Diagnostic Classifications and Resource Utilization of Decedents Served by the Department of Veterans Affairs

Background: Given the volume and cost of inpatient care during the last year of life, there is a critical need to identify patterns of dying as a means of planning end-of-life care services, especially for the growing number of older persons who receive services from the Veterans Health Administration (VHA). Methods: A retrospective computerized record review was conducted of 20,933 VHA patients who died as inpatients between October 1, 2001 and September 30, 2002. Diagnoses were aggregated into one of five classification patterns of death and analyzed in terms of health care resource utilization (mean number of inpatient days and cumulative outpatient visits in the year preceding the patient's death). Results: Cancer deaths were the most common (30.4%) followed by end-stage renal disease (ESRD) (23.2%), cardiopulmonary failure (21.4%), frailty (11.6%), “other” diagnoses (7.3%), and sudden deaths (6.1%). Those with ESRD were more likely to be male and nonwhite (p < 0.05) and those with frailty were more likely to be older and married (p < 0.05). Controlling for demographic variables, those with frailty had the highest number of inpatient days while those with ESRD had the highest number of outpatient visits. Nonmarried status was associated with more inpatient days, especially among younger decedents. Conclusion: As a recognized leader in end-of-life care, the VHA can play a unique role in the development of specific interventions that address the diverse needs of persons with different dying trajectories identified through this research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63159/1/jpm.2006.0256.pd

Hidden from Plain Sight: Residents' Domestic Violence Screening Attitudes and Reported Practices

Domestic violence (DV) is prevalent across all racial and socioeconomic classes in the United States. Little is known about whether physicians differentially screen based on a patient's race or socioeconomic status (SES) or about resident physician screening attitudes and practices. OBJECTIVE : To assess the importance of patient race and SES and resident and clinical characteristics in resident physician DV screening practices. DESIGN, PARTICIPANTS : One-hundred and sixty-seven of 309 (response rate: 54%) residents from 6 specialties at a large academic medical center responded to a randomly assigned online survey that included 1 of 4 clinical vignettes and questions on attitudes and practices regarding DV screening. MEASUREMENTS : We measured patient, resident, and clinical practice characteristics and used bivariate and multivariate methods to assess their association with the importance residents place on DV screening and if they would definitely screen for DV in the clinical vignette. RESULTS : Residents screened the African-American and the Caucasian woman (51% vs 57%, P =.40) and the woman of low SES and high SES (49% vs 58%, P =.26) at similar rates. Thirty-seven percent of residents incorrectly reported rates of DV are higher among African Americans than Caucasians, and 66% incorrectly reported rates are higher among women of lower than of higher SES. In multivariate analyses, residents who knew where to refer DV victims (adjusted odds ratio [AOR]=3.54, 95% confidence interval [CI]: 1.43 to 8.73) and whose mentors advised them to screen (AOR=3.46, 95% CI: 1.42 to 8.42) were more likely to screen for DV. CONCLUSION : Although residents have incorrect knowledge about the epidemiology of DV, they showed no racial or SES preferences in screening for DV. Improvement of mentoring and educating residents about referral resources may be promising strategies to increase resident DV screening.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75245/1/j.1525-1497.2006.00494.x.pd

Ageing and Long-Term Care Planning Perceptions of Hispanics in the USA: Evidence from a Case Study in New London, Connecticut

This paper explores the ageing attitudes and long-term care planning behavior of adult Hispanics in New London, Connecticut, a town with 30 thousand inhabitants that is rapidly ageing. We conducted six focus groups and had 37 participants share their ageing perceptions and long-term care needs. Our main findings suggest that informal care arrangements are vulnerable and unsustainable especially since women have historically and disproportionately provided most family eldercare even at their own personal and financial expense. Though male participants expected their female relatives to care for them when they age and need personal assistance, female participants did not necessarily expect the same from their relatives including their daughters. Also, both formal and government long-term care systems lack cultural competence and can be prohibitively costly. Therefore, Hispanics plan for ageing within their circles of family care and their resilience in a context of cultural exclusion and socio-economic disadvantage epitomizes strong intergenerational values. These support networks may help explain why may outlive whites (the Hispanic paradox ) who, on average, have higher wealth and education levels. Long-term care planning is a complex process that cannot be relayed to families only. Adequate training for family members from other relatives, and from private and government entities to appropriately convey this type of planning is vital to ensure that Hispanic families understand their options