Self-administration of medication by patients and family members during hospitalization.

The current trend of shorter hospital stays has heightened concern about the adequacy of preparation of patients and their families to understand and follow prescribed medication regimens properly following discharge. Cooperative Care, an education-intensive unit incorporating a living-in family member or friend acting as a 'care partner,' has had a self-administration of medication program (SAM) for the past 16 years. This paper describes SAM and reports on two studies of its effectiveness. The first was a 1-week survey of all patients (151) admitted to the unit. 126 (83.4%) were taking a mean of five medications, with a range of one to 17. Of those, 102 (80.9%) were able to participate in SAM independently, and 11 (8.7%) were on SAM with supervision by their care partners. The second study reviewed medication administration errors within Cooperative Care and the traditional nursing units of Tisch Hospital over a 4-year period (1991-1994). Cooperative Care accounted for 19.4% of discharges (22,164/114,206) and 10.3% of patient days (97,037/944,230), but only 4.6% of medication errors (80/1723). The medication error rate per 1000 discharges was 3.6 for Cooperative Care, and 17.8 for the traditional units. Comparative error rates per 10,000 medication orders were 3.06 at Cooperative Care and 4.01 on the traditional units. 74.8% of Cooperative Care patients were on SAM, but only 30% of the errors were attributed to patients or care partners. The other errors were attributed to nursing staff (50%), equipment defects (12.5%) or pharmacists (5%). Our data indicate that SAM during hospitalization is a safe and effective modality of care.

A new structured database for clinical information.

Assessing a patient's functional status and psychosocial conditions is accomplished more easily and with greater accuracy in the home. But how can physicians organize a database to convey information about specific clinical problems?

Physician's guide to managing home care of older patients.

One of the responsibilities of the physician in overseeing home care is to periodically assess overall functional ability in the home. Specific home visits for this purpose--whether by physician aides or the physician--should incorporate a home care "review of systems," exploring the adequacy of the home environment, the patient's capabilities, the family's ability, and the accuracy of medication administration. Reestablishing family equilibrium following hospital discharge should begin by encouraging the hospital staff to share responsibility with the family, allowing them to "rehearse" the roles they will play at home. The cardinal tasks for which the physician can support the family in attempting to perform are: providing emotional support for the patient, making observations, providing physical assistance, performing household chores, participating in the treatment regimen, and calling for assistance. These functions are the backbone of successful family involvement in home care, even when "high-tech" procedures are being used. Referral to self-help groups or appropriate home health aide services is also an important role the informed physician can perform.

Effectiveness of a hospital-based cooperative care model on patients' functional status and utilization.

The primary objective of this study was to test the hypothesis that inpatient care which emphasized structured, patient education, self-care and social support from a care partner (the Cooperative Care Program) is a cost-effective alternative to the more expensive staff-intensive, traditional hospital care; and that such care can be substituted without resulting in poorer outcomes with regard to subsequent health status or use of services. The effects of this program on patient and physician acceptance, patient knowledge and treatment and health status, were evaluated by means of an experimental design with comparable groups of patients assigned to experimental (cooperative care) or control (usual hospitalization) group status. Follow-up analyses of both groups of patients for a 12-month time period concluded that there were comparable and equally positive post-hospitalization experiences, with greater than 90% of both groups of patients functioning well with respect to a series of measures of functional status. There was no evidence that Cooperative Care patients were re-hospitalized more often or needed more emergency, home care or other types of services. There was, on the other hand, evidence of the positive effect on patient understanding, adherence to treatment, satisfaction, and self-management.

New York University Medical Center's Cooperative Care Unit: patient education and family participation during hospitalization--the first ten years.

The New York University Medical Center Cooperative Care (CC) program is a model of a delivery system of acute inpatient hospital care characterized by a live-in family member or friend acting as a "care partner". It has an emphasis on education in order to encourage full patient and family involvement in care during the acute hospitalization, thereby preparing both parties for management at home after discharge. The education-intensive experience of CC provides an alternative to traditional inpatient hospital care with the expected outcome of CC being to increase patient and family knowledge and satisfaction, adherence to the medical regimen, and appropriate self-management. The functioning ability of the patient-care partner team should be improved on discharge, which may result in decreased subsequent utilization of high cost healthcare resources such as rehospitalization. This paper describes the structure of the CC form of inpatient care, the types of patients appropriate for such care, and the experience of its first ten years of operation, with its implications as a replicable model for other institutions.

Methionine intolerance: a possible risk factor for coronary artery disease.

Homocystinuria, an inherited disorder associated with premature atherosclerosis, represents a severe form of methionine intolerance. To analyze the importance of milder forms of methionine intolerance in the genesis of vascular disease, the relation between provokable methionine intolerance and coronary artery disease was investigated. In a group of 138 men, aged 31 to 65 years (mean 53), referred for cardiac catheterization, plasma homocystine was measured before and 6 hours after an oral l-methionine load (0.1 g/kg). Thirty-nine subjects found to have normal coronary arteries had a mean post-load plasma homocystine level of 0.59 +/- 0.37 mumol/liter. A criterion at the 95th percentile (1.64 SD above the mean) was selected and applied to the remaining 99 subjects with coronary artery disease (0.70 +/- 0.68 mumol/liter). Sixteen (16%) of 99 subjects with coronary artery disease exceeded this level as compared with 1 (2%) of 39 subjects without coronary artery disease (p less than 0.04). The risk of coronary artery disease in men with provokable methionine intolerance was increased sevenfold as estimated by the odds ratio. By correlation matrix and multivariate regression analyses, provokable homocystinemia was predictive of coronary artery disease and was independent of tobacco smoking, hypertension, diabetes mellitus, serum cholesterol and age. It is proposed that men with mild methionine intolerance exposed to the high methionine content of the Western diet may develop intermittent homocystinemia and thus may be at greater risk for the development of coronary artery disease.

Hyperalgesic pseudothrombophlebitis. New syndrome in male homosexuals.

Five male homosexuals, four of whom had Kaposi's sarcoma, presented with painful swelling of the lower extremity. The overlying skin was erythematous and exquisitely tender. Deep vein thrombosis was strongly suspected in all patients. Venography, however, revealed no evidence of venous occlusion. This condition, which in this report is termed the hyperalgesic pseudothrombophlebitis syndrome, appears to be another unusual manifestation of the acquired immune deficiency syndrome. It should be considered among the entities known to mimic deep vein thrombosis and must be recognized in order to prevent unnecessary anticoagulation in these patients.

The thrombogenicity of 6-azouridine.

The antimetabolite 6-azauridine blocks the de novo synthesis of pyrimidines and causes increased serum levels of several amino acids including homocystine. 6-Azauridine was was withdrawn from clinical use for the treatment of psoriasis because of the occurence of arterial and venous thromboembolic episodes in some psoriatic patients. Utilizing a standard animal model for the recognition of venous and arterial thrombosis, 6-azauridine was demonstrated in this study to cause thrombosis without producing homocystinemia when administered orally or intravenously.

Homocystinuria: pathogenetic mechanisms.

Homocystinuria with elevated plasma homocysteine and methionine levels is the result of deficient activity of cystathionine synthetase, the enzyme catalyzing conversion of homocysteine to cystathionine. It is inherited as an autosomal recessive trait with a worldwide distribution. The major clinical manifestations result from the elevated plasma homocysteine level. The excitotoxic effect of homocysteic acid accounts for mental retardation and seizures. Interference with collagen cross-linking by sulfhydryl groups of homocysteine causes ectopia lentis and skeletal deformities. Sulfation factor-like effects contribute to disruption of vascular endothelium, which is followed by platelet thrombosis and widespread arterial and venous occlusions. Low methionine homocystinuria, with deficient remethylation of homocysteine, results from deranged vitamin B(12) metabolism and from deficient 5,10-methylene-tetrahydrofolate reductase. Administration of azaribine produces homocystinuria by mechanism not yet elucidated.