Accuracy and bias of licensed practical nurse and nursing assistant ratings of nursing home residents' pain.

BACKGROUND: This study evaluated the accuracy of licensed practical nurses' (LPN) and nursing assistants' (NA) Minimum Data Set (MDS) pain ratings of nursing home residents and evaluated the bias in pain ratings associated with residents' race, gender, mental status, function, depression, or disruptive behavior. METHODS: Data were obtained on the same day directly from residents, LPNs, and NAs by trained interviewers in two safety-net nursing homes. A total of 252 residents were included in this study: 79% were Black, and 60% were men. MDS items J2a and J2b evaluated pain frequency and pain intensity during the last 7 days (weekly pain frequency and weekly pain intensity). A parallel question evaluated pain intensity on the day of the interview (daily pain intensity). MDS data were obtained for the MDS Cognition Scale, the MDS Activities of Daily Living-Long Form Scale, the MDS Depression Rating Scale, and the MDS Disruptive Behavior Scale. RESULTS: Kappa coefficients documented fair to good resident-LPN (K =.70,.56, and.50) and resident-NA (K =.72,.58, and.60) agreement for weekly pain frequency, weekly pain intensity, and daily pain intensity ratings. LPNs and NAs underestimated residents' weekly pain frequency (p <.001 for LPNs, and p <.001 for NAs), weekly pain intensity (p <.001 for LPNs, and p <.001 for NAs), and daily pain intensity (p <.001 for LPNs, and p =.002 for NAs). LPNs underestimated weekly and daily pain intensity more than NAs did (p =.016 for weekly pain intensity, and p =.035 for daily pain intensity). LPN and NA pain ratings were not biased by resident race, gender, mental status, function, depression, or disruptive behavior. CONCLUSIONS: Results documented that (i) LPNs and NAs underestimated residents' pain frequency and pain intensity, (ii) NAs were more accurate than LPNs for pain intensity, and (iii) resident characteristics did not bias LPN or NA pain ratings.

The cumulative effects of historical and physical examination findings on the prognostic value of the electrocardiogram.

The electrocardiogram has been shown in epidemiologic studies to be an independent predictor of survival. These studies have adjusted for selected covariates simultaneously. This article assesses the value of the electrocardiogram as a predictor of survival when introduced at progressive stages of the common clinical encounter. Data collected from 4,518 patients ages of 60 to 96 years with isolated systolic hypertension who were followed-up for up to 6 years as part of the Systolic Hypertension in the Elderly Project were analyzed. Survival curves and 3- and 5-year survival rates (Cox regression methods) of groups with normal and abnormal resting electrocardiograms were compared. Blocks of covariates representing demographic information, risk factors for cardiovascular disease, clinical history, and physical examination findings were added to the survival models sequentially to mimic the sequence of the common clinical encounter, and the independent significance of the electrocardiogram as a predictor of survival was assessed at each step. An abnormal electrocardiogram was associated with reduced survival when no adjustment for covariates is made. Survival was also significantly (P <.05) different for groups with normal and abnormal electrocardiograms when demographic and risk factor variables were included in the statistical models, but not after findings from the clinical history and physical examination were added. The prognostic value of the electrocardiogram varies with the stage in the clinical encounter in which it is introduced.

Reliability assessment of a rod photoreceptor outer segment grading system.

The purpose of this study was to assess the reliability of a rod photoreceptor outer segment (PR-OS) grading system based on the analysis of 1 microm thick retinal sections obtained from Xenopus laevis whole-eye organ cultures. Digitally captured images, representative of the entire spectrum of rod PR-OS organization levels, were selected and coded numerically. A total of 102 individual rod PR-OS profiles were graded according to a six-step classification scheme based on the percentage of rod PR-OS membrane organization. Unweighted (exact agreement) and weighted kappa (kappa) coefficients (for use with ordered categorical rating scales) were calculated. Differences between kappa coefficients were tested for by chi-square analysis. To investigate the intra- and inter-rater variability and the possible presence of an interaction of the measurements with time, a repeated-measures analysis of variance was performed. The overall unweighted and weighted intra-rater kappa coefficients were 0.78 and 0.92, respectively. The overall unweighted and weighted inter-rater kappa coefficients were 0.73 and 0.90, respectively. There was no significant difference between raters or between first and second reading, nor was interaction between raters and time of rating documented. Individual kappa coefficients were equivalent both between raters and between sessions. Intra- and inter-rater agreement was within one step in 100% of cases. The estimated values of the kappa coefficients are consistent with a good to excellent degree of reliability and reproducibility of this rod PR-OS grading system. This system will be useful in the assessment of rod PR-OS morphology in studies of photoreceptor physiology and pathology.

Clinical significance of detrusor sphincter dyssynergia type in patients with post-traumatic spinal cord injury.

OBJECTIVES: To investigate the significance of categorizing detrusor sphincter dyssynergia (DSD) by type in patients with chronic spinal cord injury. METHODS: A retrospective review of the charts, video-urodynamic studies, and upper tract radiographic studies of 269 patients with post-traumatic, suprasacral spinal cord injuries was performed. The patients were categorized according to the DSD type (intermittent or continuous), level and completeness of injury, intravesical pressure at leak, upper tract complications, and interval since injury. RESULTS: Of the 269 patients, 20 (7.4%), 216 (80.3%), and 33 (12.3%) had no DSD, intermittent DSD, and continuous DSD, respectively. No significant association between the specific level of injury and the DSD type was found (P = 0.71). The presence of DSD was associated with complete injuries, elevated intravesical pressures, and upper tract complications (P <0.01); these associations were more prominent with continuous DSD than with intermittent DSD. The proportion of patients with no DSD, intermittent DSD, and continuous DSD was unchanged during the chronic follow-up period. CONCLUSIONS: The clinical significance of DSD type is not crucial, since patients with both intermittent and continuous DSD require urodynamic surveillance and expedient treatment to minimize urologic complications. However, the presence of continuous DSD is one of several factors that may require earlier urodynamic follow-up.

Stability of performance of activities of daily living using the MDS.

The Minimum Data Set (MDS) requires assessment of performance of activities of daily living (ADLs) by newly admitted nursing home residents over all shifts for a 7-day period, for a total of 21 assessments. This study evaluated within-subject equivalence of multiple assessments of 42 residents' admission MDS ADL performance. Friedman two-way analysis of variance for ranks documented no significant within-subject differences among repeated measurements for all 13 MDS ADL variables. Thus, fewer than 21 assessments may accurately assess ADL performance.

Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients.

PURPOSE: Controversy continues on the optimal method of bladder management in spinal cord injured patients. We investigated the effects of bladder management on bladder compliance and changes in compliance with time. MATERIALS AND METHODS: We retrospectively reviewed the charts, and video urodynamic and upper tract radiographic studies of 316 patients with spinal cord injury. Patients were categorized according to interval since injury and bladder management method, including clean intermittent catheterization, spontaneous voiding and chronic Foley catheterization. Those with upper tract complications were compared with asymptomatic controls at the bladder compliance threshold values of 10.0, 12.5, 15.0 and 20.0 cc/cm. water. RESULTS: No significant differences were noted among bladder management method groups for followup, level, completeness or mechanism of injury. A bladder compliance threshold of 12.5 cc/cm. water was selected for the remaining comparisons based on the frequency of complications compared with asymptomatic controls. Patients using intermittent catheterization had a significantly higher incidence of normal compliance than the Foley management group for suprasacral, complete and incomplete injury (p<0.01). Normal bladder compliance was more common in patients with suprasacral than sacral and incomplete than complete spinal cord injury for each bladder management type. Logistic regression analysis of compliance versus bladder management and age of injury (interval since injury) revealed that intermittent catheterization and spontaneous voiding were associated more with normal compliance than Foley catheterization (RR = 9.2, 5.4 and 1.0, respectively). Combined data showed that each successively older age of injury cohort was at 23% greater risk for loss of normal compliance than the preceding cohort. Low compliance was statistically associated with vesicoureteral reflux, radiographic upper tract abnormality, pyelonephritis and upper tract stones (p<0.01, <0.01, 0.04 and <0.01, respectively). CONCLUSIONS: Clean intermittent catheterization protects bladder compliance in spinal cord injured patients regardless of the level or completeness of injury and helps to prevent low compliance with time. Also, in the population studied low compliance was associated with upper tract complications. Therefore, clean intermittent catheterization is the superior method for preserving bladder compliance and preventing the upper tract complications associated with low compliance.

Interdisciplinary geriatric primary care evaluation and management: two-year outcomes.

BACKGROUND: The long-term efficacy of interdisciplinary outpatient primary care Geriatric Evaluation and Management (GEM) has not been proven. This article focuses on results obtained during the 2 years of the study. METHODS: In this 2-year randomized clinical trial, at the Veterans Affairs Medical Center, Memphis, TN, 128 veterans, age 65 years and older, were randomized to outpatient GEM or usual care (UC). Two-year follow-up analyses are based on the 98 surviving individuals. Study outcome measurements included health status, function, and quality of life including affect, cognition, and mortality. RESULTS: At 2 years, there were positive intervention effects for eight of 1 outcome measures, five of which had attained significance at 1 year. GEM subjects, compared with UC subjects, had significantly greater improvement in health perception (P = .001), smaller increases in numbers of clinic visits (P = .019) and instrumental activities of daily living (IADL) impairments (P = .006), improved social activity (P<.001), greater improvement in Center for Epidemiologic Studies-Depression (CES-D) scores (P = .003), general well-being (P = .001), life satisfaction (P<.001), and Mini-Mental State Exam (MMSE) scores (P = .025). There were no significant treatment effects in activities of daily living (ADL) scores (P = .386), number of hospitalizations (P = .377), or mortality (P = .155). CONCLUSIONS: These findings suggest that a primary care approach that combines an initial interdisciplinary comprehensive assessment with long-term, interdisciplinary outpatient management may improve outcomes for targeted older adults significantly. Findings suggest further that outcomes may continue to improve over time and that the GEM care model provides an effective way to manage health care of older adults.

Biobehavioral effects of therapeutic touch.

PURPOSE: To document immediate and short-term biobehavioral effects of therapeutic touch (TT), estimate the magnitude of TT effects, and compare TT effects to placebo responses. DESIGN: A repeated measures, pretest-posttest quasi-experimental design. TT and mimic TT were administered using standardized protocols to 11 adults in a controlled setting. METHODS: Four physiological (total pulse amplitude, blood pressure, pulse, temperature) and three subjective (stress, self-assessment of health, time perception) variables were evaluated over 24 hours. FINDINGS: Total pulse amplitude and time perception decreased significantly immediately after TT intervention, indicating vasoconstriction and time passing "faster," with large and medium effect sizes significantly greater than were placebo responses. Vasodilation, a relaxation response, was expected instead of vasoconstriction. CONCLUSIONS: TT may have adverse and positive outcomes.

Burnout among leaders of Department of Veterans Affairs medical centers: contributing factors as determined by a longitudinal study.

Significant increases in the intensity of psychological burnout among leaders of local Department of Veterans Affairs (VA) medical centers occurred from 1989 to 1997. This longitudinal study was designed to analyze which demographic and behavioral variables were associated with the intensity of burnout. Responses of 83 Medical Center Directors, Associate Directors, and Chiefs of Staff to questionnaires sent in 1989, 1992, and 1997 were analyzed using path analysis. Burnout was assessed by the Maslach Burnout Inventory and the phase model for analysis. Questions also assessed antecedents (e.g., role characteristics and job support) and consequences (e.g., job satisfaction) of burnout. The presence of high levels of burnout rose from 25.3% in 1989 to 38.1% in 1997. Burnout phase in 1997 was directly related to burnout phase in 1992 and inversely related to the respondent's age. Phase in 1992 was inversely related to both resource availability and role clarity in 1989 if only accepted antecedents of burnout were included in the model. If consequences and antecedents were included in the model, burnout phase in 1997 was inversely related to job satisfaction and resource availability and directly related to intent to stay in the VA in 1989. Findings demonstrated that specific demographic and job site characteristics are associated with high levels of burnout in the VA. These could form the basis for interventional efforts.

Determinants of health-related hardiness among urban older African-American women with chronic illnesses.

A systematic probability sample of 100 community-living older African-American women with chronic illnesses was evaluated during clinic visits to an urban safety-net hospital to explore health and demographic factors predictive of health-related hardiness (HRH). Questionnaires on HRH, function, self-assessed health, morbidity, health behavior, and selected demographics were used for collection of data. Multiple linear regression analyses ascertained that years of education and function explained 20% of the variance in HRH. Findings raise issues regarding validity of HRH prediction models and the cultural appropriateness of current methods of assessing HRH in older African-American women.

Variations in the use of cardiac procedures in the Veterans Health Administration.

BACKGROUND: Considerable variability exists in the use of cardiac procedures for patients with heart disease. One cause for this variability is the availability of local facilities to perform these procedures. This study was initiated to identify health system features that are related to rates of catheterization, percutaneous coronary angioplasty, and coronary artery bypass graft surgery in the Veterans Affairs health care system in which structured referral systems are intended to compensate for variation in local resource availability. METHODS: Medical records of 30,901 patients admitted to a Veterans Affairs medical center with coronary artery disease were analyzed. Odds ratios (OR) and 95% confidence intervals (CI) for undergoing each procedure, based on clinical variables (age, sex, race, coronary artery disease type, and a computed comorbidity score), and local Veterans Affairs facility features (geographic region, primary service area size, and hospital complexity) were estimated by logistic regression. RESULTS: Regression models demonstrated significant associations between the odds of undergoing each procedure and medical center geographic and complexity features, after adjustment for clinical variables. Associations included the presence of a cardiac catheterization laboratory for undergoing catheterization (OR 1.86, CI 1.76 to 1.95) and the presence of a cardiac surgical program for angioplasty (OR 1.46, CI 1.36 to 1.57) and bypass grafting (OR 1.43, CI 1.34 to 1.53). Including health system variables in addition to clinical variables in the regression models improved the discriminating ability of the models by 44.2% to 51.4%. CONCLUSIONS: Geographic location and the complexity of the local Veterans Affairs hospital are important determinants of the use of cardiac procedures in the Veterans Affairs health care system, even though referral networks are intended to correct for local differences in hospital complexity.

Trends in burnout and related measures of organizational stress among leaders of Department of Veterans Affairs medical centers.

Psychological burnout significantly and detrimentally affects individuals and the organizations for which they work. Leaders with burnout often display characteristics that are the opposite of those required to implement major organizational change. This study was undertaken to assess the level of psychological burnout of leaders of the Department of Veterans Affairs (VA) medical centers during a period of rapid change. The objective was to quantify trends in the level of burnout and associated measures of psychological stress. Surveys of medical center directors, associate medical center directors, and chiefs of staff of each VA medical center were conducted in 1989, 1992, and 1997 to evaluate burnout, role characteristics, and job satisfaction. Burnout was measured using the Maslach Burnout Inventory and scored using the phase model of burnout. Findings demonstrated higher prevalences of more advanced levels of burnout in the 1992 and 1997 surveys than in the 1989 survey. Role clarity, perceived adequacy of resources to complete assigned tasks, and several measures of job satisfaction were lower in the 1997 survey compared to the earlier survey data. Therefore, psychological burnout and other indicators of stress increased during the 1989 to 1997 study period. These findings suggest cause for concern as the largest integrated healthcare system in the United States undertakes major organizational change to meet present and future challenges.

Does syndrome X exist in hypertensive elderly persons with impaired glycemic control?

BACKGROUND: This report focuses on the glycemic state in relation to insulin and lipid levels of a cohort of elderly hypertensive persons to estimate the prevalence of syndrome X. METHODS: A cross-sectional study was performed at the University of Tennessee, Memphis, and the General Clinical Research Center (GCRC) on 95 participants in the Trial of Nonpharmacologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study. A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels and a fasting lipid profile were obtained. RESULTS: In this sample of healthy elderly participants with hypertension who were taking an antihypertensive medication, 43 (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had impaired glucose tolerance (IGT), and 11 (11.6%) had undiagnosed non-insulin-dependent diabetes mellitus (NIDDM). Fasting hyperinsulinemia occurred in only one participant, who was in the IGT group. Hypertriglyceridemia and low high density lipoprotein (HDL) occurred in four persons, none of whom had hyperinsulinemia. Persons in the NIDDM and IGT groups had decreased beta cell function compared to persons in the NGT group, but did not have increased peripheral insulin resistance as estimated from the OGTT data. CONCLUSIONS: Our data demonstrated that in this cohort of elderly hypertensive participants with a high prevalence of central obesity, impaired glycemic control was common, but was not associated with fasting hyperinsulinemia or peripheral insulin resistance. Furthermore, we conclude that syndrome X essentially did not occur in these participants and postulate that the primary etiology for their impaired glycemic control is beta cell dysfunction. Further research is needed to elucidate these relationships.

The experience of living-dying in a nursing home: self-reports of black and white older adults.

PURPOSE: The purpose of this study was to describe and compare the experiences, needs, priorities, and concerns reported by black and white nursing home residents during the living-dying interval. The living-dying interval is defined as the time between the knowledge of one's impending death and death itself. DESIGN: This qualitative study was part of a larger ethnographic project. Residents participated in from one to four individual, in-depth, semi-structured, audiotaped interviews. SETTING: Residents lived in two large county-financed nursing homes that have historically provided care to indigent black and white older adults. PARTICIPANTS: Purposive sampling was used to identify eight black and five white residents with terminal cancer diagnoses who could serve as rich resources about the experience of living-dying in a nursing home. MEASURES: Residents were asked open-ended questions about how things have been and what would make things better; what comforts them and would make them more comfortable; what dying means to them; and what things are important for nursing staff to know. RESULTS: Verbatim transcripts of the interviews were coded using QRS NUD-IST software. Codes were placed in categories, categories were reviewed for common and different concepts, themes, and patterns, and a conceptual model was developed. The model identified six care needs: (1) day-to-day living; (2) inadequate pain relief for black residents; (3) difficulty chewing and swallowing; (4) importance of religious activities; (5) giving care to others; and (6) appreciation of respectful and prompt care. Residents validated all components of the conceptual model. CONCLUSION: Black and white terminally ill residents focused on the quality of living rather than on dying, and black residents may be undertreated for pain. Important care needs for pain and religion are not routinely addressed by the Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) triggers.

Impact of race and age on the effects of regionalization of cardiac procedures in the Department of Veterans Affairs Health Care System.

Previous studies have demonstrated that regionalization of resources for cardiac catheterization, percutaneous coronary artery angioplasty (PTCA), and coronary artery bypass graft surgery (CABG) reduces the rate of procedure use. It was hypothesized that the impact of regionalization would be greater for the elderly and for African-Americans than for other populations. Discharge medical records of 30,901 patients admitted to a Veterans Affairs (VA) medical center between October 1, 1993, and September 30, 1994, with a diagnosis of coronary artery disease were analyzed. The presence of a cardiac catheterization laboratory in the patients' local VA facility significantly increased the likelihood of undergoing catheterization, PTCA, and CABG, as determined by odds ratios and associated confidence limits estimated by logistic regression techniques. The presence of a cardiac surgical facility also significantly increased the likelihood of having the procedures. The odds ratios estimating the effects of resource availability were significantly greater for the subgroup of patients aged > or =70 years than for the younger subgroup for catheterization, PTCA, and CABG and for African-Americans than for white patients for PTCA and CABG. Thus, within the VA health care system, regionalization of cardiac procedures has a significant impact on utilization rates of tertiary cardiac procedures. These differences are significantly greater for the elderly and for African-Americans than for the general population.

Prevalence of undiagnosed non-insulin-dependent diabetes mellitus and impaired glucose tolerance in a cohort of older persons with hypertension.

OBJECTIVE: To determine the prevalence of undiagnosed non-insulin-dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in a cohort of older persons with hypertension. To examine the usefulness of screening for NIDDM in this study population. DESIGN: Cross-sectional study. SETTING: University of Tennessee, Memphis and the General Clinical Research Center (GCRC). PATIENTS: Ninety-five participants in the Trial of Nonpharmacologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study. MEASUREMENTS: A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels was performed before the beginning of the TONE intervention. RESULTS: In this cohort, 43 participants (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had IGT, and 11 (11.6%) had undiagnosed NIDDM. The positive predictive value for NIDDM of a fasting glucose > or = 115 mg/dL in our participants was 57%. Hyperinsulinemia occurred in only one participant, a subject in the IGT group. CONCLUSIONS: Our data demonstrate that undiagnosed NIDDM is common in our cohort of older persons who are being treated for essential hypertension and that impaired glucose tolerance may be more common than in the general population of the same age. Further, our data show that the vast majority of this older, obese, hypertensive cohort did not have fasting hyperinsulinemia. We also infer that a fasting glucose alone has a low positive predictive value for screening of NIDDM in our older cohort. As the prevalence of NIDDM and impaired glucose tolerance in older hypertensive patients in the general population is unknown, we believe that further investigation is needed to characterize the relationship of hypertension, glycemic status, and hyperinsulinemia in the general population.

Accuracy of nurse aides' functional health assessments of nursing home residents.

BACKGROUND: Nurse aides provide assessments of nursing home residents' functional health for use in care planning and quality assurance. Nurse practitioner assessments can serve as a standard for analysis of nurse aides' accuracy. This study compared nurse aide to nurse practitioner assessments of nursing home residents' functional health with regard to possible bias and extent of correlation. METHODS: Nurse aides' accuracy in assessing nursing home residents' activities of daily living was evaluated by comparisons to assessments performed by a master's-prepared nurse practitioner using four functional assessment instruments: the Barthel Index, the Katz Index of Activities of Daily Living, the Multidimensional Observation Scale for Elderly Subjects, and the Scaled Outcome Criteria. Data were collected in a 159-bed nonprofit nursing home licensed for skilled and intermediate care. Residents had a wide variety of functional and cognitive abilities and disabilities. Ninety-six nursing home residents provided data for the study. Functional health assessments by 24 nurse aides, each assessing 4 different nursing home residents, were compared to those of 1 nurse practitioner. Statistical analysis of accuracy used paired samples t-tests and Pearson product moment correlation coefficients. RESULTS: Nurse aide assessments and nurse practitioner assessments were highly correlated. Most functional health assessments evidenced no significant nurse aide bias. When bias was present it usually resulted from nurse aides electing more optimistic choices when using an assessment instrument that offered fewer response levels for rating residents. CONCLUSIONS: Nurse aides can accurately use well-calibrated instruments to assess nursing home residents' functional health. Demonstration of assessment accuracy in nurse aides, who provide the majority of direct care for nursing home residents, documented a valuable clinical resource for planning and evaluating resident care.