How prevalent are hospital-based palliative care programs? Status report and future directions.

In the United States, the majority of deaths occur in the hospital but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers. The development of hospital-based palliative care programs (HBPCPs) can vastly improve inpatient end-of-life care. This study is the first to examine the prevalence and characteristics of HBPCPs in the United States, thus providing a snapshot of the characteristics of these HBPCPs. It also serves as a baseline and benchmark against which future development and patterns of HBPCPs can be compared. Phase 1: Data were obtained from the American Hospital Association (AHA) 1998 Annual Survey, on the existence of end-of-life care (EOLC) and pain management (PM) services in U.S. hospitals. Phase 2: A focused survey further assessed programs in Phase 1 and was sent to all registered hospitals that responded affirmatively to the AHA survey questions as having either a PM service, an EOLC service, or both. In phase 1, 1,751 (36%) hospitals reported having a PM service and 719 (15%) had an EOLC service, for a total of 2,015 unique hospitals that had one or both. For Phase 2, 1,120 of 2,015 responded (56%). Of these, 337 (30%) hospitals reported having an HBPCP, and another 228 (20.4%) had plans to establish one. HBPCPs are most commonly structured as inpatient consultation service and hospital-based hospice. They tend to be based in oncology, general medicine, and geriatrics. We also assessed reasons for consultation, patient characteristics, and future development needs. These findings can help guide future funding, educational, and programming efforts in hospital-based palliative care.

Exercise in the healthy older adult.

Habitual exercise provides numerous health benefits to the older adult. While dynamic aerobic activities increase stamina and lung capacity, isometric or resistance training improves muscle strength and endurance. Long-term benefits of continued exercise include a decreased risk of death from heart disease, enhanced balance and mobility, a decreased risk of diabetes, and an improvement in depressive symptoms. While the hazards of exercise relate predominantly to extremes of intensity and duration, all older adults should consult with a physician before beginning a new activity program. A prescription for exercise should include both aerobic and resistance training components, and frequent follow-up to improve adherence is highly recommended.

Taking account of quality. Discussion.

Another report from the Institute of Medicine in March 2001 has joined a large body of literature documenting serious quality and safety problems. Eight health care leaders discuss ways in which organizations can reduce medical errors and improve patient outcomes.

Successful aging. How increased life expectancy and medical advances are changing geriatric care.

If the unprecedented increase in life expectancy has a downside, it is the exposure of risk to chronic age-related disorders. As clinicians work to foster healthy aging, we must also seek ways to prevent the disabling disorders that keep many older persons from enjoying their longevity. The high prevalence of chronic illness and functional limitation among older persons underscores the need for strategically directed health and social services. Successful patient management must extend beyond diagnosis and disease treatment and include promotion of function and prevention of decline. Achieving this goal requires a seamless continuum of management and interdisciplinary caregiving. There also must be a focus on improving the understanding of the science of aging. New treatment approaches for managing aging may one day include cognitive enhancers, designer hormones, telomerase, antioxidants, and gene therapy.

Physician firearm ownership as a predictor of firearm injury prevention practice.

OBJECTIVES: This study explored the relation between physicians' gun ownership and their attitudes and practices regarding firearm injury prevention. METHODS: Internists and surgeons were surveyed, and logistic regression models were developed with physicians' personal involvement with firearms (in the form of a gun score) as the primary independent variable. RESULTS: Higher gun scores were associated with less agreement that firearm injury is a public health issue and that physicians should be involved in firearm injury prevention but with a greater likelihood of reporting the inclusion of firearm ownership and storage as part of patient safety counseling. CONCLUSIONS: Despite being less likely to say that doctors should participate in firearm injury prevention, physician gun owners are more likely than nonowners to report counseling patients about firearm safety.

In defense of a department of geriatrics.

Departmental status for geriatrics offers many advantages, all of which are related to strengthening academic and clinical programs in aging. The training programs and the content of medical school curriculum in geriatrics remain inadequate under the current structures. A department of geriatrics can provide a stronger faculty base and allow effective interaction with other departments (including but not limited to internal medicine) that need geriatric training. A department of geriatrics also focuses on a model of care that involves working closely with other disciplines, such as nursing and social work. This interdisciplinary model helps expert providers work efficiently throughout the spectrum of care, strengthening continuity. The department can include other medical specialists, such as family practitioners, psychiatrists, and physiatrists, who work with caregivers and patients throughout a course of treatment to manage chronic illness and help maintain and enhance function and independence as long as possible. Comprehensive care and proper care management also substantially benefit institutions by expanding the patient population, reducing length of stay, and avoiding unnecessary hospitalization of older patients through effective discharge planning and transitional care. This requires strong relationships with long-term care providers, a characteristic strength of geriatricians. Although not all research in aging needs to be housed in a department of geriatric medicine, the presence of a critical mass of basic and clinical researchers creates an environment that can stimulate new initiatives and attract external funding. Additional research bridging basic translational and clinical phases relevant to the elderly population is best encouraged by maintaining relationships with other basic science and clinical departments.

Geriatrics for the 3rd millennium.

It is a common knowledge that the population around the world is growing old at an unprecedented rate. This is the success story of increasing life expectancy. The demographic breakthroughs occurred in the 20th century. The quality of life breakthrough is our challenge for the 21st century. The implications of the growing elderly population are many, including: rising total health care expenditures; the increasing needs for long-term care services; and the need for expert and focused health care services. Since health care costs increase with advancing age of populations, these costs will fall on older persons, families, and society generally. There is real value for everyone in meeting the needs of an aging society, especially if seen as part of a social contract. The ability to live independently improves with access to good care, but decreases dramatically for those with age-related disabling conditions. With the decreasing number of informal caregivers around the world, frail elderly will require more formal long-term care services. However, due to inadequate attention given to long-term care issues, numerous developed countries have recently started to struggle to develop long-term care service programs that will both meet the rising needs for this service and be cost-effective. Effective medical care requires expertise in functional assessment, interdisciplinary care, and advances in treating symptoms of aging. The field of geriatrics is essential to modern health care, and geriatricians need to have proper training that focuses diagnosing and treating this group of patients. Quality care will not only help the elderly to live productively and independently, but it will also tremendously benefit families and communities.

Quantification of interventions and outcomes in an outpatient telemanagement and care management congestive heart failure program.

The congestive heart failure continuum was developed in collaboration with the medical management committee of our hospital in response to a need to decrease readmissions for this chronic and progressive disease. This is accomplished via a multidisciplinary team that provides education and long-term telemanagement, as well as care management to assist these patients in maintaining an optimum level of functioning and the ability to remain in their homes for as long as possible. Since October 1996 there have been 375 patients referred with a decrease in the 31-day readmission rate from 21% to an average of 5%. Costs are presently $55.00 per month per patient. Evaluation of the congestive heart failure phone management tool revealed a strong 77% positive correlation between the patient's score and the number of interventions needed to stabilize the patient. Care management visits, when necessary, help reduce the need for hospitalization. (c)2000 by CHF, Inc.

Restructuring Medicare for the next century: what will beneficiaries really need?

Medicare coverage falls short of its original mandate of access to modern medicine and protection against the high costs of medical care. These shortfalls destabilize both health outcomes and the economic viability of older adults and their families. Our proposed revisions would promote, rather than discourage, optimal care for beneficiaries. By replacing incentives for fragmented, episodic care with an orientation toward functional status, care management, and integration with long-term care, we can make an invaluable investment in a successfully aging society.

Poverty and ill health: physicians can, and should, make a difference.

A growing body of research confirms the existence of a powerful connection between socioeconomic status and health. This research has implications for both clinical practice and public policy and deserves to be more widely understood by physicians. Absolute poverty, which implies a lack of resources deemed necessary for survival, is self-evidently associated with poor health, particularly in less developed countries. Over the past two decades, economic decline or stagnation has reduced the incomes of 1.6 billion people. Strong evidence now indicates that relative poverty, which is defined in relation to the average resources available in a society, is also a major determinant of health in industrialized countries. For example, persons in U.S. states with income distributions that are more equitable have longer life expectancies than persons in less egalitarian states. There are numerous possible approaches to improving the health of poor populations. The most essential task is to ensure the satisfaction of basic human needs: shelter, clean air, safe drinking water, and adequate nutrition. Other approaches include reducing barriers to the adoption of healthier modes of living and improving access to appropriate and effective health and social services. Physicians as clinicians, educators, research scientists, and advocates for policy change can contribute to all of these approaches. Physicians and other health professionals should understand poverty and its effects on health and should endeavor to influence policymakers nationally and internationally to reduce the burden of ill health that is a consequence of poverty.

Erectile dysfunction: a multifaceted disorder.

The cause may be vascular, neurogenic, hormonal, drug-related, psychogenic, or a combination thereof. In older men in particular, underlying causes may include life-threatening disorders. Evaluation requires directed questioning, since men often fail to volunteer important related symptoms. Clinical findings guide laboratory testing and treatment is tailored to the etiology.

Case management and recidivism of mentally ill persons released from jail.

OBJECTIVE: The study tested the hypothesis that case management provided to mentally ill offenders both in jail and after release from jail would reduce their recidivism. METHODS: A total of 261 inmates of the Lucas County (Toledo, Ohio) jail who were diagnosed with a mental disorder were tracked for three years after their release. The relationships between recidivism and diagnostic, demographic, and case management variables were examined through event history analysis. RESULTS: Recidivism was associated with age, employment, previous arrests, and receipt of community-based case management. Receipt of jail-based case management, although not directly related to recidivism, significantly increased the probability of receiving community-based case management. Receipt of community case management was significantly associated with a lower probability of rearrest and a longer period before rearrest. CONCLUSIONS: This study found hopeful signs that expanding access to case management, both inside and outside jail, will help mentally ill people live in their communities and stay out of jail.