Impact of continued geriatric outpatient management on health outcomes of older veterans.

BACKGROUND: Although previous trials have proved inpatient-based geriatric assessment to be beneficial, to our knowledge, the effectiveness of outpatient geriatric assessment has not been established. We examined the effectiveness of an outpatient geriatric evaluation and management (GEM) clinic. METHODS: Hospitalized veterans aged 65 years or older with impairment of activities of daily living, chronic disease, polypharmacy, or two or more hospitalizations in the previous year were randomized to an outpatient GEM team clinic (n = 60) or usual care (n = 68). After an initial comprehensive assessment, they received long-term management in the geriatric clinic. Principal outcomes included health status (mortality, hospitalizations, health perception, and medications), function (activities of daily living, instrumental ADL, and social activity), affect (Center for Epidemiologic Studies-Depression test score and life satisfaction), and cognition (Mini-Mental State examination score). RESULTS: At randomization, no significant differences were noted between the groups. The average age of the patients was 71 years (range, 65 to 93 years). At 1 year following randomization, GEM clinic patients compared with subjects receiving usual care had significantly improved health perception, took fewer medications despite increased number of diagnoses, reported greater social activity, had improved Center for Epidemiologic Studies-Depression scale scores, and had higher life satisfaction scores. There was a trend toward improved performance of activities of daily living for GEM clinic patients. The GEM clinic patients had a 54% lower mortality (6.8% vs 14.9%). Overall, no differences were observed in the total number of hospitalizations between the groups. CONCLUSIONS: The combination of long-term management following comprehensive outpatient assessment significantly improved aspects of health status (including health perception and medications), function (including social activity), and affect (including depression and life satisfaction) for older veterans and may influence mortality and function.

Variation in utilization of cardiac procedures in the Department of Veterans Affairs health care system: effect of race.

OBJECTIVES: Utilization rates for cardiac catheterization and cardiac surgery in the Department of Veterans Affairs (VA) health care system were studied to determine whether racial differences existed in a delivery plan in which access is not determined by patient finances. BACKGROUND: Prior studies have demonstrated significant differences in utilization of cardiac diagnostic and therapeutic resources by white and black patients. Reasons for the reduced utilization by black patients include socioeconomic, biologic and sociocultural effects. METHODS: Computerized discharge records of 30,300 patients with coronary artery disease and 1,335 patients with valvular heart disease who were discharged from any of 172 VA Medical Centers between October 1, 1990 and September 30, 1991 were studied. RESULTS: For patients with coronary artery disease, utilization rates of cardiac catheterization were significantly greater for white patients (503.4 procedures/1,000 patients) than for black patients (433.2/1,000 patients), with a relative odds ratio of 1.33. Rates for surgery (179.0 vs. 124.5/1,000 patients) were also greater for whites than for blacks, with a relative odds ratio of 1.53. For the subset with valve disease, the catheterization rate was significantly greater for whites than for blacks (575.4 vs. 432.6 procedures/1,000 patients), with a relative odds ratio of 1.78. Surgical rates were not significantly different (423.8 vs. 354.6 operations/1,000 patients). Racial differences for both catheterization and surgery varied widely as a function of geographic region and the level of complexity of the local VA facility. CONCLUSIONS: Racial differences in resource utilization exist in a health care system in which economic influences are minimized. The pattern of these differences depends on numerous variables and suggests both biologic and sociocultural factors as underlying causes.

Performance of two species of quail on basic reinforcement schedules.

Two bobwhite quail (Colinus virginianus) and two Japanese quail (Coturnix coturnix japonica) were trained to peck a response key to obtain food. In general, performance on fixed ratio 20 and variable- and fixed-interval 60-sec schedules was comparable to the response patterns of other species under these schedules.