Threading the Needle: When a Cranial Burr Hole Is Palliative Therapy.

Subdural hematoma (SDH) impacts up to 58.1 per 100,000 individuals aged ≥65 years. Some patients or proxies elect to focus exclusively on comfort care treatments, whereas others may consider surgical procedures such as a craniotomy or cranial trephination (burr hole) to relieve intracranial pressure. The central lesson of this case report is that the burr hole is a potential palliative care treatment in terms of experiences and outcomes, even among very old adults provided they have excellent baseline function. We present a case of a 95-year-old woman presenting to the emergency department with acute on chronic SDH and aphasia. Neurosurgical consultation and cranial trephination reversed her aphasia, and she continues to live independently with good function three years postsurgery. We discuss how the burr hole is consistent with a palliative care approach as well as the value of interdisciplinary discussions of minimally invasive neurosurgical interventions with potential for enhancing quality of life.

Planning for Older Adult Day Programs in an Arab American Community: Perceptions From Older Adults, Caregivers, and Professional Providers.

Background and Objective: This study explored Arab American stakeholders' perceptions about potential future adult day programming to inform geriatric service providers about relevant services for culturally diverse older adults. Research Design and Method: Participants (N = 28) in five focus groups were recruited through a social service provider in Metropolitan Detroit, Michigan. Results were analyzed using thematic analysis. Results: Themes included basic requirements, promoting clear and transparent understanding of adult day programs (ADPs), respecting the person, social engagement and activities, explaining complex ethnic and geographic identities, and implementing diversity. Discussion and Implications: ADP service providers can enhance services by drawing on the life experiences, resilience, and creativity of older Arab Americans. Person-focused policies and programs that draw on the strengths of the diverse local community should be developed and communicated clearly for potential participants, family members, and service providers.

Informal Support, Health, and Burden Among Parents of Adult Children With Autism.

BACKGROUND AND OBJECTIVES: Many adults with autism spectrum disorders require lifelong reliance on caregiver support. As these caregivers age and experience health challenges, social support can be critical. This study seeks to understand if caregiver health moderates the relationship between informal social support and caregiver burden. RESEARCH DESIGN AND METHODS: A total of 320 parents (age 50+ years) of adult children diagnosed with ASD were recruited from autism organizations and support groups and completed a web-based survey. Separate moderation analyses were used to determine if caregiver health was moderating the relationship between informal social support and composite caregiver burden, as well as the separate domains of developmental, time dependence, emotional burden, and impact of caregiving on finances. For each analysis, perceptions of available informal social support were the independent variable, composite and domains of caregiver burden were dependent variables, and parents' self-reported general health was the moderating variable. RESULTS: Caregiver health had a statistically significant moderating effect when predicting the relationships between informal social support and composite caregiver burden, as well as time dependence burden and impact of caregiving on finances. DISCUSSION AND IMPLICATIONS: Increased attention should be focused on supporting the current and future needs of both aging caregivers and their adult children with ASD. Future research on the dynamics of social support, health, and burden is also urgently needed to address the growing number of aging caregivers of adults diagnosed with ASD.

Results of a Hospital-Based Palliative Care Intervention for Patients With an Acute Exacerbation of Chronic Heart Failure.

BACKGROUND: Palliative interventions are an important part of advanced heart failure (HF) care. However, these interventions are historically underutilized, particularly by African Americans. METHODS AND RESULTS: We performed a prospective randomized intervention trial in patients with advanced HF who were hospitalized for acute decompensation at 3 urban hospitals, comparing the effect of palliative care consultation (PCC) with that of usual care. The primary end point was the proportion choosing comfort-oriented care (hospice and/or "do not resuscitate" [DNR] order) 3-6 months after randomization. A total of 85 patients (mean age 68 years, 91.8% African American) were enrolled over a 2-year period. Four of the 43 patients (9.3%) randomized to the PCC group chose comfort-oriented care versus 0 of the 42 control group members (risk difference = 9.3%; 95% confidence interval = -11.8% to 30.0%). CONCLUSIONS: In this predominantly African-American cohort of hospitalized patients with advanced HF, PCC did not lead to a greater likelihood of comfort care election compared with usual care. More robust palliative interventions should be developed to meet the needs of diverse groups of patients with HF.

Cost analysis of a novel interdisciplinary model for advanced illness management.

PURPOSE: This research project evaluated cost outcomes for patients in the @HOMe Support program, a novel interdisciplinary home-based program for patients and caregivers facing advanced illness drawing on the Chronic Care Model. METHODS: Cost analysis involved paired sample t-tests to examine pre-post differences in health care expenditures obtained from Health Maintenance Organization (HMO) claims data for program participants. RESULTS: Average 6-month costs per month significantly declined for patients older than 65 years of age from 1 HMO (US$9300-US$5900, P = .001). Evaluation of the second HMO showed that patients less than 65 years of age with lower preentry costs (<70 000) had a nonsignificant decline in total costs (US$18 787-US$13 781, P = .08). CONCLUSIONS: Study findings suggest @HOMe Support is associated with reductions in the use and cost for most health services over time.

Fidelity of implementation: development and testing of a measure.

BACKGROUND: Along with the increasing prevalence of chronic illness has been an increase in interventions, such as nurse case management programs, to improve outcomes for patients with chronic illness. Evidence supports the effectiveness of such interventions in reducing patient morbidity, mortality, and resource utilization, but other studies have produced equivocal results. Often, little is known about how implementation of an intervention actually occurs in clinical practice. While studies often assume that interventions are used in clinical practice exactly as originally designed, this may not be the case. Thus, fidelity of an intervention's implementation reflects how an intervention is, or is not, used in clinical practice and is an important factor in understanding intervention effectiveness and in replicating the intervention in dissemination efforts. The purpose of this paper is to contribute to the understanding of implementation science by (a) proposing a methodology for measuring fidelity of implementation (FOI) and (b) testing the measure by examining the association between FOI and intervention effectiveness. METHODS: We define and measure FOI based on organizational members' level of commitment to using the distinct components that make up an intervention as they were designed. Semistructured interviews were conducted among 18 organizational members in four medical centers, and the interviews were analyzed qualitatively to assess three dimensions of commitment to use--satisfaction, consistency, and quality--and to develop an overall rating of FOI. Mixed methods were used to explore the association between FOI and intervention effectiveness (inpatient resource utilization and mortality). RESULTS: Predictive validity of the FOI measure was supported based on the statistical significance of FOI as a predictor of intervention effectiveness. The strongest relationship between FOI and intervention effectiveness was found when an alternative measure of FOI was utilized based on individual intervention components that had the greatest variation across medical centers. CONCLUSIONS: In addition to contextual factors, implementation research needs to consider FOI as an important factor in influencing intervention effectiveness. Our proposed methodology offers a systematic means for understanding organizational members' use of distinct intervention components, assessing the reasons for variation in use across components and organizations, and evaluating the impact of FOI on intervention effectiveness.

Community-based tele-health systems for persons with diabetes: development of an outcomes model.

The purpose of this study was to obtain information on the perceptions of persons with diabetes regarding participation in a tele-health program. We conducted three focus groups among diabetics who had used a monitoring and messaging device (MMD), a commonly used tele-health care system. Analysis involved open and axial coding to identify major themes and relationships. Results suggest that these systems enhance communication, care-manager relationships, self-discipline, and clinical follow-up. The results suggest mechanisms by which tele-health systems influence the health care system and point to areas for further tele-health development.

Diagnostic classifications and resource utilization of decedents served by the Department of Veterans Affairs.

BACKGROUND: Given the volume and cost of inpatient care during the last year of life, there is a critical need to identify patterns of dying as a means of planning end-of-life care services, especially for the growing number of older persons who receive services from the Veterans Health Administration (VHA). METHODS: A retrospective computerized record review was conducted of 20,933 VHA patients who died as inpatients between October 1, 2001 and September 30, 2002. Diagnoses were aggregated into one of five classification patterns of death and analyzed in terms of health care resource utilization (mean number of inpatient days and cumulative outpatient visits in the year preceding the patient's death). RESULTS: Cancer deaths were the most common (30.4%) followed by end-stage renal disease (ESRD) (23.2%), cardiopulmonary failure (21.4%), frailty (11.6%), "other" diagnoses (7.3%), and sudden deaths (6.1%). Those with ESRD were more likely to be male and nonwhite (p < 0.05) and those with frailty were more likely to be older and married (p < 0.05). Controlling for demographic variables, those with frailty had the highest number of inpatient days while those with ESRD had the highest number of outpatient visits. Non-married status was associated with more inpatient days, especially among younger decedents. CONCLUSION: As a recognized leader in end-of-life care, the VHA can play a unique role in the development of specific interventions that address the diverse needs of persons with different dying trajectories identified through this research.

The use of telehealth for diabetes management: a qualitative study of telehealth provider perceptions.

BACKGROUND: Monitoring and Messaging Devices (MMDs) are telehealth systems used by patients in their homes, and are designed to promote patient self-management, patient education, and clinical monitoring and follow-up activities. Although these systems have been widely promoted by health care systems, including the Veterans Health Administration, very little information is available on factors that facilitate use of the MMD system, or on barriers to use. METHODS: We conducted in-depth qualitative interviews with clinicians using MMD-based telehealth programs at two Veterans Affairs Medical Centers in the Midwestern United States. RESULTS: Findings suggest that MMD program enrollment is limited by both clinical and non-clinical factors, and that patients have varying levels of program participation and system use. Telehealth providers see MMDs as a useful tool for monitoring patients who are interested in working on management of their disease, but are concerned with technical challenges and the time commitment required to use MMDs. CONCLUSION: Telehealth includes a rapidly evolving and potentially promising range of technologies for meeting the growing number of patients and clinicians who face the challenges of diabetes care, and future research should explore the most effective means of ensuring successful program implementation.