Poverty and access to maternal health care in Tajikistan

Using recently available survey data for Tajikistan, this paper investigates changes in the pattern of maternal health care over the last decade, and the extent to which inequalities in access to that care have emerged. In particular, the link between poverty, women's education status and the utilisation of maternal health services is investigated. The results demonstrate a significant decline in the use of maternal health services in Tajikistan since independence, as well as changes in the location of delivery and type of person providing assistance, with a clear shift away from giving birth in a health facility toward giving birth at home. Over two-fifths of all women who gave birth in the year prior to the survey in 1999 had a home delivery. There are clear differences in access by socio-economic status with women from the poorest quintile being three times more likely to experience a home delivery with no trained assistance than women from the richest quintile

Is There Extra Cost of Institutional Care for MS Patients?

Throughout life, patients with multiple sclerosis (MS) require increasing levels of support, rehabilitative services, and eventual skilled nursing facility (SNF) care. There are concerns that access to SNF care for MS patients is limited because of perceived higher costs of their care. This study compares costs of caring for an MS patient versus those of a typical SNF patient. We merged SNF cost report data with the 2001-2006 Nursing Home Minimum Data Set (MDS) to calculate percentage of MS residents-days and facility case-mix indices (CMIs). We estimated the average facility daily cost using hybrid cost functions, adjusted for facility ownership, average facility wages, CMI-adjusted number of SNF days, and percentage of MS residents-days. We describe specific characteristics of SNF with high and low MS volumes and examine any sources of variation in cost. MS patients were no longer more costly than typical SNF patients. A greater proportion of MS patients had no significant effect on facility daily costs (P = 0.26). MS patients were more likely to receive care in government-owned facilities (OR = 1.904) located in the Western (OR = 2.133) and Midwestern (OR = 1.3) parts of the USA (P < 0.05). Cost of SNF care is not a likely explanation for the perceived access barriers that MS patients face

Predictors of spiritual care provision for patients with dementia at the end of life as perceived by physicians : a prospective study

Background: Spiritual caregiving is part of palliative care and may contribute to well being at the end of life. However, it is a neglected area in the care and treatment of patients with dementia. We aimed to examine predictors of the provision of spiritual end-of-life care in dementia as perceived by physicians coordinating the care. Methods: We used data of the Dutch End of Life in Dementia study (DEOLD; 2007-2011), in which data were collected prospectively in 28 Dutch long-term care facilities. We enrolled newly admitted residents with dementia who died during the course of data collection, their families, and physicians. The outcome of Generalized Estimating Equations (GEE) regression analyses was whether spiritual care was provided shortly before death as perceived by the on-staff elderly care physician who was responsible for end-of-life care (last sacraments or rites or other spiritual care provided by a spiritual counselor or staff). Potential predictors were indicators of high-quality, person-centered, and palliative care, demographics, and some other factors supported by the literature. Resident-level potential predictors such as satisfaction with the physician's communication were measured 8 weeks after admission (baseline, by families and physicians), physician-level factors such as the physician's religious background midway through the study, and facility-level factors such as a palliative care unit applied throughout data collection. Results: According to the physicians, spiritual end-of-life care was provided shortly before death to 20.8% (43/207) of the residents. Independent predictors of spiritual end-of-life care were: families' satisfaction with physicians' communication at baseline (OR 1.6, CI 1.0; 2.5 per point on 0-3 scale), and faith or spirituality very important to resident whether (OR 19, CI 5.6; 63) or not (OR 15, CI 5.1; 47) of importance to the physician. Further, female family caregiving was an independent predictor (OR 2.7, CI 1.1; 6.6). Conclusions: Palliative care indicators were not predictive of spiritual end-of-life care; palliative care in dementia may need better defining and implementation in practice. Physician-family communication upon admission may be important to optimize spiritual caregiving at the end of life

Assessment of the effect of a protein calorie supplement on change in CD4 count among art-naïve female TB patients co-infected with HIV in Dar Es Salaam, Tanzania

RATIONALE: Tuberculosis and HIV infection together form a highly mortal combination. Even after the advent of highly active antiretroviral therapy (HAART) medications, management for Tuberculosis and HIV/AIDS still remains a challenge. Poor outcomes (in both morbidity and mortality) are still being witnessed throughout the world, and especially in the poorly developed countries that bear the bulk of the burden of the cases. It is assumed that one of the major contributors to the poor outcomes is poor nutritional status resulting from the disease process itself, poverty and toxicity from medications being used to treat these diseases that substantially reduce appetite. An assessment of the role that nutritional status has on change in CD4 as a surrogate marker of disease progression is therefore of importance. OBJECTIVES: To evaluate the role that nutritional supplementation has on change in CD4 in TB patients co-infected with HIV who are receiving standard care of treatment. METHODS: Data from a randomized controlled trial of a Protein Calorie Supplement (PCS) were used. To assess the effect of randomization to a nutritional supplement, baseline characteristics were compared among the intervention and the control groups and confounder variables, such as age, BMI, baseline CD4, socioeconomic status, previous exposure to TB and compliance with HAART medication were analyzed and adjusted for in a model using multivariate linear regression. RESULTS: 151 HIV-infected women with TB disease were enrolled; 72 received PCS while 79 did not. We found that the PCS intervention had no significant effect on change in CD4 between baseline and 8 months. Average change in CD4 count was similar for intervention and control groups (204 vs. 207 units). This similarity persisted after adjusting for baseline BMI and previous TB disease. CONCLUSION: Randomization (i.e. nutritional supplement) did not have a significant effect on change in CD4 count among study participants. However, an effect could have been masked by high compliance with ART

Evaluation of the Wellspring Model for Improving Nursing Home Quality

Examines how successfully the Wellspring model improved the quality of care for residents of eleven nonprofit nursing homes in Wisconsin. Looks at staff turnover, and evaluates the impact on facilities, employees, residents, and cost

Models for providing improved care in residential care homes: a thematic literature review

This Annotated Bibliography is one output from a review of the available research evidence to support improved care in residential care homes as the needs of older people intensify. Key findings The review identified extremely little published evidence on residential care homes; the research base is almost exclusively related to provision of care in nursing homes. Much of this research is from the US or other non-UK sources. Although it could be argued that some findings are generalisable to the UK residential care context, a systematic process is required to identify which. The literature often makes no distinction between nursing and residential homes; use of generic terms such as ‘care home’ should be avoided. There is considerable international debate in the quality improvement literature about the relationship between quality of care and quality of life in nursing and residential homes. Measures of social care, as well as clinical care, are needed. The centrality of the resident’s voice in measuring quality of life must be recognised. Ethnic minority residents are almost entirely absent from the quality improvement literature. Some clinical areas, internationally identified as key in terms of quality e.g. palliative care, are absent in the general nursing and residential home quality improvement literature. Others such as mental health (dementia and depression), diabetes, and nutrition are present but not fully integrated. Considerable evidence points to a need for better management of medication in nursing homes. Pharmacist medication reviews have shown a positive effect in nursing homes. It is unclear how this evidence might relate to residential care. There is evidence that medical cover for nursing and residential care home residents is suboptimal. Care could be restructured to give a greater scope for proactive and preventive interventions. General practitioners' workload in care homes may be considered against quality-of-care measures. There is US literature on the relationship between nurse staffing and nursing care home quality, with quality measured through clinical-based outcomes for residents and organisational outcomes. Conclusions are difficult to draw however due to inconsistencies in the evidencebase. Hospital admission and early discharge to nursing homes research may not be generalisable to residential care. The quality of inter-institutional transfers and ensuring patient safety across settings is important. To date research has not considered transfer from residential to nursing home care. The literature on district nurse and therapist roles in care homes includes very little research on residential care. Partnership working between district nurses and care home staff appears largely to occur by default at present. There is even less research evidence on therapist input to care homes. Set against the context outlined above, the international literature provides evidence of a number of approaches to care improvement, primarily in nursing homes. These include little discussion of cost-effectiveness other than in telecare. Research is needed in the UK on care improvement in residential homes

Surgical assessment of the geriatric oncology patient

BACKGROUND: The aging population in the United States will correlate with an increased number of cancer diagnoses as cancer is primarily a disease of the elderly. Providing this ever-growing group of individuals with quality surgical management, while taking into account the unique needs and desires of this cohort, is a great challenge facing both geriatricians and surgeons going forward. The best approach to ensure that oncogeriatric patients receive the best tailored treatment is through the completion of a pre-surgical geriatric assessment. However, only a minority of oncogeriatric patients is undergoing a comprehensive pre-surgical geriatric assessment despite the majority of geriatricians and surgeons acknowledging its importance in order to properly risk stratify their patients. LITERATURE REVIEW FINDINGS: Multiple theories exist as to why geriatric assessments are not being utilized more frequently, but the most probable answer is that these assessments are very time-consuming, making it virtually impossible for incorporation into a healthcare provider’s busy schedule. Comprehensive literature review regarding geriatric assessments amongst the oncogeriatric population found that the most sensitive and specific domains of the geriatric assessments predicting morbidity and mortality include Frailty Index, Social Support Survey, Mini-Nutritional Assessment, and Geriatric Depression Screening. PROPOSED METHODS: A novel educational intervention will be proposed to teach Physician Assistant and Medical Students about the domains of the geriatric assessment most predictive of post-surgical risk during their surgical clerkship. The curriculum will utilize both simulation- and competency-based education training under the guidance of geriatricians and surgeons. Students will first learn the necessary skills in a controlled classroom environment and then proceed to incorporate these skills during their clerkship with patients on their service. CONCLUSIONS: The goal of the proposed method is to instill the confidence and skills necessary to provide an accurate geriatric assessment for oncogeriatric patients in future clinicians. The field of geriatric oncology is going to grow exponentially in the up-coming years and familiarizing future clinicians with the most predictive domains regarding surgical outcome will improve treatment outcomes for oncogeriatric patients in the immediate and foreseeable future

Optimising nutrition in residential aged care: A narrative review

In developed countries the prevalence of protein-energy malnutrition increases with age and multi-morbidities increase nutritional risk in aged care residents in particular. This paper presents a narrative review of the current literature on the identification, prevalence, associated risk factors, consequences, and management of malnutrition in the <i>residential aged care (RAC)</i> setting. We performed searches of English-language publications on <i>Medline, PubMed, Ovid and the Cochrane Library</i> from January 1 1990 to November 25 2015. We found that, on average, half of all residents in aged care are malnourished as a result of factors affecting appetite, dietary intake and nutrient absorption. Malnutrition is associated with a multitude of adverse outcomes, including increased risk of infections, falls, pressure ulcers and hospital admissions, all of which can lead to increased health care costs and poorer quality of life. A number of food and nutrition strategies have demonstrated positive nutritional and clinical outcomes in the <i>RAC</i> setting. These strategies extend beyond simply enhancing the nutritional value of foods and hence necessitate the involvement of a range of committed stakeholders. Implementing a nutritional protocol in <i>RAC</i> facilities that comprises routine nutrition screening, assessment, appropriate nutrition intervention, including attention to food service systems, and monitoring by a multidisciplinary team can help prevent decline in residents’ nutritional status. Food and nutritional issues should be identified early and managed on admission and regularly in the <i>RAC</i> setting

Changing Economic Incentives in Long-Term Care

Just as managed care has changed utilization and incentives in other parts of health care, there is a whole set of incentives built around long-term care that really matter. For example, if nursing homes have a financial incentive to hospitalize people with certain health conditions, then in the long run they are not going to develop the programs and invest in the resources to treat those people in the facility. Instead they're going to use those resources to stay in business or to provide other types of care. And while we can assume that policymakers do not create regulations that they expect will lead to poor quality, efforts to increase access or efficiency sometimes have the unintended consequence of reducing quality. Health care sectors in which spending is rising particularly rapidly or in which access seems to be problematic may be prone to regulations that fail to take into account potential effects on quality. There's a lot of money spent on nursing homes; there's certainly a lot of interest from public funders in nursing homes; and nursing homes have a long history of quality-of-care problems. Not surprisingly, then, some of the most interesting sets of bad incentives for quality can be found in nursing homes.nursing home, Medicare, Medicaid, long-term care, elderly, social welfare.