Socioeconomic determinants of overnight and weekend emergency department use for acute rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Prior work has shown Medicaid and self-pay insurance status is associated with emergency department (ED), rather than outpatient clinic, presentation for uncomplicated acute rhinosinusitis (ARS). We investigate whether the disparate use of ED resources for this nonemergent condition by patients with Medicaid and self-pay insurance can be attributed to presentation overnight or on weekends. STUDY DESIGN: Cross-sectional survey of 990,849 patients from the 2009 and 2010 National Hospital Ambulatory Medical Care Survey presenting to EDs with uncomplicated ARS. Patients with orbital and intracranial complications of ARS were excluded. METHODS: Univariate and multivariate associations identified demographic and socioeconomic characteristics, including insurance status, which were independently associated with overnight (between 5 pm and 7 am) or daytime weekend ED presentation for uncomplicated ARS. RESULTS: Medicaid or self-pay insurance status was associated with evening/overnight ED presentation (odds ratio=1.88, P=.018) in comparison to private or Medicare insurance. However, weekend daytime ED presentation was not associated with Medicaid or self-pay insurance statuses (P=.144). Income and education levels of patients' zip codes, taken as markers of socioeconomic status, were not associated with either evening/overnight or daytime weekend ED presentation for uncomplicated ARS (P>.05). CONCLUSIONS: ARS patients with Medicaid or self-pay status, previously shown to preferentially use EDs for uncomplicated ARS, were more likely to present for overnight ED care compared to patients with private insurance or Medicare. These findings suggest a potential lack of access to extended-hours primary care during evenings and nights for Medicaid patients. LEVEL OF EVIDENCE: 4.

Ownership conversion and closure in the nursing home industry.

Ownership conversions and closures in the nursing home literature have largely been treated as separate issues. This paper studies the predictors of nursing home ownership conversions and closure in a common framework after the implementation of the Prospective Payment System in Medicare skilled nursing facilities. The switch in reimbursement regimes impacted facilities with greater exposure to Medicare and lower efficiency. Facilities that faced greater financial difficulty were more likely to be involved in an ownership conversion or closure, but after controlling for other factors the effect of exposure to Medicare is small. Further, factors that predict conversion were found to vary between not-for-profit and for-profit facilities, while factors that predict closure were the same for each ownership type.

Patterns of community-based end-of-life care in rural areas of the United States.

There is relatively little empirical data on the supply of community-based end-of-life (EOL) providers especially in rural areas despite projections for growth. This study examined the availability of community-based EOL providers in eight states using mapping techniques and statistical approaches. Analysis of variance and geographic information system approaches were used to compare the availability of community-based EOL providers at the county level by degree of rurality. Examining numbers of rural counties by provider, it was found that hospices were the least available community-based EOL providers in rural counties with 62% to 92% of rural counties not having hospice providers (exception: Vermont). When examining the number of providers by population older than 65 years, few differences were found. It is concluded that there are substantially fewer hospice providers in the most rural areas, raising issues of access to care. Examination of both unadjusted and adjusted numbers of providers is important to understand community-based EOL provider supply.

Investigar en cuidados con o sin barreras / No disponible

La investigación en el cuidado de la salud por parte de las enfermeras está siendo un procesolento y contranatural, dada la limitación para el doctorado en muchas universidades a nivel internacional.A pesar de ello, la producción científica de las enfermeras españolas mantiene un crecimientoexponencial desde hace más de 30 años. En este sentido, se puede mencionar que ha existido ciertofomento de la investigación en cuidados por parte del Instituto Carlos III con un número crecientede proyectos financiados. No obstante, dicha financiación sigue siendo muy escasa y la producción científicagenerada lo es todavía más.En sus convocatorias, se observa un desequilibrio en las oportunidades de acceso para profesionalessanitarios no médicos, destacando: un baremo no acorde al área disciplinar para la evaluaciónde publicaciones considerando exclusivamente la base de datos MEDLINE, y la evaluación de la productividadde los investigadores sólo mediante el factor de impacto del Science Citation Index.Al mismo tiempo, esta situación está favoreciendo e incentivando la publicación científica en lenguainglesa (también en Medicina), que choca frontalmente con la política de promoción del español,que realiza el Ministerio de Cultura a través del Instituto Cervantes.La generación de conocimiento debe ser reconocida y valorada independientemente del área disciplinar,del idioma y de la base de datos donde se albergue la revista científica. Así, se echan en faltalas bases de datos IME, PsichoINFO,PSICODOC, ISOC-Sociología y CC. Políticas, CUIDEN o CINAHL;así como los índices bibliométricos desarrollados por el Instituto de Estudios Documentales de laCiencia (CSIC-Universidad de Valencia) y por la Fundación Index

Nursing care research is a low and counternatural process, once known the access limitationto phD studies in many international universities. Nevertheless, scientific publications producedby spanish nurses keep an exponential growth for the last 30 years. By the way, it can be mentioned that there has been some help by the Institute Carlos III for nursing research. However,nursing research funds has been short, and it has been even shorter the scientific publicationproduced from it.Research funds access is unbalanced, detrimentally to non-medical health professionals: Standardsare not adjusted to every professional for publications evaluation, considering just MEDLINE database;and researchers production evaluation is performed only via the impact factor from the Science CitationIndex.At the same time, this situation is helping and supporting scientific publication in english language(also in medicine), opposing to the promotion of Spanish which the Ministery of Culture carries outthrough the Cervantes Institute around the world.Knowledge generation must be recognised and valued independently of the disciplinary area, languageand database where the scientific journal is indexed. So, it is important to take into account: databasessuch as “IME”,“PsichoINFO”,“PSICODOC”,“ISOC-Sociología y CC.Políticas”,“CUIDEN”or ”CINAHL”,and bibliometric indexes developed by the Institute of Science Documental Studies (CSIC-Universityof Valencia) and by Index Foundation

Likelihood of home death associated with local rates of home birth: influence of local area healthcare preferences on site of death.

OBJECTIVES: We tested whether local cultural and social values regarding the use of health care are associated with the likelihood of home death, using variation in local rates of home births as a proxy for geographic variation in these values. METHODS: For each of 351110 adult decedents in Washington state who died from 1989 through 1998, we calculated the home birth rate in each zip code during the year of death and then used multivariate regression modeling to estimate the relation between the likelihood of home death and the local rate of home births. RESULTS: Individuals residing in local areas with higher home birth rates had greater adjusted likelihood of dying at home (odds ratio [OR]=1.04 for each percentage point increase in home birth rate; 95% confidence interval [CI] = 1.03, 1.05). Moreover, the likelihood of dying at home increased with local wealth (OR=1.04 per $10000; 95% CI=1.02, 1.06) but decreased with local hospital bed availability (OR=0.96 per 1000 beds; 95% CI=0.95, 0.97). CONCLUSIONS: The likelihood of home death is associated with local rates of home births, suggesting the influence of health care use preferences.

A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service.

BACKGROUND: Delays in the care of hospitalized patients may lead to increased length of stay, iatrogenic complications, and costs. No study has characterized delays among general medicine inpatients in the current prospective payment era of care. OBJECTIVE: To quantify and characterize delays in care which prolong hospitalizations for general medicine inpatients. DESIGN: Prospective survey of senior residents. SETTING: Urban tertiary care university-affiliated teaching hospital. PARTICIPANTS: Sixteen senior residents were surveyed regarding 2,831 patient-days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were collected on 97.6% (2,762) of patient-days eligible for evaluation. Three hundred seventy-three patient-days (13.5% of all hospital days) were judged unnecessary for acute inpatient care, and occurred because of delays in needed services. Sixty-three percent of these unnecessary days were due to nonmedical service delays and 37% were due to medical service delays. The vast majority of nonmedical service delays (84%) were due to difficulty finding a bed in a skilled nursing facility. Medical service delays were most often due to postponement of procedures (54%) and diagnostic test performance (21%) or interpretation (10%), and were significantly more common on weekend days (relative risk [RR], 1.49; P=.02). Indeed, nearly one fourth of unnecessary patient-days (24% overall, 88 patient-days) involved an inability to access medical services on a weekend day (Saturday or Sunday). CONCLUSIONS: At our institution, a substantial number of hospital days were judged unnecessary for acute inpatient care and were attributable to delays in medical and nonmedical services. Future work is needed to develop and investigate measures to decrease delays.

How much is postacute care use affected by its availability?

OBJECTIVE: To assess the relative impact of clinical factors versus nonclinical factors-such as postacute care (PAC) supply-in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care. DATA SOURCES AND STUDY SETTING: Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data. STUDY DESIGN: We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements. DATA COLLECTION/EXTRACTION METHODS: A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999. PRINCIPAL FINDINGS: PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there. CONCLUSIONS: We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes-or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.

Integrar el Rol de Enfermería en nuestra práctica diaria / To integrate the Role of Nurses in our daily practice

Se trata de un estudio que combina métodos cuantitativos y cualitativos. Desde el método el equipo de enfermería inicia un proceso de unificación de conocimientos y lenguaje enfermero. Se ha realizado un estudio transversal identificando necesidades de cuidados a los pacientes ingresados desde el 01-2000 al 05-2000 con diagnóstico de pancreatitis. Se ha realizado una valoración enfermera por patrones funcionales de M. Gordon. Es necesario utilizar un proceso de atención enfermero con enfoque científico dirigido a la solución de problemas que ofrezca un marco conceptual para la organización, planificación y actuación de enfermería. (AU)

Eficacia y seguridad de la biopsia selectiva del ganglio centinela en enfermas con cáncer de mama / Efficacy and safety of selective sentinel node biopsy in female patients with breast cancer

Se realiza una revisión bibliográfica de los artículos publicados entre 1998 y 2000 sobre la aplicación de la biopsia selectiva del ganglio centinela (BSGC), con objeto de discutir la eficacia y seguridad de esta técnica en enfermas con cáncer de mama. Dichos estudios indican que la BSGC presenta una eficacia técnica superior al 90 por ciento en los grupos con experiencia y una dedicación especial a la cirugía mamaria. Asimismo se confirma que la combinación del marcaje isotópico con el colorante incrementa esta eficacia en la detección del ganglio centinela. Finalmente, las características clínicas de la enferma influyen decisivamente en el resultado de la técnica, lo que obliga a una correcta selección de las pacientes para la práctica quirúrgica de la BSGC. En lo referente a la seguridad de la BSGC, la ausencia de estudios aleatorios no permite actualmente conocer el impacto de esta técnica en la supervivencia global y la supervivencia libre de enfermedad, si bien en las experiencias no aleatorias no se ha demostrado un incremento del fracaso axilar. (AU)

Market entry and exit in long-term care: 1985-2000.

Market entry and exit of skilled nursing providers is analyzed to observe initial industry responses to Medicare prospective payment. Supply adjustments were immediate, and were stronger in urban than in rural areas. After 12 years of steady growth, widespread market expansion ceased in 1998, but net reductions in the number of facilities occurred primarily in the hospital-based sector. In county-level modeling with controls for State policy effects, post-prospective payment system (PPS) reductions in the number of skilled nursing facilities (SNFs) were associated with supply considerations; reductions were more likely to occur in areas with higher bed-to-population ratios prior to PPS implementation, and in areas that had recently seen expansion in capacity. County-level reduction in the number of SNFs was not associated with low income or other sociodemographic risk factors.