Cardiac Assessment.

Heart disease remains the number one cause of mortality in both men and women in the United States and patients with heart failure are at high risk for hospitalization. Thirty-day readmission rates have become a benchmark for hospitals and home healthcare agency reimbursement. Physical exam and history taking are essential to evaluate patients with suspected or known heart disease, and to detect early symptoms of worsening heart failure. Home care clinicians have the opportunity to assess the patient in the home environment, identify significant changes in the patient's status, and form a plan of care for effective intervention to prevent the need for emergency department care or rehospitalization. In this second article of a four-part series, the subjective and objective assessment of the cardiovascular system exam is reviewed.

Avoiding emergency department visits for COPD, pneumonia, and heart failure: when should patients go to the emergency department?

Patients with pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure make frequent visits to the emergency department. Heart failure alone is the reason for more than 1 million emergency department visits annually in the United States. This article describes strategies home care clinicians can use to prevent unnecessary emergency department visits for patients with pneumonia, COPD and heart failure.

Value of the periodic health evaluation.

OBJECTIVES: To systematically review evidence on definitions of the periodic health evaluation (PHE), its associated benefits and harms, and system-level interventions to improve its delivery. DATA SOURCES: Electronic searches in MEDLINE, and other databases; hand searching of 24 journals and bibliographies through February 2006. REVIEW METHODS: Paired investigators abstracted data and judged study quality using standard criteria. We reported effect sizes for mean differences and proportions in randomized controlled trials (RCTs). We adapted GRADE Working Group criteria to assess quantity, quality and consistency of the best evidence pertaining to each outcome, assigning grades of "high," "medium," "low," or "very low." RESULTS: Among 36 identified studies (11 RCTs), definitions of the PHE varied widely. In studies assessing benefits, the PHE consistently improved (over usual care) the delivery/receipt of the gynecological exam/Pap smear (2 RCTs, small effect (Cohen's d (95% confidence interval (CI)):0.07 (0.07,0.07)) to large effect (Cohen's d (CI):1.71 (1.69, 1.73)), strength and consistency graded "high"); cholesterol screening (1 RCT, small effect (Cohen's d (CI):0.02 (0.00,0.04)) with large associations in 4 observational studies, graded "medium"); fecal occult blood testing (2 RCTs, large effects (Cohen's d (CI): 1.19 (1.17, 1.21) and 1.07 (1.05, 1.08)), graded "high"). Effects of the PHE were mixed among studies assessing delivery/receipt of counseling (graded "low"), immunizations (graded "medium"), and mammography (graded "low"). In one RCT, the PHE led to a smaller increase in patient "worry" (13%) compared to usual care (23%) (graded "medium"). The PHE had mixed effects on serum cholesterol (graded "low"), blood pressure, body mass index, disease detection, health habits and health status (graded "medium"), hospitalization (graded "high"), and costs, disability, and mortality (graded "medium"). No studies assessed harms. Delivery of the PHE was improved by scheduling of appointments for PHE (1 RCT, medium effects (Cohen's d (CI): 0.69 (0.68, 0.70)) and offering a free PHE (1 non-RCT, 22% increase) (graded "medium"). CONCLUSIONS: The evidence suggests delivery of some recommended preventive services are improved by the PHE and may be more directly affected by the PHE than intermediate or long-term clinical outcomes and costs. Descriptions of the PHE and outcomes were heterogeneous, and some trials were performed before dissemination of recommendations by the U.S. Preventive Services Task Force, limiting interpretations of findings. Efforts are needed to clarify the long-term benefits of receiving multiple preventive services in the context of the PHE. Future studies assessing the PHE should incorporate diverse populations, carefully define comparisons to "usual care," and comprehensively assess intermediate outcomes, harms, and costs.