Complexity of Chronic Conditions' Impact on End-of-Life Expense Trajectories of Medicare Decedents.

OBJECTIVE: The aim of this study is to determine if the pattern of monthly medical expense can be used to identify individuals at risk of dying, thus supporting providers in proactively engaging in advanced care planning discussions. BACKGROUND: Identifying the right time to discuss end of life can be difficult. Improved predictive capacity has made it possible for nurse leaders to use large data sets to guide clinical decision making. METHODS: We examined the patterns of monthly medical expense of Medicare beneficiaries with life-limiting illness during the last 24 months of life using analysis of variance, t tests, and stepwise hierarchical linear modeling. RESULTS: In the final year of life, monthly medical expense increases rapidly for all disease groupings and forms distinct patterns of change. CONCLUSION: Type of condition can be used to classify decedents into distinctly different cost trajectories. Conditions including chronic disease, system failure, or cancer may be used to identify patients who may benefit from supportive care.

Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity.

Patient Readiness to Exercise After Cardiac Surgery: Development of the Readiness to Change Exercise Questionnaire.

BACKGROUND: Readiness to change plays a significant role in patient adherence to an exercise regimen; thus, accurate assessment of readiness to change is necessary to direct interventions. To date, an accurate scale for measuring readiness to exercise after cardiac surgery is not available. OBJECTIVES: The purpose of this study was to develop the Readiness to Change Exercise Questionnaire for use among Thai cardiac surgery patients and to evaluate its psychometric properties. METHODS: The Readiness to Change Exercise Questionnaire was developed based on the Transtheoretical Model, a comprehensive literature review, and input from experts and cardiac surgery patients. Participants were 533 patients who had undergone cardiac surgery within the previous 3 months. The study was conducted in 7 hospitals in 4 geographical regions of Thailand. RESULTS: Confirmatory factor analysis showed satisfactory goodness of fit for the 13-item scale. The analysis supported a 4-factor structure corresponding to 4 readiness stages: precontemplation, contemplation, preparation, and action. Cronbach's α coefficients were .68 for precontemplation, .75 for contemplation, .72 for preparation, and .75 for action. CONCLUSIONS: The scale was found to be a valid and reliable instrument for the determination of patient readiness to exercise after cardiac surgery. However, further testing of the scale is needed to confirm its concurrent and predictive validity.

Physical and psychosocial effects of Wii Fit exergames use in assisted living residents: a pilot study.

The purpose of this study was to investigate the physical and psychosocial effects of the Wii Fit exergames incorporating self-efficacy theory on assisted living residents. The study was a quasi-experimental pre/post-test design. Thirty-two participants were recruited from two assisted living facilities. Sixteen participants received the Wii Fit exergames incorporating self-efficacy theory twice a week for 4 weeks. The other participants received a health education program. Physical function, fear of falling, depression, and quality of life were evaluated. T tests were used for data analysis. After the 4-week intervention, the Wii Fit group showed significant improvements in balance (p < .01), mobility (p < .01), and depression (p < .05). The education group showed no significant improvement in any of the outcomes. Integrating concepts of self-efficacy theory with the exergames show promise as a potential tool to improve and maintain physical and psychosocial health for older adults.

Frequent emergency department utilization and behavioral health diagnoses.

BACKGROUND: There are 12 million emergency department (ED) visits each year related to behavioral health diagnoses. Frequent ED utilization among subpopulations, such as those with behavioral health diagnoses, flags the need for more accessible and effective healthcare delivery systems. Reducing frequent ED use is essential to controlling healthcare cost and poor outcomes of ED overcrowding. OBJECTIVES: The purpose of this study is to stratify individuals by overall health complexity and examine the relationship of behavioral health diagnoses (psychiatric and substance abuse) as well as frequent treat-and-release ED utilization in a cohort of Medicaid recipients. METHODS: This study was a retrospective analysis of 2009 Medicaid claims from two Western New York State counties. The claims represented 56,491 individuals (18-64 years old). Individuals were stratified into four separate cohorts for analysis based on underlying disease complexity. Data were analyzed using logistic regression models. RESULTS: The following factors significantly increased the odds of frequent treat-and-release ED use in all the four complexity cohorts: psychiatric diagnosis (ORs = 1.4-2.3), substance abuse (ORs = 2.4-3.8), and smoking (ORs = 1.7-4.0). Medicaid patients with behavioral health diagnoses show high risk of frequent treat-and-release ED use. DISCUSSION: The results of this study show that psychiatric diagnosis, substance abuse, and smoking are associated with increased odds of frequent treat-and-release ED utilization for Medicaid recipients in all categories of underlying disease complexity. Our findings support associations reported in the literature.

Multi-level model of missed nursing care in the context of hospital merger.

The aim of this study was to delineate the multi-level relationships of individual registered nurse (RN) and nursing unit factors on missed nursing care. This was a quantitative model-building study using a descriptive, cross-sectional design. Surveys (N = 553) and administrative unit records from nurses in one hospital system undergoing merger were included. The results showed that 36% of the variation in missed nursing care is due to the unit context, with a corresponding 64% due to individual nurse differences. At the unit level, workload, skill mix, and critical unit type affected the amount of missed nursing care. At the individual nurse level, more experience, supplies problems, communication problems, and involvement in errors of commission all increased the perception of the amount of missed nursing care. Education level was not related to the amount of missed nursing care. The findings highlight the importance of unit- and individual-level interventions to redesign hospital nursing care.

Transitioning the premature infant from nonsupine to supine position prior to hospital discharge.

PURPOSE: The purpose of this study was to document the clinical practice of transitioning the hospitalized premature infant to the supine position and determine if hospital policy influenced practice. DESIGN: This study was a retrospective medical chart review. SAMPLE: The charts were reviewed from two urban hospitals that had Level III NICUs in upstate New York. MAIN OUTCOME VARIABLE: The outcome variable was to determine clinical practice of transitioning premature infants to the supine position. RESULTS: The percentage of premature infants who were transitioned to the supine position at least 24 hours prior to hospital discharge varied, but the postmenstrual age at transition did not vary. The hospital with a policy transitioned premature infants to the supine position one week prior to discharge as compared with two days in the hospital without a policy. Despite national recommendations, no infants were transitioned into the supine position by 32 weeks postmenstrual age.

Electrocardiogram-based predictors of clinical outcomes: a meta-analysis of the prognostic value of ventricular repolarization.

OBJECTIVES: To estimate age- and sex-specific prognostic values of eight electrocardiographic repolarization descriptors to predict various mortality endpoints. BACKGROUND: Using electrocardiographic markers for risk stratification is well studied; however, the prognostic value of many markers is controversial, and their clinical utility remains debatable. No meta-analyses exist that address the prognostic value of ECG markers. METHODS: Data were synthesized from 106 primary studies using a random-effect variance model. Age and sex subgroups were analyzed using sensitivity analysis. RESULTS: Four classic (i.e., duration, amplitude, inversion, and ST-T changes) and four novel (i.e., axis, loop, wavefront direction, and waveform complexity) repolarization descriptors were studied. These novel descriptors were particularly useful in predicting sudden death. Abnormal repolarization duration, vectors, and loops have greater impact on negative cardiovascular outcomes in women compared to men; additionally, ischemic repolarization changes have greater impact on negative cardiovascular outcomes in younger versus older adults. CONCLUSIONS: Assessing repolarization abnormalities is particularly helpful in women and younger adults. Researchers need to further explore the clinical utility of these abnormalities in management algorithms.

Exergames-based intervention for assisted living residents: a pilot study.

The physical and psychosocial benefits of exergames have been reported in various literature. A pre-posttest, single-group design was used to test the effects of an exergames-based intervention on cognition, depression, and health-related quality of life (QOL) in assisted living residents. Bandura's self-efficacy theory was applied. Seven residents (mean age = 86, SD = 5 years) participated in the program two times per week for 8 weeks. Outcome measures included cognition, depression, and health-related QOL. No statistically significant differences were found in any of the outcomes after the intervention. A tendency toward improved cognition occurred, but the outcomes of depression and health-related QOL did not follow a similar trend. However, improved socialization and motivation to exercise were reported. Continued research is needed to investigate the cognitive and psychosocial effects of exergames on this population. Nurses can collaborate with other health care professionals to engage residents in exercise and thus improve residents' QOL.

The feasibility of an intervention combining self-efficacy theory and Wii Fit exergames in assisted living residents: A pilot study.

The purpose of this study was to examine the feasibility of a self-efficacy based intervention using Wii exergames in assisted living residents. The study was a single-group pre- and post-test design. Seven older adults (aged 80-94 years) were instructed to engage in exergames twice a week for 8 weeks. Physical function (balance, mobility, and walking distance), fear of falling, self-efficacy for exercise, and outcome expectations for exercise were evaluated. All participants had enjoyable experiences and no serious adverse events were reported. Participants had significant improvement on balance. Although not significant, there were trends indicating that participants improved mobility, walking endurance, and decreased fear of falling. The use of Wii exergames was an acceptable, safe, and potentially effective approach to promote physical activity in older adults. Findings provide support for the applications of integrating self-efficacy theory into exergames as a mechanism to encourage older adults to engage in exercise.

Nursing control over practice and teamwork.

Nurses' control over practice is essential to nursing care quality and fosters teamwork at the point of care delivery. This article describes a study to measure the impact of nurses' control over their practice from the perspective of teamwork. The purpose of this study was to measure the relationship of control over practice to the five following dimensions of teamwork: team structure, leadership, situation monitoring, mutual support, and communication. The study method was a secondary analysis of 456 surveys from registered nurses working in a five-hospital system. Study results demonstrated that the global measure of teamwork correlated with control over practice and nursing experience, but not with teamwork training. All five individual dimensions of teamwork were perceived as better for those who had a high level of control over practice compared to those who did not. In the discussion section, we consider situation monitoring since this dimension demonstrated an interaction effect between teamwork training and control over practice. Nursing control over practice demonstrates a positive relationship with teamwork and should be considered in future education, policy, and research efforts. Further study is needed to understand control over practice as a potential moderator or mediator of other predecessors of effective teamwork.

Depression, anxiety, and suicidal ideation among Chinese Americans: a study of immigration-related factors.

The aim of this study was to identify anxiety, depression, and suicidal ideation disparities among Chinese Americans and how immigration-related factors affected the outcomes. We tried to explain the differences as a function of the Chinese culture. Data were derived from the National Latino and Asian American Study, the first national epidemiological survey of these populations in the United States. We used only the Chinese sample (N = 600) and focused on depressive disorder, anxiety disorder, and suicidal ideation. The United States-born Chinese and those Chinese who immigrated to the United States at 18 years or younger were at higher risk for lifetime depressive or anxiety disorders or suicidal ideation than were their China-born counterparts who arrived in the country at or after 18 years of age. For Chinese Americans, immigration-related factors were associated with depression and anxiety disorders and suicidal ideation. The higher prevalence of these disorders might be attributed to the psychological strains experienced by those who are at higher risk of cultural conflicts.

Influence of demographic factors, knowledge, and beliefs on Jordanian women's intention to undergo mammography screening.

PURPOSE: The purpose of this study was to determine the influence of demographic characteristics, breast cancer knowledge, fatalistic beliefs, health beliefs, and subjective norms on Jordanian women's intention to participate in mammography screening. DESIGN: A cross-sectional survey was used to collect data at 14 comprehensive healthcare centers in Amman and Zarqa, Jordan. A convenience sample of 142 Jordanian women 40 years of age or older with no history of breast cancer and able to read and write in Arabic participated. METHODS: Self-report surveys included a combination of researcher-designed and existing instruments to measure the study variables. Data were analyzed using descriptive statistics, Pearson's correlation, t tests, and multiple logistic regression. FINDINGS: Jordanian women surveyed lacked knowledge about breast cancer. Social norms and self-efficacy highly influenced these women's intention to engage in mammography screening. Younger women were more willing to indicate intention to engage in mammographic screening. CONCLUSIONS: Self-efficacy and the social connectedness of Jordanian society, but not religious beliefs or perceived barriers to screening, influence Jordanian women's intention to undergo mammography. Future research should examine cultural influences, rather than religious beliefs, and investigate Jordanian women's potentially unique perspectives on barriers to actual mammography screening behavior. CLINICAL RELEVANCE: The prevalence of mammography screening may be enhanced by focusing interventions on Jordanian women's support systems and empowering women by providing knowledge and skills needed to engage in the procedure.

The relationship between acculturation and oral contraceptive use among Korean immigrant women.

We explored the relationship between acculturation and beliefs, attitudes, norms, and intention regarding oral contraceptive use among Korean immigrant women using acculturation and the theory of reasoned action (TRA) as the frameworks. A total of 1,494 Korean surname-based telephone numbers were sampled in New York City. One hundred forty-five Korean immigrant women completed a telephone survey. The findings support the assumption that acculturation affects intention to use oral contraceptives indirectly only through one or more of the TRA components. Acculturation could function as an antecedent to changes in beliefs, attitudes, norms, and intention in this population. Acculturation assessment tools could provide health professionals insight into how to better approach this population on such culturally sensitive health issues as contraceptive use.

Applying the transtheoretical model to health care proxy completion.

BACKGROUND: For many, an important health decision is whether or not to document end-of-life wishes using an advance directive (e.g., health care proxy). To date, interventions targeting this health behavior have had little effect on increasing advance directive completion rates. Health behavior models, such as the transtheoretical model (TTM) could be useful for understanding the health decision-making processes used along a continuum, from no intention to complete an advance directive to completing one and discussing it with an appointed advocate. PURPOSE: To explore the applicability of the TTM for a previously understudied health behavior-completing a health care proxy (HCP). METHOD: Four established TTM measures for completing a HCP (stages of change, processes of change, decisional balance, and self-efficacy) were administered to 566 adults with coverage from 1 of 2 health insurance companies. Separate analyses of variance were used to test the relationships between the independent variable (stages of change) and dependent variables (processes of change, decisional balance, self-efficacy scores). RESULTS: Consistent with other TTM research both the experiential and the behavioral processes of change revealed the lowest scores in the precontemplation stage peaking in the preparation stage. The pattern of pros and cons was replicated from previous TTM studies, with the 2 scores crossing over just prior to the preparation stage. Self-efficacy scores incrementally increased across the stages of change with the largest effect evident from the precontemplation to preparation stage. CONCLUSION: The models developed from this study can be used to guide the development of stage-based interventions for promoting health care proxy completion.

Effects of a 6-week walking program on Taiwanese women newly diagnosed with early-stage breast cancer.

BACKGROUND: In Western culture, evidence has shown that in women with breast cancer exercise decreases fatigue and improves quality of life. However, only 1 pilot study about the effect of exercise has been examined in the Asian breast cancer population that indicated feasibility. Therefore, it is important to further study the effect of an exercise program for Taiwanese women with breast cancer. OBJECTIVE: The purpose of this study was to test the effects of a walking program on Taiwanese women newly diagnosed with early-stage breast cancer. METHODS: This was an experimental, longitudinal study with 4-time repeated measures based on Bandura's Self-efficacy Theory, with the aim of implementing interventions to boost exercise self-efficacy and to evaluate research outcomes. SPSS 17.0 with descriptive statistics using frequency, percentage, mean, and SD as well as inferential statistics such as t test, χ test, hierarchical linear model, repeated-measures analysis of variance, and analysis of covariance was used for data analysis. RESULTS: Results of this study indicated that subjects in the exercise group had significantly better quality of life, less fatigue, less sleep disturbances, higher exercise self-efficacy, more exercise behavior, and better exercise capacity compared with those in the usual-care group after the intervention. CONCLUSIONS: This program was effective and feasible, but more research studies with experimental, longitudinal design to verify the effects of this exercise program on Taiwanese women with breast cancer will be needed. IMPLICATIONS FOR PRACTICE: Nurses, depending on skill and knowledge, can encourage physical activity, refer patients to rehabilitation programs, and prescribe and monitor exercise in breast cancer population.

Factors related to quality-of-life pattern changes in recipients of implantable defibrillators.

PURPOSE: The implantable cardioverter defibrillator (ICD) has proven life-saving, yet it is important to understand its psychological effects on recipients. This study examined longitudinal changes in patterns of quality-of-life (QOL) scores in the first 3 months after an implant, and determined what variables tested as predictors of patterns. METHODS: This longitudinal, prospective, descriptive, correlational survey study followed 80 ICD patients, with data collection at a baseline preinsertion, and 1 and 3 months after implant. RESULTS: Findings revealed eight patterns of QOL change that were recoded into 3 groups: no change (44.7%), worse (20.7%), and improved (34.2%). No significant difference was evident in groups according to age at implant, gender, education, ejection fraction, number of device discharges, and comorbidities. State anxiety was significantly higher for the worsening group. CONCLUSION: This finding supports the practice of identifying and supporting patients with anxiety, which correlates with a worsening QOL.

Thai Family Health Routines: scale development and psychometric testing.

The aims of the study were to develop and test the psychometric properties of the Thai Family Health Routines (TFHR) scale, a 70-item self-report questionnaire used to measure the health of Thai families through their routine behaviors in daily life. Development of the TFHR was based on the structural domains of Denham's Family Health Model. The TFHR scale was initially composed of 85 items and tested on 1,040 families living in the central region of Thailand. The confirmatory factor analysis, with an acceptable factor structure model, yielded 70 items aligned with six factors: self-care, safety and prevention, mental health behavior, family care, family caregiving, and illness care routines. The preliminary psychometric properties demonstrated that the TFHR scale had satisfactory internal consistency, criterion validity, and construct validity. The test results suggested that the TFHR scale has potential benefits for family and community nurses to assess Thai family health for both research and clinical purposes.

Psychometric testing of four transtheoretical model questionnaires for the behavior, completing health care proxies.

The purpose of the study was to develop four questionnaires based on the transtheoretical model (TTM) to assess the behavior, completing a healthcare proxy (HCP). The aims were to (a) operationalize the four TTM constructs for completing a HCP and (b) evaluate the psychometric properties of the questionnaires. The questionnaires were constructed and content validity established using an expert panel. Internal consistency values for each questionnaire and subscales within each questionnaire were >.79. Confirmatory factor analysis provided evidence that decisional balance and the processes of change questionnaires each contained two factors. Our data support validity and reliability of the TTM questionnaires related to HCP completion.

Measuring usability of assistive technology from a multicontextual perspective: the case of power wheelchairs.

Assistive technology (AT) devices enable people with disabilities to function in multiple contexts and activities. The usability of such devices is fundamentally indicative of the user's level of participation in multiple roles and occupations. Seventy people who used power wheelchairs were interviewed using a novel tool, the Usability Scale for Assistive Technology (USAT). The USAT uses a human factors science framework to investigate the wheelchair user's perceived independence in mobility-related activities within home, workplace, community, and outdoors in accordance with the characteristics of the wheelchair, environmental factors, and abilities and skills of the user to operate the wheelchair. Descriptive analysis of the data revealed usability issues with the use of power wheelchairs in all contexts. Users confronted far more significant issues within the community and outdoor environment compared with those at home and in the workplace. These issues have been elucidated and applied to an intervention framework with relevance to a multitude of AT stakeholders.