Fear of Victimization Among Incarcerated Youths: Examining the Effects of Institutional “Neighborhood” Characteristics and Gang Membership

This study examines whether neighborhood factors found to predict fear of crime among the general population can be adapted to explain inmate fear of victimization inside juvenile correctional institutions. We test (a) whether institutional physical disorder, resident trust, and formal social control can predict fear of victimization, and (b) whether the importance of these factors for fear of victimization varies based on preincarceration street gang status. Using data from a large national sample of incarcerated youths, findings indicate non-gang members are more afraid of institutional victimization than gang members, confirming findings about levels of fear between these groups on the street. “Neighborhood” (institutional) physical disorder and resident trust predicted fear for gang and non-gang youths, whereas formal social control was significant only among non-gang youths. We discuss policy implications and directions for future research

Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents With Differing Levels of Dementia Severity

OBJECTIVES: To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. DESIGN: Retrospective cohort study. SETTING: Public Health System. PARTICIPANTS: A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. MEASUREMENTS: Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. RESULTS: Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia (P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants' time to first ED visit (P < .05 for all). After accounting for these effects, dementia severity (P = .66), years in nursing home before qualification (P = .46), and gender (P = .36) lost their significance. CONCLUSIONS: This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED

Nursing Home Staff Palliative Care Knowledge and Practices: Results of a Large Survey of Frontline Workers

CONTEXT: Deficits in quality end-of-life care for nursing home (NH) residents are well known. Palliative care is promoted as an approach to improve quality. The Palliative Care Survey (PCS) is designed to measure NH staff palliative care knowledge and practice. OBJECTIVES: To comparing palliative care knowledge and practices across NH staff roles using the PCS, and to examine relationships between facility characteristics and PCS scores. METHODS: The PCS was administered to frontline NH staff-certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), and social workers (SWs)-in 51 facilities in 2012. Descriptive statistics were calculated by job role. Linear mixed effects models were used to identify facility and individual factors associated with palliative care practice and knowledge. RESULTS: The analytic sample included 1200 surveys. CNAs had significantly lower practice and knowledge scores compared to LPNs, RNs, and SWs (P < 0.05). LPNs had significantly lower psychological, end-of-life, and total knowledge scores than RNs (P < 0.05 for all). Although knowledge about physical symptoms was uniformly high, end-of-life knowledge was notably low for all staff. A one-point higher facility star rating was significantly associated with a 0.06 increase in family communication score (P = 0.003; 95% CI: 0.02-0.09; SE = 0.02). Higher penetration of hospice in the NH was associated with higher end-of-life knowledge (P = 0.003; parameter estimate = 0.006; 95% CI: 0.002-0.010; SE = 0.002). Sixty-two percent of respondents stated that, with additional training, they would be interested in being leaders in palliative care. CONCLUSION: Given observed differences in palliative care practice and knowledge scores by staff training, it appears the PCS is a useful tool to assess NH staff. Low end-of-life knowledge scores represent an important target for quality improvement

Anticholinergics Influence Transition from Normal Cognition to Mild Cognitive Impairment in Older Adults in Primary Care

Study Objective To determine the influence of anticholinergic medications on transitions in cognitive diagnosis of older adults in primary care. Design This observational cohort study was conducted over a mean follow‐up of 3.2 years. Anticholinergic exposure was defined by pharmacy dispensing and claims records. Cognitive diagnosis was performed by an expert panel at baseline and annually up to 4 years. Data Source Medication exposure and other clinical data were extracted from the Indiana Network for Patient Care (INPC). The cognitive diagnosis was derived from a cognitive screening and diagnosis study. Participants A total of 350 adults 65 years and older without dementia and receiving primary care in a safety net health care system. Measurement and Main Results Cognitive diagnosis followed a two‐phase screening and consensus‐based neuropsychiatric examination to determine a baseline diagnosis as normal cognition, mild cognitive impairment (MCI), or dementia, with a follow‐up neuropsychiatric examination and consensus‐based diagnosis repeated annually. The Anticholinergic Cognitive Burden scale was used to identify anticholinergics dispensed up to 10 years before enrollment and annually throughout the study. A total standard daily dose of anticholinergics was calculated by using pharmacy dispensing data from the INPC. Among 350 participants, a total of 978 diagnostic assessments were completed over a mean follow‐up of 3.2 years. Compared with stable cognition, increasing use of strong anticholinergics calculated by total standard daily dose increased the odds of transition from normal cognition to MCI (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.01–1.31, p = 0.0342). Compared with stable MCI, strong anticholinergics did not influence the reversion of MCI to normal cognition (OR 0.95, 95% CI 0.86–1.05, p = 0.3266). Conclusion De‐prescribing interventions in older adults with normal cognition should test anticholinergics as potentially modifiable risk factors for cognitive impairment

Age Differences in the Association Between Body Mass Index Class and Annualized Medicare Expenditures

OBJECTIVE: The aim of the study is to assess the relationship between body mass index (BMI) class and Medicare claims among young-old (65-69), old (70-74), and old-old (75+) adults over a 10-year period. METHOD: We assessed costs by BMI class and age group among 9,300 respondents to the 1998 Health and Retirement Study (HRS) with linked 1998-2008 Medicare claims data. BMI was classified as normal (18.5-24.9), overweight (25-29.9), mild obesity (30-34.9), or severe obesity (35 or above). RESULTS: Annualized total Medicare claims adjusted for age, gender, ethnicity, education, and smoking history were 109% greater for severely obese young-old adults in comparison with normal weight young-old adults (US$9,751 vs. US$4,663). Total annualized claim differences between the normal weight and severely obese in the old and old-old groups were not statistically significant. DISCUSSION: Excess Medicare expenditures related to obesity may be concentrated among severely obese young-old adults. Preventing severe obesity among middle and older aged adults may have large cost implications for society

Gastric Tube Placement in Children 1-215 Months Old

poster abstractFeeding by a nasogastric/orogastric (NG/OG) tube is preferred when the gastrointestinal system is functional and the need for assisted feeding is expected to be short-term. Preliminary studies in children show that between 21% and 44% of these tubes are placed incorrectly. When tubes are out of place, children can be seriously harmed, causing increased morbidity and occasionally death. The aims of this study were to determine the best method to predict the insertion distance for placing NG/OG tubes and to determine the best clinical methods of testing the location of NG/OG tubes once they were inserted. A randomized clinical trial was conducted. The three insertion-distance prediction methods tested were nose-ear-xiphoid (NEX); nose-ear-mid-umbilicus (NEMU); and age-related, height-based (ARHB). An abdominal radiograph was obtained immediately following tube insertion to determine the internal location of the tube tip and orifice(s). Based on data from 95 children age 1-220 months (M = 51.8, SD = 54.9, median = 33.4), both the ARHB and NEMU methods were superior to NEX in placing the tube in the stomach (p = .0064). ARHB and NEMU were not significantly different from each other. NEX was frequently too short (41.93% of tube insertions) leaving the tube tip and/or orifices in the esophagus. The three clinical methods of testing tube location were CO2 monitoring and measuring pH and bilirubin in tube aspirate. Measuring pH of tube aspirate was the superior clinical method of determining tube location. Aspirate was available for testing in 84 children (88.42%). Based on a pH cutoff of 5 (recommended by Metheny in fasting adults), the sensitivity was 26.67 (low), specificity was 80.60 (high), positive predictive value was 23.53 (low), and negative predictive value was 83.08 (high). Measuring the NEX distance is the method most commonly used by nurses in practice; therefore, based on the results of this study and studies of other researchers, a practice change to either ARHB or NEMU should improve the safety of enteral feeding in children. Because of the low sensitivity in predicting misplaced tubes using pH, the superior clinical method, obtaining an abdominal x-ray to ensure placement in the stomach at the time of tube insertion is recommended

Hospice in the nursing home: perspectives of front line nursing home staff

OBJECTIVE: Use of hospice has been associated with improved outcomes for nursing home residents and attitudes of nursing home staff toward hospice influences hospice referral. The objective of this study is to describe attitudes of certified nursing assistants (CNAs), nurses, and social workers toward hospice care in nursing homes. DESIGN, SETTING, AND PARTICIPANTS: We conducted a survey of 1859 staff from 52 Indiana nursing homes. MEASUREMENTS: Study data include responses to 6 scaled questions and 3 open-ended qualitative prompts. In addition, respondents who cared for a resident on hospice in the nursing home were asked how often hospice: (1) makes their job easier; (2) is responsive when a patient has symptoms or is actively dying; (3) makes care coordination smooth; (4) is needed; (5) taught them something; and (6) is appreciated by patients/families. Responses were dichotomized as always/often or sometimes/never. RESULTS: A total of 1229 surveys met criteria for inclusion. Of the respondents, 48% were CNAs, 49% were nurses, and 3% were social workers; 83% reported caring for a nursing home patient on hospice. The statement with the highest proportion of always/often rating was 'patient/family appreciate added care' (84%); the lowest was 'hospice makes my job easier' (54%). More social workers responded favorably regarding hospice responsiveness and coordination of care compared with CNAs (P = .03 and P = .05, respectively). CONCLUSIONS: A majority of staff responded favorably regarding hospice care in nursing homes. About one-third of nursing home staff rated coordination of care lower than other aspects, and many qualitative comments highlighted examples of when hospice was not responsive to patient needs, representing important opportunities for improvement

Validation of a Scale to Measure Patient-Perceived Barriers to Medication Use

AIMS: Medication adherence may explain why patients show very different clinical outcomes. Previous assessments of adherence have used refill rates and pill counts. Few studies have investigated patient-identified barriers to using medications as prescribed. This is particularly true for persons with diabetes, most of whom are using poly-pharmacy regimens. We created a questionnaire to measure patient perceptions of barriers to medication adherence (PBMA) targeting a predominately low income, inner-city minority population. METHODS: Twenty items (Likert scale) leading with "I sometimes don't take my diabetes medicines because..." were developed from 5 focus groups (N=48). A questionnaire including these items was mailed to 1000 patients who have diabetes. RESULTS: Using data from 267 respondents (Mean age=58, 74%female, 43% non-Hispanic Caucasian, 77% income<$15,000), exploratory factor analyses with varimax rotation identified 5 factors, that may contribute to poor medication adherence: personal access to medications (F1); communication with providers (F2); understanding or appropriately following the prescribed regimen (F3); side effects (F4) and system factors that inhibited access to medication (F5). Cronbach alphas ranged from .73 to .83 for the five factors and was .92 for total scale score. No relationships were found between total scores and gender, race, or income. Greater perception of barriers was significantly (p<0.01) associated with being younger (r= -0.21), being bothered more by physical (r= -0.40) and emotional side effects (r= 0.43), and less satisfaction with control of blood sugar by diabetes medications (r= 0.45). CONCLUSIONS: This instrument is reliable, factorially valid, and consistent with clinical observation regarding factors known to be associated with patient medication adherence. Although study participants were patients with diabetes, the PBMA may be applicable to other therapeutic areas

Mild Cognitive Impairment, Incidence, Progression, and Reversion: Findings from a Community-based Cohort of Elderly African Americans

Objective To examine the long-term outcomes of community-based elderly African Americans by following their transitions from normal cognition to mild cognitive impairment (MCI), and to dementia. Methods Participants were from the community-based Indianapolis Dementia Project. A total of 4104 African Americans were enrolled in 1992 or 2001 and followed until 2009 with regularly scheduled evaluation of cognitive assessment. A two-stage sampling was used at each evaluation to select individuals for extensive clinical assessment following the results of stage one cognitive testing. Age and gender specific incidence, progression and reversion rates for MCI were derived using the person-year method in a dynamic cohort and predicted probabilities from weighted multinomial logistic models of transitional probabilities among normal cognition, MCI and dementia. Results Annual overall incidence rate for MCI is 5.6% (95% CI: 4.6–6.6%). Annual progression rate from MCI to dementia is 5.9% (95% CI: 5.3–6.5%) and annual reversion rate from MCI to normal is 18.6% (95% CI: 16.7–20.4%). Both MCI incidence rates and MCI to dementia progression rates increase with age, while reversion rates from MCI to normal decrease with age. Conclusion MCI progression to dementia is much more frequent in the older age groups than in the younger participants where reversion to normal cognition is more common. Future research is needed to determine factors related to the heterogeneous outcomes in MCI individuals

Responding to American Indian Communities: Southwest American Indian Collaborative Network (SAICN) Cancer Educational Activities

Developing educational materials and providing trainings in American Indian communities is a highly rewarding activity. However, to do so successfully a number of complex issues must be faced and cultural-tailored strategies to promote awareness must be developed based on the unique traditions of each tribe. In this paper we describe the educational activities conducted over a four year period by the Southwest American Indian Collaborative Network, a project funded by the National Cancer Institute’s Center to Reduce Cancer Health Disparities. Activities fell into two broad areas: dissemination of cancer information through trainings and workshops and development of culturally-tailored educational materials