healthcare network. In addition to reporting the features in different types of facilities in the Veterans Affairs (VA), we present an economic characterization useful for hospital and nursing home administrators whose decision-making processes incorporate clinical, management, and financial factors. We conclude that, theoretically, benefits likely outweigh the costs of instituting dementia SCUs in VA nursing homes with a large number of cognitively impaired residents.