Stroke patients' preferences and values about emergency research.

BACKGROUND: In the USA, the Food and Drug Administration waiver of informed consent permits certain emergency research only if community consultation occurs. However, uncertainty exists regarding how to define the community(ies) or their representatives. OBJECTIVE: To collect data on the actual preferences and values of a group-those at risk for stroke-most directly affected by the waiver of informed consent for emergency research. DESIGN: Face to face focused interviews were conducted with 12 patients who were hospitalised with a stroke diagnosis in the previous year. The interviews were audiotaped and a transcript based method was used for their analysis. RESULTS: All 12 participants felt "that it was important that new treatments for stroke be developed", but they were initially confused about the distinction between "research for stroke" and "emergency research for stroke". However, after explanation, most (n = 10; 83%) expressed willingness to participate in the latter. In the absence of a surrogate to give informed consent in a stroke emergency situation, the majority (n = 11; 92%) said they would want the physician to "go ahead and enrol them in the trial". CONCLUSIONS: This study is the first to identify the values and concerns of individuals most directly affected by stroke emergency research. Further interviews and focus groups are needed to develop and test a validated questionnaire on the preferences and values surrounding emergency research for stroke.

Feasibility of a nurse-run asthma education program for urban African-Americans: a pilot study.

The objective of the study was to assess the feasibility of implementing and evaluating a culturally appropriate in-patient asthma education program specifically targeted for African-Americans. A consecutive sample of 28 African-American patients ages 18-50 who were hospitalized for asthma were randomized to an intervention group, which received three one-on-one sessions on chronic asthma management, or a control group, which received the usual care. Data on symptom frequency, self-management behaviors, quality of life, depression, and health care resource use were collected at baseline and at 3 and 6 months. Although the time required to recruit our sample took longer than anticipated, 28 subjects agreed to be in the study (70% acceptance rate) and complete the baseline interview. We observed no statistically significant differences from baseline or changing trends in frequency of asthma symptoms, self-management behaviors, and health care resource use between the intervention and control groups at 3 and 6 months. However patients in the intervention group demonstrated a greater average increase in asthma-related quality of life and a greater average decrease in depression than the control group. Feasibility issues included shortened length of stay, which necessitated conducting all three self-management sessions together; multiple interruptions during the sessions, and retention issues at 3- and 6-month follow-ups. The lessons learned from this pilot study are invaluable in that they will enable us to make changes in our existing protocol to ensure the success of a larger clinical trial.

Depression, social support, and quality of life in older adults with osteoarthritis.

PURPOSE: To develop an understanding of the quality of life of older adults with osteoarthritis (OA) with varying levels of depression and social support as a basis for nursing interventions. Osteoarthritis in the United States is the number one chronic disease in late life and the major cause of disability in older adults. In addition to the functional disability and economic effect of OA, older people with this disease experience suffering, depression, and diminished quality of life. DESIGN: For this cross-sectional survey, a convenience sample of 50 older adults with OA was recruited from two U.S. hospital-based arthritis clinics in northern Ohio for 3-months during 1995. METHODS: During face-to-face interviews, the Arthritis Impact Scales, Center for Epidemiological Studies Depression Scale, Social Support Questionnaire, and Quality of Life Survey, were used to measure osteoarthritis severity, depression, informal social support, and quality of life. FINDINGS: Although few formal social support services were used, high levels of satisfaction from the subjects' large informal networks of family and friends were reported. In addition, satisfaction with subjects' quality of life was extremely high despite depression, co-morbid conditions, pain, and functional limitation. CONCLUSIONS: Social support appeared to play an important role in moderating the effects of pain, functional limitation, and depression on these subjects' quality of life. Nurses who work with older adults are in a unique position to help them adjust to living with osteoarthritis by providing them the support needed to help them manage their disease.

A comparison of asthma-related healthcare use between African-Americans and Caucasians belonging to a health maintenance organization (HMO).

The objective of this study was to determine whether racial differences in patterns of asthma care persist in a healthcare environment when financial barriers to health care are minimized. The study cohort consisted of African-American (AA) and Caucasian (C) patients, 18-50 years old, enrolled in a large HMO and hospitalized for asthma in 1993-1995. Baseline and 1-year follow-up data were collected from the HMO computerized database. Of the 193 patients in the cohort, 124 (65.3%) were AA and 67 (34.7%) were C. AAs were younger (mean = 36.2, SD = 9.9) than Cs (mean = 39.4, SD = 9.1), had a lower median household income, and made more asthma-related emergency department (ED) visits (45.2%) than Cs (22.4%) during the 1 year after the initial hospitalization (all p values <0.001). During the same time period, Cs made more asthma-related primary care (70.2%) and allergy/pulmonary visits (38.8%) than AAs (47.6% and 27%, respectively). Although there were no significant racial differences in the rehospitalization rate, AA Medicaid contract patients (32%) had more rehospitalizations for asthma than AA regular contract patients (15.8%). These differential patterns in the use of asthma-related healthcare in this study indicate that the provision of health insurance alone is not sufficient to promote optimal levels of asthma management by all beneficiaries. Asthma education programs targeted for low-income AA patients may improve inappropriate healthcare use patterns.

Dual diagnosis in elders discharged from a psychiatric hospital.

Recent evidence indicates persons 60 years and over experience significant alcohol and substance abuse problems. Since a combination of alcoholism and depression is likely to increase the relative rsk of suicide, it is important to examine the prevalence of dual diagnosis in older adults. The purpose of this study is to examine the prevalence and correlates of dual diagnosis in older psychiatric inpatient populations and compare our results with findings from studies of younger hospitalized dually diagnosed patients. A retrospective chart audit was performed on 101 elders who were discharged from three psychiatric hospitals. Clinical variables that were examined included length of hospital stay, psychiatric and medical diagnoses, medications and history of suicidal ideation or intent. The leading psychiatric disorder diagnosis for our sample of hospitalized psychiatric elders was depression. Over one-third (37.6%) had a substance abuse disorder in addition to a psychiatric disorder, and almost three-fourths (71%) of this 'dual diagnosis' group abused alcohol and 29% abused both alcohol and other substances. In addition, significantly more elders in the "dual diagnosis' group (17.7%) than in the group with only a mental disorder diagnosis (3.3%) made a suicide attempt prior to admission to the hospital. Because, affective disorders in conjunction with alcohol abuse are the most frequently found disorders in completed suicides, our findings have important relevance for the advocating of routine use of diagnostic assessment and screening for both substance abuse and mental disorders in this population.

Does home health care affect strain and depressive symptomatology for caregivers of impaired older adults?

The demands of providing care to impaired older adults frequently results in strain and depressive symptomatology. These outcomes of caregiving may be affected by social support such as home health care. Forty-nine caregivers to impaired older adults receiving home health care and 51 caregivers not receiving home health care were interviewed soon after identification by hospital personnel and 3 months later. Strain and depressive symptomatology were not significantly lower and positive caregiving appraisal was not significantly higher for caregivers receiving home health care even when controlling for their pretest measures. Strain and depressive symptomatology were significantly higher for caregivers of cognitively impaired persons. Home health care nurses need to identify those caregivers at greater risk to individualize services.

Relationship between pretransplant noncompliance and posttransplant outcomes in renal transplant recipients.

Approximately 5% to 18% of kidney transplant recipients do not comply with their posttransplant medical treatment. This study examined the relationship between pretransplant noncompliance and posttransplant outcomes. Using a longitudinal retrospective chart audit, pretransplant and posttransplant data were collected for 126 kidney transplant recipients over a 3-year period. Sixty-one percent of those identified as noncompliant before transplant lost their graft or died after transplant. Significant relationships between pretransplant noncompliance and graft loss and between pre- and posttransplant noncompliance were found. Clinicians must identify those with pretransplant noncompliance, as they are at risk for poor outcomes and might benefit from an intensive posttransplant follow-up regimen.

Public policy and adolescent pregnancy: a reexamination of the issues.

PIP: In the United States 45% of female adolescents engage in premarital sex; 40% will become pregnant before reaching the age of 20; and 4/5 of these pregnancies will be unintended. Adolescent pregnancy has been associated with increased health risks for both the mother and the child. Only 6 in 10 adolescents will graduate from high school compared with 9 in 10 of their peers who delayed parenthood. The increasing number of single-parent families has contributed significantly to the increase in child poverty rates from 15% in 1960 to 20.3% in 1988. Further, such families cost billions of dollars to taxpayers because of public assistance and medical care. From a historical viewpoint the number of teen childbearing reached a peak in 1957 with 97.3 births per 1000 women 15-17 years old; it declined to 52.8/1000 by 1977 and to 51.8/1000 by the 1980s. The legalization of abortion in 1973 had a major impact on the resolution of adolescent pregnancies. Since the 1960s there has been a faster increase in early sexual activity, pregnancy, and birth among White adolescents than among minority groups. The United States has higher rates than western European countries, while it is also more ambivalent on sexuality issues. Tremendous change did take place in the 1960s in American culture as regards the family, and social and sexual relationships. Yet there is still a double standard with respect to female morality, and adolescents get a conflicting message about sexuality. Teenage mothers and their infants face an uncertain economic future because the much maligned welfare system is undergoing an overhaul and the market is shrinking for unskilled workers. Although increasing numbers of pregnant adolescents remained in school after amendments were passed to the education act, adolescent pregnancy has not been tackled at its very footing, its socioeconomic causes.^ieng

Depression in an elderly clinic population: findings from an ambulatory care setting.

Findings of a study of depression in an elderly hospital-based clinic population indicate that over 50% of older adults seen in specialty (psychiatric) clinics had a depressive diagnosis, but less than 2% of the elders seen in nonspecialty (medical) clinics were diagnosed with depression. Depressed patients in nonspecialty clinics had significantly more neurologic, respiratory and gastrointestinal comorbid conditions, nonpsychotropic medications, medical clinic visits, and medical hospitalizations than those elders treated for depression in the specialty clinic. Management of depression differed in type of provider and use of psychotherapy. However, there were no differences in the frequency, class, and specific type of psychotropic medications used in both clinic types.

Differences in the use of hospital-based outpatient mental health services by the elderly.

Visits to hospital outpatient clinics and emergency rooms by patients age 65 and over were studied. Differences were found in the use of mental health services between the oldest old and youngest old. A significant portion of psychiatric and substance abuse disorders was found among the youngest old, while the oldest old made a greater number of visits to emergency rooms.

Psychiatric visits to general hospital clinics by elderly persons and younger adults.

Findings of a study of mental health visits to general hospital outpatient clinics and emergency rooms by elderly persons and younger adults were compared with findings from an earlier survey of mental health visits to office-based physicians. In both studies, about half of the visits were to psychiatric clinics or to psychiatrists. However, the findings differed in that 43 percent of all visits to hospital clinics were for substance abuse, compared with only 4 percent of the visits to private physicians. Almost three-fourths of the hospital-based mental health visits by elderly patients were to psychiatric clinics, while only a third of the office visits by elderly patients were to psychiatrists. The authors discuss the policy implications of the high utilization of clinic services by elderly patients.