Strategies to Improve Care Transitions between Nursing Homes and Emergency Departments

OBJECTIVE To identify testable solutions that may improve the quality and safety of care transitions between nursing homes (NHs) and emergency departments (EDs). DESIGN Structured focus group interviews. SETTING Group interviews took place in Indianapolis, Indiana. PARTICIPANTS NH administrators, nurses, and physicians; emergency medical services (EMS) directors, paramedics, and emergency medicine technicians (EMTs); ED nurses and physicians; and a representative from the Indiana State Department of Health. MEASUREMENTS Opinions, perceptions, and insights of participants. RESULTS 18 participants were included. The central theme was the need for additional structure to support care transitions between NHs and EDs. Participants agreed that the structure afforded by hospital-to-hospital transfers would benefit patients and providers during transitions between NHs and EDs. Because transfer forms currently vary from NH to NH, participants recommended that the entire state use the same form. They recommended that the transfer form be useful in both directions by including a section for the ED provider to complete to support the ED-to-NH transition. Participants suggested that systems use a transfer checklist to help ensure that all processes occur as expected. They strongly recommended verbal communication across care settings to complement written communication and to improve on deficiencies that occur with transfer form-only strategies. Notably, participants suggested that the different care sites engage in relationship-building efforts to improve compliance with recommendations (e.g., form completion) and collaborative problem solving. CONCLUSION Participants advised additional structure to NH-ED care transitions, similar to hospital-to-hospital transfers, that includes a 2-way, statewide transfer form; a checklist; and verbal communication

A computationally efficient method for obtaining model forecast winds in the vicinity of complex coastal orography

Advances in computers have provided the means for generating fine resolution mesoscale numerical weather predictions (NWPs). Each computer advance brings demands for forecasts on ever smaller scales, especially by such disciplines as air pollution modeling and fire weather forecasting. Weather forecasts and observations on very small scales are essential for driving the models used in these important decision-making processes. Even with the improvements in mesoscale NWPs, the horizontal scales desired by these communities are still too small to be treated by current computer technology in a timely and practical fashion. Even if the computer resources were adequate, mesoscale model parameterizations are not necessarily appropriate for these small scales, thereby potentially introducing significant model error in mesoscale NWPs.The use of supercomputers supported by the Department of Defense High Performance Computing Modernization Program was necessary to generate the results presented in this study

Evolution of Low-level Flow Patterns in Littoral Regions when Extratropical Marine Cyclones Encounter Coastal Mountains

LONG-TERM GOALS: The long term goal of this project is to understand the interaction of slightly different large scale flows interaction with complex coastal topography to produce both regions of enhanced and diminished near surface winds.Award Number: N0001499WR3012

Dependence of Mesoscale Coastal Predictability on Data Assimilation and Distribution of Observations

The long term goal of this project is to determine the mesoscale atmospheric predictability and how it relates to synoptic scale uncertainty due to sampling and data assimilation of incomplete samples on the larger scale.Award Number: N0001401WR2003

SSM/I Rainfall Volume Correlated with Deepening Rate in Extratropical Cyclones

With the emergence of reasonably robust, physically based rain rate algorithms designed for the Special Sensor Microwave/Imager (SSM/I), a unique opportunity exists to directly observe a physical component which can contribute to or be a signature of cyclone deepening (latent heat release). The emphasis of the research in this paper is to seek systematic differences in rain rate observed by the SSM/I, using the algorithm of Petty in cases of explosive and nonexplosive cyclone deepening

Adverse outcomes and correlates of change in the Short Physical Performance Battery over 36 months in the African American health project

BACKGROUND: The Short Physical Performance Battery (SPPB) is a well-established measure of lower body physical functioning in older persons but has not been adequately examined in African Americans or younger persons. Moreover, factors associated with changes in SPPB over time have not been reported. METHODS: A representative sample of 998 African Americans (49-65 years old at baseline) living in St. Louis, Missouri were followed for 36 months to examine the predictive validity of SPPB in this population and identify factors associated with changes in SPPB. SPPB was calibrated to this population, ranged from 0 (worst) to 12 (best), and required imputation for about 50% of scores. Adverse outcomes of baseline SPPB included death, nursing home placement, hospitalization, physician visits, incident basic and instrumental activity of daily living disabilities, and functional limitations. Changes in SPPB over 36 months were modeled. RESULTS: Adjusted for appropriate covariates, weighted appropriately, and using propensity scores to address potential selection bias, baseline SPPB scores were associated with all adverse outcomes except physician visits, and were marginally associated with hospitalization. Declines in SPPB scores were associated with low falls efficacy (b = -1.311), perceived income adequacy (-0.121), older age (-0.073 per year), poor vision (-0.754), diabetes mellitus (-0.565), refusal to report household income (1.48), ever had Medicaid insurance (-0.610), obesity (-0.437), hospitalization in the prior year (-0.521), and kidney disease (-.956). CONCLUSIONS: The effect of baseline SPPB on adverse outcomes in this late middle-age African American population confirms reports involving older, primarily white participants. Alleviating deterioration in lower body physical functioning guided by the associated covariates may avoid or delay multiple age-associated adverse outcomes

POSITIVE AFFECT PREDICTS FUTURE BODY MASS INDEX: A 2-YEAR PROSPECTIVE ANALYSIS OF THE AFRICAN AMERICAN HEALTH STUDY

poster abstractAlthough prospective studies indicate that negative affective factors (e.g., depression) predict increases in body mass index (BMI), few studies have examined whether positive affect is prospectively related to BMI in African Americans. Thus, it is unknown whether positive affect is related to BMI, independently of negative affect, for this ethnic group. This deficit in the literature is unfortunate, given that positive affect may protect against increases in BMI, and African Americans have among the highest rates of obesity (BMI ≥ 30 m/kg2). Accordingly, our objective was to determine whether positive affect predicts 2-year changes in BMI, independently of negative affective factors, in middle-aged African Americans. Participants were 674 African Americans aged 57-72 years who were enrolled in the African American Health study. For our study, all variables were measured in 2008 (baseline) and at 2-year follow-up. Positive affect was assessed using the 4-item positive affect subscale of the Center for Epidemiologic Studies-Depression Scale (CES-D), whereas depressive symptoms were assessed using the remaining CES-D items. Anxiety was measured using the GAD-7, and low vitality was assessed with the SF-36. Self-reported BMIs were used. Multiple linear regressions revealed that greater baseline positive affect predicted 2-year decreases in BMI (β = -.048, p = .026) after adjusting for age, sex, baseline BMI, depressive symptoms, anxiety, and low vitality. Depressive symptoms, anxiety, and low vitality did not predict BMI (ps > .10). Baseline BMI did not predict 2-year changes in positive affect (p = 55). Our findings suggest that positive affect may exert a protective effect against obesity in African Americans, whereas negative affective factors (i.e., depressive symptoms, anxiety, and low vitality) were unrelated to BMI in our sample. A key implication is that interventions for increasing positive affect in African Americans may be helpful in obesity prevention efforts for this at-risk population

Intensive Pedestrian Archaeological Survey of the Lower Segment of San Pedro Creek, South Alamo Street to the Apache-Alazán Creek Confluence, San Antonio, Bexar County, Texas

Raba Kistner Environmental, Inc. was contracted by Pape-Dawson Engineers, Inc., on behalf of the San Antonio River Authority, to perform an intensive archaeological pedestrian survey of the Lower Segment of San Pedro Creek. The northern boundary of the project area is the South Alamo Street Bridge, and the southern boundary is the confluence with Apache-Alazán Creek. The project area consisted of a 70- ft wide corridor along the center-line of San Pedro Creek. The field investigations were conducted over the course of three days in June of 2014. These days were preceded by several days of archival investigations to assess the types and degree of historic impacts within the project area. The fieldwork was followed by additional historic investigations and the analysis of the materials recovered and the consideration of recommendations associated with the planned project. The pedestrian survey was conducted under Texas Antiquities Committee permit number 6913, issued to Dr. Steve A. Tomka, who served as the Principal Investigator. Currently the project does not fall under the jurisdiction of Section 106 of the National Historic Preservation Act (NHPA) of 1966, although, proposed improvements may cause it to come under the regulations in the future. Kristi Miller Nichols served as Project Archaeologist. The field crew consisted of Chris Murray and Mark Luzmoor. As part of the project, a 100 percent intensive pedestrian survey of the Area of Potential Effect (APE) was conducted by Raba Kistner archaeologists. A total of fourteen shovel tests were excavated along the creek banks. The shovel tests encountered modern materials mixed with some potentially historic artifacts. Common items encountered included glass, plastic, and metal fragments. A total of three backhoe trenches were excavated in selected areas to search for deeply buried deposits along the bank, and to confirm the extensive disturbances within the APE. No significant cultural deposits were encountered during the course of the project. The shovel testing and backhoe trenching reveal extensive disturbances along the creek bank due to channelization and industrial activities that bordered San Pedro Creek spatially during the first half of the 20th century. Given the extent of disturbances within the APE and the lack of intact prehistoric or historic cultural deposits noted during the survey, RKEI suggests that the planned project will not impact significant buried cultural deposits within its APE. However, because the actual extent of impacts, their specific locations, their depth and their spatial extent is not known at this time, it is recommended that if extensive below ground excavations are needed to accomplish the goals of the project, archaeological monitors be available during construction. Monitoring should take place any time subsurface disturbances exceed 3-feet below the modern surface. San Pedro Springs and the creek which it forms have played a significant role in the region both prehistorically and historically and it is likely that pockets of significant undisturbed deposits may be present in the APE, even if they were not encountered during this survey. All curated materials, as well as all project related documents, will be temporarily housed at the RKEI Laboratory until permanently transferred to the curation facility at the University of Texas at San Antonio-Center for Archaeological Research, upon the acceptance of this draft final technical report

Three-year measured weight change in the African American health study

OBJECTIVE: This study examines 3-year weight change in African Americans. METHOD: Nine hundred and ninety-eight participants 49 to 65 years old were assessed at baseline and 3 years later. Weight was measured, and weight change was defined as clinically meaningful increases or decreases (+/- 5 kg). Potential risk factors were investigated using multinomial logistic regression. RESULTS: In-home measured weights were available for 752 participants (75%): 504 (67%) had stable weights, 131 (17%) gained more than 5 kg, and 117 (16%) lost more than 5 kg. Among all participants, the risks for weight gains were cancer, chronic obstructive pulmonary disease, lower income, and Medicaid status; the risks for weight losses were angina, cancer, high measured systolic blood pressure, asthma, and physical inactivity. Sex-stratified analyses reveal differences involving age, socioeconomic status, cancer, blood pressure, and lower body function. DISCUSSION: Three-year weight changes in middle-aged African Americans were frequent and significantly associated with several risk factors

Observer ratings of neighborhoods: Comparison of two methods

BACKGROUND: Although neighborhood characteristics have important relationships with health outcomes, direct observation involves imperfect measurement. The African American Health (AAH) study included two observer neighborhood rating systems (5-item Krause and 18-item AAH Neighborhood Assessment Scale [NAS]), initially fielded at two different waves. Good measurement characteristics were previously shown for both, but there was more rater variability than desired. In 2010 both measures were re-fielded together, with enhanced training and field methods implemented to decrease rater variability while maintaining psychometric properties. METHODS: AAH included a poor inner city and more heterogeneous suburban areas. Four interviewers rated 483 blocks, with 120 randomly-selected blocks rated by two interviewers. We conducted confirmatory factor analysis of scales and tested the Krause (5-20 points), AAH 18-item NAS (0-28 points), and a previous 7-item and new 5-item versions of the NAS (0-17 points, 0-11 points). Retest reliability for items (kappa) and scales (Intraclass Correlation Coefficient [ICC]) were calculated overall and among pre-specified subgroups. Linear regression assessed interviewer effects on total scale scores and assessed concurrent validity on lung and lower body functions. Mismeasurement effects on self-rated health were also assessed. RESULTS: Scale scores were better in the suburbs than in the inner city. ICC was poor for the Krause scale (ICC=0.19), but improved if the retests occurred within 10 days (ICC=0.49). The 7- and 5-item NAS scales had better ICCs (0.56 and 0.62, respectively), and were higher (0.71 and 0.73) within 10 days. Rater variability for the Kraus and 5- and 7-item NAS scales was 1-3 points (compared to the supervising rater). Concurrent validity was modest, with residents living in worse neighborhood conditions having worse function. Unadjusted estimates were biased towards the null compared with measurement-error corrected estimates. CONCLUSIONS: Enhanced field protocols and rater training did not improve measurement quality. Specifically, retest reliability and interviewer variability remained problematic. Measurement error partially reduced, but did not eliminate concurrent validity, suggesting there are robust associations between neighborhood characteristics and health outcomes. We conclude that the 5-item AAH NAS has sufficient reliability and validity for further use. Additional research on the measurement properties of environmental rating methods is encouraged