Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room.

INTRODUCTION: Moderate sedation outside the operating room is performed for a variety of medical and surgical procedures. It involves the administration of different drug combinations by nonanesthesia professionals. Few data exist on risk stratification and patient outcomes in the adult population. Current literature suggests that sedation can be associated with significant adverse outcomes. OBJECTIVES: The aims of this study were to evaluate the nature of adverse events associated with moderate sedation and to examine their relation to patient characteristics and outcomes. METHODS: In this retrospective review, 52 cases with moderate sedation safety incidents were identified out of approximately 143,000 cases during an 8-year period at a tertiary care medical center. We describe types of adverse events and the severity of associated harm. We used bivariate and multivariate analyses to examine the links between event types and both patient and procedure characteristics. RESULTS: The most common adverse event and unplanned intervention were oversedation leading to apnea (57.7% of cases) and the use of reversal agents (55.8%), respectively. Oversedation, hypoxemia, reversal agent use, and prolonged bag-mask ventilation were most common in cardiology (84.6%, 53.9%, 84.6%, and 38.5% of cases, respectively) and gastroenterology (87.5%, 75%, 87.5%, and 50%) suites. Miscommunication was reported most frequently in the emergency department (83.3%) and on the inpatient floor (69.2%). Higher body mass index was associated with increased rates of hypoxemia and intubation but lower rates of hypotension. Advanced age boosted the rates of oversedation, hypoxemia, and reversal agent use. Women were more likely than men to experience oversedation, hypotension, prolonged bag-mask ventilation, and reversal agent use. Patient harm was associated with age, body mass index, comorbidities, female sex, and procedures in the gastroenterology suite. CONCLUSIONS: Providers should take into account patient characteristics and procedure types when assessing the risks of harmful sedation-related complications.

Using a micro-level model to generate a macro-level model of productive successful aging.

PURPOSE OF THE STUDY: Aging successfully entails good physical and cognitive health, as well as ongoing participation in social and productive activity. This study hones in on participation in productive activity, a factor that makes an important contribution to successful aging. One conceptual model of productive activity in later life specifies the antecedents and consequences of productivity. This study draws on that micro-level model to develop a corresponding macro-level model and assesses its utility for examining the predictors of and explaining the relationships between one form of productivity (labor force participation rates) and one aspect of well-being (average life expectancy) among males and females. DESIGN AND METHODS: Random effects regression models and path analysis were used to analyze cross-national longitudinal data for 24 high-income Organization for Economic Co-operation and Development (OECD) countries at seven time points (1980-2010; 168 observations total). RESULTS: OECD countries with higher labor force participation rates among older workers have higher life expectancies. Labor force participation mediates the effects of gross domestic product per capita on male and female life expectancy, and it mediates the effect of self-employment rate for men, but it acts as a suppressor with regard to the effect of public spending on male and female life expectancy. IMPLICATIONS: A well-known micro-level model of productive activity can be fruitfully adapted to account for macro-level cross-national variation in productivity and well-being.

Causal effects of retirement timing on subjective physical and emotional health.

OBJECTIVES: This article explores the effects of the timing of retirement on subjective physical and emotional health. Using panel data from the Health and Retirement Study (HRS), we test 4 theory-based hypotheses about these effects-that retirements maximize health when they happen earlier, later, anytime, or on time. METHOD: We employ fixed and random effects regression models with instrumental variables to estimate the short- and long-term causal effects of retirement timing on self-reported health and depressive symptoms. RESULTS: Early retirements--those occurring prior to traditional and legal retirement age--dampen health. DISCUSSION: Workers who begin their retirement transition before cultural and institutional timetables experience the worst health outcomes; this finding offers partial support to the psychosocial-materialist approach that emphasizes the benefits of retiring later. Continued employment after traditionally expected retirement age, however, offers no health benefits. In combination, these findings offer some support for the cultural-institutional approach but suggest that we need to modify our understanding of how cultural-institutional forces operate. Retiring too early can be problematic but no disadvantages are associated with late retirements. Raising the retirement age, therefore, could potentially reduce subjective health of retirees by expanding the group of those whose retirements would be considered early.

Affective interactions in medical visits: ethnic differences among American Indian older adults.

OBJECTIVE: Investigate influence of ethnicity on older American Indian patients' interpretations of providers' affective behaviors. METHOD: Using data from 115 older American Indian patients, random effects ordered logit models related patient ratings of providers' respect, empathy, and rapport first to separate measures of American Indian and White American ethnicity, then to "ethnic discordance," or difference between providers' and patients' cultural characteristics. RESULTS: In models accounting for patients' ethnicity only, high scores for American Indian ethnicity were linked to reduced evaluations for providers' respect; high scores on White ethnicity were associated with elevated ratings for empathy and rapport. In models accounting for provider-patient ethnic discordance, high discordance on either ethnicity scale was associated with reduced ratings for the same behaviors. DISCUSSION: Findings support "orthogonal ethnic identity" theory and extend "cultural health capital" theory, suggesting a pathway by which ethnicity becomes relevant to experience of health care among older adults.

Perceptions of medical interactions between healthcare providers and American Indian older adults.

Cultural competence models assume that culture affects medical encounters, yet little research uses objective measures to examine how this may be true. Do providers and racial/ethnic minority patients interpret the same interactions similarly or differently? How might patterns of provider-patient concordance and discordance vary for patients with different cultural characteristics? We collected survey data from 115 medical visits with American Indian older adults at a clinic operated by the Cherokee Nation (in Northeastern Oklahoma, USA), asking providers and patients to evaluate nine affective and instrumental interactions. Examining data from the full sample, we found that provider and patient ratings were significantly discordant for all interactions (Wilcoxon signed-rank test p

Cultural identities and perceptions of health among health care providers and older American Indians.

BACKGROUND: Differences in provider-patient health perceptions have been associated with poor patient outcomes, but little is known about how patients' cultural identities may be related to discordant perceptions. OBJECTIVE: To examine whether health care providers and American-Indian patients disagreed on patient health status ratings, and how differences related to these patients' strength of affiliation with American-Indian and white-American cultural identities. DESIGN: Survey of patients and providers following primary care office visits. PARTICIPANTS: One hundred and fifteen patients > or =50 years and 7 health care providers at a Cherokee Nation clinic. All patients were of American-Indian race, but varied in strength of affiliation with separate measures of American-Indian and white-American cultural identities. MEASUREMENTS: Self-reported sociodemographic and cultural characteristics, and a 5-point rating of patient's health completed by both patients and providers. Fixed-effects regression modeling examined the relationships of patients' cultural identities with differences in provider-patient health rating. RESULTS: In 40% of medical visits, providers and patients rated health differently, with providers typically judging patients healthier than patients' self-rating. Provider-patient differences were greater for patients affiliating weakly with white cultural identity than for those affiliating strongly (adjusted mean difference=0.70 vs 0.12, P=.01). Differences in ratings were not associated with the separate measure of affiliation with American-Indian identity. CONCLUSIONS: American-Indian patients, especially those who affiliate weakly with white-American cultural identity, often perceive health status differently from their providers. Future research should explore sources of discordant perceptions.