Characteristics of Hospice Programs With Problematic Live Discharges.

CONTEXT: Little is known about how hospice live discharges vary by hospice providers' tax status and chain affiliation. OBJECTIVES: To characterize hospices with high rates of problematic patterns of live discharges. METHODS: Three hospice-level patterns of live discharges were defined as problematic when the facility rate was at the 90th percentile or higher. A hospice with a high rate of patients discharged, hospitalized, and readmitted to hospice was considered to have a problematic live discharge pattern, which we have referred to as burdensome transition. The two other problematic live discharge patterns examined were live discharge in the first seven days of a hospice stay and live discharge after 180 days in hospice. A multivariate logistic model examined variation in the hospice-level rate of each discharge pattern by the hospice's chain affiliation and profit status. This model also adjusted for facility rates of medical diagnoses, nonwhite patients, average age, and the state in which the hospice program is located. RESULTS: In 2010, 3028 hospice programs had 996,208 discharges, with 18.0% being alive. Each proposed problematic pattern of live discharge varied by chain affiliation. For-profit providers without a chain affiliation had a higher rate of burdensome transitions than did for-profit providers in national chains (18.2% vs. 12.1%, P < 0.001), whereas not-for-profit providers had the lowest rate of burdensome transitions (1.4%). About one in three (33.8%) for-profit providers exhibited one or more of these discharge patterns compared with 9.0% of not-for-profit providers. CONCLUSION: Problematic patterns of live discharges are higher among for-profit providers, especially those not affiliated with a hospice chain.

Family perceptions of quality of hospice care in the nursing home.

CONTEXT: Nursing homes (NHs) are increasingly the site of hospice care. High quality of care is dependent on successful NH-hospice collaboration. OBJECTIVES: To examine bereaved family members' perceptions of NH-hospice collaborations in terms of what they believe went well or could have been improved. METHODS: Focus groups were conducted with bereaved family members from five diverse geographic regions, and included participants from inner city and rural settings, with oversampling of African Americans. RESULTS: A total of 28 participants (14.8% African American, mean age 61.4 years) identified three major aspects of collaboration as important to care delivery. First, most (67.9%) voiced concerns with knowing who (NH or hospice) is responsible for which aspects of patient care. Second, nearly half (42.9%) stated concern about information coordination between the NH and hospice. Finally, 67.9% of the participants mentioned the need for hospice to advocate for high-quality care rather than their having to directly do so on behalf of their family members. CONCLUSION: The important concerns raised by bereaved family members about NH-hospice collaboration have been incorporated into the revised Family Evaluation of Hospice Care, a post-death survey used to evaluate quality of hospice care.

Reducing livestock effects on public lands in the western United States as the climate changes: a reply to Svejcar et al.

Svejcar et al. (Environ Manage, 2014) offered several perspectives regarding Beschta et al. (Environ Manage 51:474-491, 2013)--a publication that addressed the interacting ecological effects of climate change and domestic, wild, and feral ungulates on public lands in the western United States (US)--by largely focusing on three livestock grazing issues: (1) legacy versus current day impacts; (2) grazing as a fire reduction tool; and (3) the complexity of grazing. Regarding these issues, we indicate that (1) legacy effects to western ecosystems were indeed significant and contemporary livestock use on public lands generally maintains or exacerbates many of those effects; (2) livestock grazing has been a major factor affecting fire frequency, fire severity, and ecosystem trajectories in the western US for over a century; and (3) the removal or reduction of grazing impacts in these altered ecosystems is the most effective means of initiating ecological recovery. Svejcar et al. (Environ Manage, 2014) offer no evidence that livestock use is consistent with the timely recovery of grazing-degraded uplands, riparian areas, or stream systems. We thus conclude that public-land ecosystems can best persist or cope with a changing climate by significantly reducing ungulate grazing and related impacts.

Adapting to climate change on Western public lands: addressing the ecological effects of domestic, wild, and feral ungulates.

Climate change affects public land ecosystems and services throughout the American West and these effects are projected to intensify. Even if greenhouse gas emissions are reduced, adaptation strategies for public lands are needed to reduce anthropogenic stressors of terrestrial and aquatic ecosystems and to help native species and ecosystems survive in an altered environment. Historical and contemporary livestock production-the most widespread and long-running commercial use of public lands-can alter vegetation, soils, hydrology, and wildlife species composition and abundances in ways that exacerbate the effects of climate change on these resources. Excess abundance of native ungulates (e.g., deer or elk) and feral horses and burros add to these impacts. Although many of these consequences have been studied for decades, the ongoing and impending effects of ungulates in a changing climate require new management strategies for limiting their threats to the long-term supply of ecosystem services on public lands. Removing or reducing livestock across large areas of public land would alleviate a widely recognized and long-term stressor and make these lands less susceptible to the effects of climate change. Where livestock use continues, or where significant densities of wild or feral ungulates occur, management should carefully document the ecological, social, and economic consequences (both costs and benefits) to better ensure management that minimizes ungulate impacts to plant and animal communities, soils, and water resources. Reestablishing apex predators in large, contiguous areas of public land may help mitigate any adverse ecological effects of wild ungulates.

A longitudinal study of patient- and observer-rated quality of life in schizophrenia.

Patient-rated life satisfaction and observer-rated quality of life (ORQOL) appear to have different determinants in patients with schizophrenia, although most studies conducted to date have used cross-sectional methods or related clinical dimensions at one time point with quality of life (QOL) measured at another. The aim of this study was to investigate the relationship between changes in patient-rated QOL (PRQOL) and ORQOL over time and changes in clinical variables. Two hundred and thirty-one patients taking part in the Schizophrenia Care Assessment Program (SCAP) study at Dandenong in Australia were included in this analysis. Subjective ratings of several domains of social functioning and life satisfaction were taken from the SCAP instrument and comparisons made with data from the QOL Scale rated by research staff, as well as several psychopathology measures. Changes in these scores over 1 year were correlated to investigate relationships between measures. Weak correlations were seen between changes in PRQOL and ORQOL domains. Patient-rated domains related most closely to depressive symptoms (Montgomery-Asberg Depression Rating Scale scores) whereas observer-rated domains related to both negative symptoms and depressive symptoms. Positive psychotic symptoms had little effect on either domain. Longitudinal data appear to confirm that PRQOL and ORQOL are not closely related and may have differing determinants in patients with schizophrenia. They should be considered as separate and complementary outcome variables and utilized accordingly.

Whole-body (18)F-FDG PET identifies high-risk myeloma.

UNLABELLED: The purpose of this study was to evaluate the clinical utility of whole-body PET with (18)F-FDG in patients with multiple myeloma and related monoclonal diseases. METHODS: Between July 1, 1996, and July 2000, 98 (18)F-FDG PET scans were obtained for 66 patients, with 25 patients having 2 or more scans. The results were compared with routine clinical and staging information, including CT and MRI scans, as indicated. Of the 66 patients, 16 had previously untreated active myeloma, 14 had monoclonal gammopathy of undetermined significance (MGUS), 10 had disease in remission, and 26 had relapsing disease. RESULTS: Negative whole-body (18)F-FDG PET findings reliably predicted stable MGUS. Of the 14 MGUS patients with follow-up of 3-43+ mo, myeloma has developed in only 1 (7%), at 8 mo. Conversely, the 16 previously untreated patients with active myeloma all had focal or diffusely positive scan findings. Four (25%) of 16 previously untreated patients with positive (18)F-FDG PET findings had negative full radiologic surveys. Another 4 (25%) of 16 patients had focal extramedullary disease. This was confirmed by biopsy or other imaging techniques. Extramedullary uptake also occurred in 6 (23%) of 26 patients with relapse. This extramedullary uptake was a very poor prognostic factor both before treatment and at relapse. For example, median survival was 7 mo for patients with disease relapse. Persistent positive (18)F-FDG PET findings after induction therapy predicted early relapse. In 13 (81%) of 16 patients with relapsing disease, new sites of disease were identified. The (18)F-FDG PET results were especially helpful in identifying focal recurrent disease in patients with nonsecretory or hyposecretory disease amenable to local irradiation therapy, which was used in 6 patients. CONCLUSION: Whole-body (18)F-FDG PET provides important prognostic information, which is clinically useful and complementary to conventional methods of evaluating plasma cell disorders. (18)F-FDG PET is a unique tool for evaluation of nonsecretory myeloma. Residual or recurrent disease after therapy, especially extramedullary disease, is a poor prognostic factor.